Mother-to-be Agnes Ncube budgets up to 100 dollars each month from her informal roadside business just so she can pay for the maternal services at her local government clinic.

Ncube usually pays a maximum of 20 dollars for each consultation, depending on the service. But sometimes there are other costs that emerge, such as a referral – usually to a private doctor – where she has to pay cash upfront for a consultation.

Even though the City Council Clinic is a government facility, Ncube has to pay for each consultation because currently the Zimbabwean government does not provide free maternal care. This is because the money is needed to resuscitate a health care system that has been dysfunctional after years of underinvestment and massive staff exodus.

"I think maternal services should be provided freely for unemployed mothers-to-be," Ncube said. "At times it is difficult to meet the cost of such services when you do not have a job and depend on selling tomatoes or some informal trade."

Bulawayo’s government clinics charge a fee of about 83 dollars, a figure many expecting mothers can ill afford. These costs have been attributed to one of the contributing factors to the country’s high maternal mortality rates. According to the Zimbabwe Maternal and Prenatal Mortality Study of 2006, the country has one of the highest rates of maternal mortality estimated to be 725 deaths per 100,000 live births.

"The cost for maternal care is not affordable to many. And many women opt to give birth at home and often there are complications, some fatal, especially when they have no assistance," Siphiwe Ndlovu, a midwife, told IPS.

But the ministry of health and child welfare hopes to save the failing system and, most importantly, to curb child and maternal mortality rates.

On Oct. 8 the Zimbabwe government revealed the ‘Zimbabwe Health Sector Investment Case (2010 – 2012): Accelerating progress towards the Millennium Development Goals’ which outlines plans designed to: provide access to health services to the poorest citizens; ensure safe motherhood; and save lives.

The report launched by the Deputy Prime Minister, Thokozani Khuphe, outlines the 700 million dollar investment needed for Zimbabwe to meet the Millennium Development Goals, particularly those on reducing child mortality and improving maternal health. The investment plan is backed by the United Nations Children’s Fund and the World Health Organisation.

In the last decade as Zimbabwe witnessed a dramatic decline in primary health care services it led to a striking increase in maternal and child mortality. Currently one in three children are stunted, 100 children die daily due to easily preventable diseases while maternal mortality is more than double what it was in 1990.

According to the ministry of health and child welfare, the costs of health care are shifting to the end user as health institutions struggle to survive, keeping even the most basic services out of reach of the poorest people. For example, to deliver a baby in an urban public facility costs between 10 and 50 dollars.

The percentage of deliveries attended by trained medical personnel has declined over the last 10 years. And the poorest mothers are the ones who bear the brunt of this. The number of trained medical personnel attending births of poor women has dropped by 30 percent.

This, the ministry said, has directly contributed to the increase in maternal deaths as many poor rural women, unable to afford the government clinic fees, end up delivering at home. This has put them at risk of death and other serious complications.

Preliminary estimates indicate that 20 million dollars will be urgently required per annum to abolish user fees.

"The Inclusive Government of Zimbabwe has committed that by the end of 2011, no pregnant woman or child under five will be deprived of their right to health care because they cannot afford the fees," said Khupe at the launch of the investment report in Harare.

"To realise this commitment, it is urgent that we succeed in making the necessary financial investments to build a comprehensive public health system that can cater for everyone."

Meanwhile, many pregnant women are forced to attend private centres like Dr. Barbara Sibanda's maternal care centre. Sibanda’s Kings Maternity Home has full nursing and medical care staff and is seen to be cheaper than private hospitals and an alternative to government facilities, which often have poor services.

Situated in the heart of Bulawayo, the centre is a bustle of activity as expecting mothers come in for scheduled appointments or to enquire about the cost of services. Some come back, others never return.

While most of the up to 15 expecting mothers who use the maternal care home are working or have a steady income, some can barely afford the service. Sibanda is worried that the number of women who cannot pay for maternal services is on the rise, she has experienced it firsthand.

"I consider our rates for pre and maternal care to be among the cheapest in town but we have seen a trend where up to 50 percent of our clients often have serious difficulties paying the fees," Sibanda, explained to IPS. "At times some will pay the 10 dollar monthly consultation fee and face difficulties in paying the post natal fees opting to pay in instalments."

The Minister of Health and Child Welfare Dr. Henry Madzorera said the Health Investment Case has assisted his department to identify areas of urgent need and to further strengthen and effectively coordinate channels of funding.

Some of the Research Findings:

Focus should be placed on community-based approaches, complemented by a robust referral system and facilities which should be rolled out over three years.

Currently Zimbabwe spends nine dollars per person on health care, a far cry of the World Health Organisation recommendation of spending 34 dollars per person.

Despite the collapse of the health care system, the tradition of community involvement in health has been preserved. There are a number of home or community-based health practices or behaviours that can be carried out by households or communities themselves after receiving guidance.

Community health workers are often the key link between communities, especially rural, and local health services. But only 19 percent of villages across teh country have active health workers. The causes of this shortage include the cessation of the Zimbabwe Village Health Workers training programme, poor pay, and internal competition.