The repressive political environment in Zimbabwe has been well documented in previous Human Rights Watch reports.1 A climate of political and economic uncertainty has undermined the ability of officials, international agencies and civil society organizations to respond effectively to Zimbabwes humanitarian problems including the HIV/AIDS pandemic. In a bid to suppress criticism of its political and economic policies, the government has routinely used restrictive legislation and violent and intimidating tactics against civil society activists and the opposition.
The governments use of legislation such as the Public Order and Security Act (POSA) has restricted the work of local and international NGO organizations including those working on HIV/AIDS. The proposed NGO bill although it has not been signed into law, continues to affect the ability of NGOs to operate effectively.2 Many local HIV/AIDS NGOs are unable to advocate on issues of concern with the government, for fear of being shut down or of their registration being denied if the NGO bill eventually comes into force.
Government restrictions on humanitarian work which are frequently placed on NGOs and other humanitarian agencies were compounded last year by the governments program of evictions which took place throughout the country in May and June, and left up to 700,000 people homeless and frequently without a source of livelihood.3 In the aftermath of the evictions, the government tried to conceal the extent of the evictions and placed restrictions on the activities of local and international NGOs working in the areas where people were affected by the evictions including PLWHA.4
Zimbabwes economic environment has had a particularly detrimental effect on HIV/AIDS prevention and treatment programs in the country. Zimbabwe reportedly has one of the worlds fastest shrinking economies. Real GDP declined by 6.5 percent in 2005, which was the 8th consecutive year of negative GDP growth since 1997.5 Over the period 1997-2005, GDP declined by more than 30 percent.6 The decline in food production has resulted in a serious food deficit with particularly negative consequences for the poor.
In May 2006, year-on-year inflation reached 1193 percent, the highest in the world.7 Contributing to the economic challenges were poor economic policies and structural changes to Zimbabwes economic base, exacerbated by external shocks, such as continued droughts, the far-reaching impact of HIV/AIDS, and sharply reduced development aid flows.8
The engine of Zimbabwes economyagriculturecontracted drastically between 1999 and 2003, for a cumulative loss of around 26 percent, with maize production declining over 60 percent.9 It is estimated that production in the commercial farm sector alone fell by as much as 70 percent since 2000.10
In 2000, the government of Zimbabwe embarked on a controversial land reform program which led to the forced displacement of thousands of farm owners and farm workers, and according to economic analysts, worsened the economy and helped create acute food shortages.11 The decline in food production has resulted in a serious food deficit. In 2005, an analysis carried out by the Zimbabwe Vulnerability Assessment Committee (ZimVac) a committee composed of U.N. agencies, donors and the governmentestimated that under the most optimistic scenario 2.9 million people would require food aid in 2006.12 The mining, manufacturing and service sectors have also contracted, due to drought, shortages of foreign currency needed for imported inputs, rising production costs, as well as capital flight and large scale emigration.13
The declining economy and high levels of unemployment consequently led to the development of a large thriving informal economy in the 1990s. In 2005, the International Labor Organization (ILO) estimated that 3 to 4 million Zimbabweans earned their living through informal sector employment and supported another 5 million people.14 In contrast, the formal sector employed about 1.3 million people. However tens of thousands of people lost their livelihoods in the aftermath of Operation Murambatsvina when the government destroyed thousands of flea markets, tuck shops, and craft markets. In addition, the government continues to arrest thousands of informal traders in a bid to crackdown on informal trading in the streets.15 At least 150 hair salons in Harare, Bulawayo, Mutare, and other border towns were demolished.16 Women form a significant percentage of the population working in the informal sector and many evicted traders in the informal market were women.17
The monthly average wage of Zimbabweans is estimated to be somewhere between Z$10 million (US$100) and Z$20 million (US$200).18 However according to the governments central statistical office, the average Zimbabwean needs to earn at least Z$68 million (US$ 680) per month to rise above the poverty line.19
Zimbabwes social indicators, previously among the best in Africa, deteriorated rapidly between 1996 and 2004. The estimated proportion of the population living below the poverty line increased from 25% in 1990 to an estimated 70% in 2003.20 The World Health Organization recently estimated the life expectancy of a woman in Zimbabwe to be 34 years, a decline from 56 years in 1978 and the lowest in the world.21
The high poverty levels, in the absence of government social safety nets, put tremendous pressure on households taking care of PLWHA and those affected, including orphaned children and severely limit their capacity and that of communities to cope.
