Online databases, namely the UNISA repository, Google Scholar, PubMed, and EBSCOhost, were searched by the researcher. The keywords used to search the database were 'economic decline and Zimbabwe', 'economic crisis in Zimbabwe’, 'economy crisis and health care’, as well as 'health effects and economic crisis’. Several references, referred to in the found publications, were hand searched to find other possible publications. The original search was conducted by a librarian appointed as the subject specialist.

Articles published in English between January, 2008 and December, 2019 were selected. The time frame chosen was specifically due to the political environment that led to the economic crisis. Editorials, commentaries, and correspondence that reported on the effects of the economic crisis on health care were also considered acceptable for inclusion.

The decision on the inclusion or exclusion criteria was based on the principle of including all studies of relevance to the economic crisis and was broadly defined to avoid the probability of excluding hypothetically relevant studies [18]. Considering the relevance, 86 publications were reviewed by title and abstract by researchers interested in health research in developing countries to contribute to the rigor of the selection (Fig. 1).

Forty-nine (49) articles were excluded during the first review by title and abstract, leaving 27 for further screening. The researcher and 2 co-researchers individually did a full article review on these 27 articles for appropriateness, after which 12 articles were excluded. The review and selection process for the remaining 15 published articles was conducted using the inclusion criteria determined by the researchers, as proposed by Armitage and Keeble-Allen [17], to be considered appropriate and relevant for the study. This led to the inclusion of a final 12 articles after an agreement between the three researchers. This was after they individually and then jointly assessed the relevance and appropriateness of the selected articles (Table 1). In a structured literature review, quality is not always considered, as articles are selected based on relevance [17]. Therefore the quality of the articles per se was not the ultimate goal for inclusion in the review.

All twelve (12) publications included addressed the economic crisis and its implication on the health care resources, namely on the physical resources, material resources, human resources, and financial resources that could be impacted by the economic crisis.

In the publication by Faramarzi et al. [20], an analysis of the economic crisis as an essential socio-economic factor for healthcare resources and its association with several health outcomes was described. Unemployment rates and out-of-pocket expenditure were taken as important predictors of accessibility of health care (financial resources input). The economic crisis contributed to a decrease in health care resources for Eastern Mediterranean countries as economic decline affected employment, which, in turn, affected health funding. During the economic decline, the out-of-pocket contributions by the health care users were financing 58% of the health care services, resulting in a negative impact on health outcomes.

Levy and Sidel [21] indicated that healthcare budgets were cut due to the economic crisis, affecting access to health workers, availability of medical drugs, and accessibility of private and public health facilities. The economic crisis resulted in reduced financial support for public health care programs, affecting the control of diseases and mortality rates negatively in 2008 in the United States of America. The economic crisis contributed to unemployment, affecting access to affordable medical care insurance by healthcare users.

In the study by Suhrcke et al. [22], it is described that the economic crisis affected most of the System Model inputs. The authors mentioned the cut in the health budget that affected the availability of health infrastructure. Pharmaceutical companies reported a decline in sales and production of medical drugs; thus, health facilities failed to access medical drugs. Health workers were downsized, and available health workers failed to take sick days, affecting quality health care delivery. The financial support was cut from both internal and external funding sources, risking disruption of treatment and/or the exacerbation of drug resistance as medical drugs were unavailable.

Karanikolos et al. [23] revealed that the economic crisis in Europe resulted in changes to public health expenditure, affecting human resources and the availability of medical drugs and medical supplies. For example, some countries like Cyprus, Greece, Ireland, Lithuania, Portugal, and Romania stopped the recruitment of health workers and froze salaries of health workers, leading to a brain drain. Some health facilities were closed, and reductions in the number of hospital beds and working hours were recorded in some countries like Catalonia. In addition, the price of medical drugs increased, making it merely impossible for pensioners and those who lost employment to afford health care, and default rates increased, particularly for chronic patients.

Leach-Kemon et al. [24] mentioned that the global financial crisis affected internal health funding in most countries, despite increased bilateral donors of 4% funding for health care during the economic crisis between 2008 to 2011. The amount of health resources available and the financial support for medical drugs and medical equipment that contributed to both public and private health institutions between 1990 and 2011 were described in this publication. The UN funding for health stagnated between 2008 and 2011, while malaria and tuberculosis stopped affecting healthcare resources in developing countries. These might have prompted bilateral donors to increase funding to developing countries. The financial resources were inadequate to address the effects of economic crisis on health facilities, human resources as well as material resources needed for quality health care.

Kiriga et al. [25] found ample evidence that in Asia and Latin America, the economic and financial crisis resulted in cuts in expenditures on health care, lowering the utilisation of health facilities, loss of health workers, reduction in maintenance of medical equipment, reduced access to medical drugs and other operating expenditures related to disease surveillance or supervision. In 2008, 15 of the 46 countries in the WHO African Region devoted less than 5% of their gross domestic product (GDP) to health. While five countries were above 9% of their GDP, total government expenditure on health in the region varied from 11% downwards, and five countries met the Abuja target of allocating at least 15% of the government budget to health. The reduced GDP available for health implied cutting budg et al. location to health worker remunerations, medical drugs, health facility renovations, and medical equipment and supplies with devastating effects on health care.

In a study by Modrek et al. [26], the consequences of the economic crisis on health indicated consistent evidence that recessions led to unemployment, which, in turn, significantly affected access to health workers, affordability to access medical drugs, and accessibility to health facilities for young men. The healthcare budget was cut, affecting the maintenance of hospitals and rural health facilities negatively. It was noted that the economic crisis contributed to a rise in mortalities because of infectious diseases, which could not have been treated effectively due to a lack of medical drugs, health workers, and financial resources to access health care.

