A few days after giving birth to her youngest daughter in May 2024, Shirley Celebrate Mkono, a 34-year-old mother of four, went to her local clinic to seek help for persistent headaches. Nursing staff worried she could have uncontrolled hypertension, recalls Mkono as she cradles her daughter, now 1 year old.
“The attending nurse informed me that my blood pressure was extremely high and I could collapse at any point,” she says.
After a few minutes, Mkono agreed to call a private ambulance for US$30. Even so, she waited four distressing hours for help to come.
“If the clinic had an ambulance in sight, it could not have taken this long,” she says. “I could have died.”
Only four public ambulances serve Harare’s over 2.4 million people, far short of the 32 ambulances the city says it needs; it would take a fleet of 48 to bring Harare in line with international guidelines of one ambulance for every 50,000 people.
In February, the city council introduced a monthly emergency services levy of US$1 per household to fund additional ambulances for council clinics, collected as part of the monthly electric bill. However, the council’s poor track record in managing public funds has made residents and watchdog groups skeptical that the money raised will be deployed with transparency and accountability.
The local authority has been grappling with health care financing for a long time, says Reuben Akili, director of Combined Harare Residents Association. Akili says the emergency levy will only be effective if it is collected and spent locally to stop funds from being diverted.
“There must be a mechanism in place that ensures the money is ring-fenced to buy ambulances in places where that money was collected,” he says.
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Mkono, who lives in the suburb of Glen View, is doubtful the levy will serve its purpose.
“There is a lot of corruption at the local authority. We pay for refuse collection about
$8 per month, but they don’t carry the refuse. I remember I last saw a refuse truck in my area in October last year after the mayor visited our area,” she says.
Embezzlement is a persistent problem in local councils, as highlighted in a 2024 analysis of local authorities conducted by the Southern African Parliamentary Support Trust and a coalition of local nongovernmental organizations. Diversion of funds from critical services like health care and sanitation has contributed to a cycle of mistrust and disillusionment, where citizens are reluctant to pay toward public expenditures that don’t actually improve local services.
Akili says the scarcity of public ambulance services has led people who can afford it to use private taxis, which can cost US$10 to US$20.
In May 2024, President Emmerson Mnangagwa set up an inquiry into the opposition-led Harare City Council following reports of corruption and financial mismanagement. The inquiry revealed that the city council has misspent more than US$1 million, with executives spending over US$125,000 per year on holidays even as the city fails to provide adequate services.
Mkono questions why the local authority is adding another levy on residents who already pay user fees when they seek medical care in council clinics.
“They should buy ambulances with that money,” she says.
In a written update to residents on recently introduced levies, which also include a US$1 streetlight levy and US$1 water levy, Precious Shumba, director of Harare Residents’ Trust, says the new fees were never presented and discussed during the annual budget consultations the city council held across Harare in September 2024.
Without an accurate, transparent and functional billing system in place, Shumba writes, the levies “add to a long list of revenue streams that have the potential to be abused by the cartels running the affairs of the City of Harare.”
Caroline Machivenyika accompanied her 17-year-old pregnant daughter to the local clinic in December last year. When they got there, her daughter was referred to a hospital because she was underage, but Machivenyika learned she’d need US$70 to get a private ambulance to take them; the city ambulances were unavailable.
“I only had US$50 on me; I explained my situation, and after an hour, a private ambulance arrived,” she recalls.
Transfers of expectant mothers and traffic collisions constitute the bulk of emergency incidents that require ambulance services in the city.
Like many other residents, Machivenyika has doubts about whether any funds raised through the levy will genuinely buy ambulances.
“We have lost trust in the local authority because the necessities that we are paying for are not being adequately provided. For instance, we only get water three times a week, but we pay for these services each month,” says the mother of four..800
But she says residents’ unpaid bills are also an important reason the local authority struggles to provide adequate services.
“They are supposed to close access to water for houses with unpaid bills, but when council workers come, people pay $5 bribes and they leave. Others are not even moved because they do not have access to water daily and do not care even if their water meters are disconnected by the council,” she says.
Stanley Gama, head of corporate communications for Harare City Council, did not respond to several requests for comment.
Only one-third of African countries have emergency medical services, and most of them require patients to pay a fee.
Upon reaching the hospital, Mkono was cared for and sent home within 30 minutes. She got a prescription for a month’s worth of medication to take at home, and her condition quickly resolved.
Ambulances used to arrive promptly when there was a need, recalls Machivenyika’s mother, Esther Machivenyika, 75.
“I remember in 1995 when my husband got sick at home, we called in an ambulance and it did not take an hour to come through and he was immediately taken to the hospital,” she says as she shells peanuts.
In the 1980s, Zimbabwe had a strong ambulance system with well-trained personnel, including a public service in Harare. But decades of economic instability have left emergency services unable to maintain or procure modern equipment.
Now, Esther Machivenyika says a patient has to pay cash up front to get assistance. “You can die while negotiating payment,” she says.
Even if people pay the emergency levy, she has no hope of a change in the situation because of what she sees as a culture of greed in public service.
“They are now seeing money as more important than a person’s health,” she says. “Even at health facilities, you have to pay a bribe to get good service from nurses.”