The level of health expenditure in Zimbabwe has always ranked high relative to income. In 2000 public health expenditure in Zimbabwe was US$43 per capita, more than double the mean total public health expenditure per capita for sub-Saharan Africa (US$21).22 This was even after the total health expenditure decreased by 17.3% between 1990 and 2000.23
Recent figures on health access in Zimbabwe from a 2005-6 Demographic Health Survey are expected to show both increasing user costs and decreasing numbers of trained health professionals.24 However, data from the Ministry of Health suggest a long term trend in declining access for at least some services. For example, the number of children under five participating in growth monitoring programs at health centers has declined from a little over 2.5 million in 1995 to just under 1 million in 2004.25Vaccination coverage rates for DPT3 (diptheria, pertussis, and tetanus) and measles have declined from approximately 80% in 1999 to 58% in 2002.26 Infant (under age one) and child (under age five) mortality increased between 1995 and 2000.27 Maternal mortality increased from 695 deaths per 100,000 live births between 1995 and 199928 to 1,100 deaths per 100,000 live births in 2000.29
The impact of HIV/AIDS, harsh economic conditions, and reduced funding from international donors have all combined to severely strain the delivery of health services. The decline in the economy has led to a decrease in expenditure on health, key shortages of drugs and the emigration of medical personnel. The socio-economic and human rights situation in Zimbabwe has led three million mostly skilled professionals to leave the country since 2000.30 In the public health sector 56% and 32% of doctor and nurse positions respectively are vacant.31
High and rising expenses and inadequate foreign exchange have led to shortage of funding, drugs, and supplies. A number of doctors and health workers interviewed by Human Rights Watch reported that they were frequent shortages of drugs in government run state hospitals.32
The high cost of user fees in state hospitals puts access to quality health services well beyond the reach of many Zimbabweans. Health user fees tripled in March 2006 in state hospitals, with basic consultations increasing from Z$300,000 (US$3) to more than Z$1 million (US$10) for adults and Z$250,000 (US$2.50) for children (children under the age of 5 are free).33 Fees for maternity care in public hospitals are also high at Z$7,500,000 (US$ 75).34 Private hospitals, doctors and clinics have also increased their fees. Private sector doctors fees increased in April 2006 by 100%the second increase in the yearto Z$5,700,000 (US$58).35 The private health sector is collapsing with many people switching to the already overburdened public sector.
 See inter alia, Zimbabwe: Civil Society Groups at Risk, Proposed Law on NGOs Would Violate Basic Rights, Human Rights Watch news release, New York, September 4, 2004, http://hrw.org/english/docs/2004/09/04/zimbab9310.htm; Human Rights Watch, Under a Shadow: Civil and Political Rights in Zimbabwe, A Human Rights Watch background briefing, June 6 2003, http://hrw.org/backgrounder/africa/zimbabwe060603.htm, and Not a Level Playing Field: Zimbabwes Parliamentary Elections in 2005, A Human Rights Watch background briefing, March 2005, http://hrw.org/backgrounder/africa/zimbabwe0305/zimbabwe0305.pdf.
 For more on the proposed NGO bill see Human Rights Watch, Zimbabwes Non-governmental Organizations Bill: Out of Sync with SADC standards and a Threat to Civil Society Groups, A Human Rights Watch background briefing, December 2004, http://hrw.org/backgrounder/africa/zimbabwe/2004/12/zimbabwe1204.pdf.
 Human Rights Watch, Evicted and Forsaken: Internally Displaced Persons in the Aftermath of Operation Murambatsvina (New York: Human Rights Watch, 2005), http://hrw.org/reports/2005/zim1205/zim1205webwcover.pdf (accessed July 24, 2006).
 Ibid., p. 21.
 World Bank, Interim Strategy note for Zimbabwe, Country Department 3, August 31, 2005, http://siteresources.worldbank.org/INTZIMBABWE/Resources/ZIMBABWEISN.pdf (accessed June 12, 2006).