Nunes et al. [27] reflected on the economic crisis and its impact on health care, demonstrating the influence of nursing on the sustainability of health care. The economic crisis limited the capacity of health workers to develop and deliver high-quality care due to a lack of material resources and financial resources, thus negatively affecting their performance.

Economou et al. [28] indicated that an economic crisis negatively affected public health care as financial resources were reduced, affecting healthcare activities and resources that facilitate healthcare delivery. In most developing countries, the health care budget is vulnerable and is normally the first to be affected during an economic crisis, leading to overstretching of the public health care system. In times of economic crisis, accessibility to healthcare services is reduced while demand increases, health workers are overloaded and medical drugs are in short supply. A significant increase in people reporting unmet medical and dental needs was noted due to dwindling financial resources for health.

Simou and Koutsogeorgou [29] presented a systematic overview of the consequences that the financial crisis has had on health and health care in Greece. Reduction in public health expenditure was associated with reduced access to health care services, access to medical drugs, and an increase in hospital admissions. The reductions in healthcare budgets after 2009 resulted in more people failing to access healthcare. The remuneration of the health workers was cut by 15%, and health workers resigned, creating shortages and overloading of available health workers. This affected operations at the primary healthcare level. Some health facilities were closed in Greece, and prices of medical drugs were also increased, affecting access by the unemployed.

Chimhowu et al. [1] found that the allocation of the health budget was virtually worthless, and people were struggling to access health care in Zimbabwe. The economic crisis affected health infrastructure capital investment while the population was increasing. As lower-level health facilities were closed, referral centres like provincial and central hospitals were used as the first referral centres, causing congestion and a fall in the quality of health care services offered. Medical drug supply and health workers became scarce. The cost of medical drugs increased, and health workers continued to leave Zimbabwe for other countries.

Tapera et al. [30] mentioned that the economic crisis constrained the healthcare delivery system as there was a lack of human resources and limited access to physical resources as some health facilities closed. A lack of treatment and care due to the unavailability of medical drugs and overburdening of patients due to reliance on out-of-pocket funding for treatment services were discussed. It was found that the economic crisis affected the availability of medical equipment needed to provide quality health care.

There was growing evidence that the decline in the economy in most countries affected the physical resources available, resulting in the deterioration of the health facility infrastructure [20, 32]. According to Chimhowu via et al. [1], the Ministry of Health [33] and various media released reports that the economic crisis in Zimbabwe was no exception to this tendency. An economic crisis made it impossible to access health facilities due to the deteriorating physical infrastructure, roads in bad condition [28], rare ambulances functioning, and broken communication equipment [5]. The rural population failed to access health care at the closest health facilities and bore the cost of traveling long distances to other health facilities run by missionaries at the district level and in cities [25].

Long distances between villages and health facilities, especially in resettlement areas as a result of land reform, poor road conditions in rural areas, where potholes were not mended, non-maintenance of bridges that affected the transport system between health facilities and villages [34, 35], ultimately negatively affected the availability of material resources like medical drugs at the rural health facilities.

An economic crisis affects the supply of medical drugs in public health facilities [22]. In Zimbabwe, the economic crisis affected the capacity of the health sector to purchase medical drugs. The majority of the health facilities in rural areas had limited access to medical drugs [36]. The health care users had to purchase medical drugs from private health facilities and pharmacies at high costs, similar to what was found in Greece [29] and eastern Mediterranean countries [20]. Healthcare facilities were running below 30% of their capability, with chronic shortages of drugs due to the economic crisis [14]. The prohibitive price of medical drugs from private suppliers meant healthcare users had limited access to healthcare for curable ailments that were often fatal [30, 36].

In Zimbabwe, the economic crisis negatively impacted the availability of medical supplies like blood transfusions, sutures, needles, and candles. Patients were asked to buy their own from expensive private pharmacies unavailable in rural areas [36]. For example, pregnant women had to provide their own delivery sets, including suturing materials [36-38], making it difficult for health workers to perform their duties.

Human resources, essential in the delivery of quality health care, were most affected by the economic changes, as salaries were changed from united states dollars to bonds and open vacancies froze in 2015 [29], health workers resigned, and the workload increased for those remaining [5, 39]. This worsened the existing challenges of shortage of health workers. In Portugal, Nunes et al. [27] found out that the economic crisis limited the capacity of health workers to develop and deliver high-quality care due to a lack of financial resources.

The economic crisis affected the financial resources, which impacted not only human resources but overall health expenditures on health care delivery. Evidence in some articles indicated that in 2008, 15 of the 46 countries in the WHO African Region devoted less than 5% of their GDP to health. While five countries were above 9% of their GDP, and total government expenditure on health in the region varied from 11% downwards, with only five countries meeting the Abuja target of allocating at least 15% of the government budget to health [40]. Zimbabwe was and is facing financial challenges as evidenced by the allocation of only 10.1% of the total annual budget to health in 2020, and although it was increased from 7%, allocation in 2019 was still far below both the 13% Sub-Saharan Africa average health care annual expenditure and Abuja declaration target of 15% [41]. Zimbabwe spent an average of US$18.26 health capita in 2019, which was lower than the recommended WHO target of US$34, and the Southern Africa Development Community (SADC) average of US$145.29 [41].

The impact of the economic crisis on accessibility to health care was worse in areas where poor people were selling their livelihoods in order to afford the health care user fees and obtain access to health care, driving them into poverty [14]. User fees’ spending was a challenge to the health care users as it increased disparity to poorer health outcomes [4]. Healthcare services improved from 2009 to 2012 due to funding received from Global Fund. However, the phasing out of the Global Fund supporting the Health Retention Scheme in 2013 left a funding gap of USD 4 million in 2013 and USD 22 million in 2014 [42]. This contributed to the government cutting payment of retention allowances and further losing professional nurses.