 World Bank, Zimbabwe country brief, April 2006, http://web.worldbank.org (accessed June 12, 2006).
 See May Inflation Rises to 1193.5 percent, The Herald, June 10 2006 citing the Central Statistical Office.
 World Bank, Interim Strategy note for Zimbabwe.
 World Food Program, Zimbabwe: Appeals, projected needs for 2006, February 2006, http://www.wfp.org/country_brief/indexcountry.asp?region=3§ion=9&sub_section=3&country=716# (accessed June 12, 2006). ZimVac is composed of United Nations agencies, the government and donors and assesses household vulnerability and food insecurity around the country.
 Cited in Economy is shattered by Clean-up, The Zimbabwean, June 24-30, 2005.
 U.N. Special Envoy on Human Settlement Issues in Zimbabwe, Mrs. Anna Kajumulo Tibaijuka, Report of the Fact-Finding Missions to Zimbabwe to Assess the Scope and Impact of Operation Murambatsvina, July 22, 2005, http://www.unhabitat.org/downloads/docs/297_96735_ZimbabweReport.pdf (accessed June 10, 2006), p.35.
 Confidential memo from International organization working on the effects of Operation Murambatsvia on file with Human Rights Watch researchers, Harare, April 24, 2006.
 ActionAid International, Sectoral Impact of Operation Murambatsvina/ Restore Order, An Analysis of Operation Murambatsvina (Johannesburg: ActionAid International, 2005), p. 45.
 Remittances slow the slide into ruin, IRINnews, July 4, 2006, http://www.irinnews.org/report.asp?ReportID=54394&SelectRegion=Southern_Africa&SelectCountry=ZIMBABWE (accessed July 7, 2006). For more on household incomes and poverty in Zimbabwe, see Sarah Bracking and Lloyd Sachikonye, Remittances, poverty reduction and the informalisation of household wellbeing in Zimbabwe, Global Poverty Research Group, June 2006, http://www.gprg.org/pubs/workingpapers/pdfs/gprg-wps-045.pdf (accessed July 7, 2006).
 Family of 5 now needs Z$ 68 million, The Herald, July 11, 2006, http://www.zwnews.com/issuefull.cfm?ArticleID=14761 (accessed July 12, 2006).
 World Bank, Interim Strategy note for Zimbabwe.
 World Health Organization, The World Health Report 2006, http://www.who.int/whr/2006/annex/06_annex1_en.pdf (accessed July 24, 2006); World Health Organization, The World Health Report 1999, http://www.who.int/whr/1999/en/whr99_annex_en.pdf (accessed July 23, 2006).
 Nompumelelo Zungu-Dirwayi et al., eds., Social Aspects of HIV/AIDS and Health Programme, in An Audit of HIV/AIDS Policies in Botswana, Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe, (Cape Town: HSRC, 2004) p. 41.
 Expected results from 2005-6 Democratic Health Survey (DHS) [not yet available].
 USAID, Country Health Statistical Report,Zimbabwe, March 2004, http://www.sokwanele.com/pdfs/zimbabweUSAID2004.pdf (accessed June 12, 2006).
 Zimbabwe Millenium Development Goals: 2004 Progress Report, http://www.sarpn.org.za/documents/d0001702/Zimbabwe_MDG-report2004_goal5.pdf (accessed July 14, 2006), p. 41.
 Understanding the Brain Drain, The Financial Gazette, April 27, 2006, http://www.queensu.ca/samp/migrationnews/article.php?Mig_News_ID=2977&Mig_News_Issue=16&Mig_News_Cat=11 (accessed April 12, 2006).
 U.N., Consolidated Appeal for Zimbabwe 2006, http://ochaonline.un.org/cap/webpage.asp?Page=1332. (accessed June 12 2006).
 Huge Hike in Zimbabwe Health Fees, BBC Online news, http://news.bbc.co.uk/1/hi/world/africa/4942694.stm (accessed June 26, 2006), citing report in The Herald, Zimbabwe, April 25, 2006.
 Human Rights Watch interviews with medical personnel, Harare and Bulawayo, April 17 May 2006.