The hospital’s cavernous chapel is now filled with what looks like a giant sand dune of unshelled nuts. The hospital makes them into peanut butter that is mixed into patients’ breakfast porridge, spread on teatime snacks and melted into vegetables at dinnertime.

“We literally are providing medical services for peanuts!” exclaimed Kathy McCarty, a nurse from California who has run this rural hospital, 35 miles from the nearest tarred road, since 1981.

The hospital, along with countless Zimbabweans, turned to barter in earnest in 2008 when inflation peaked at what the International Monetary Fund estimates was an astonishing 500 billion percent, wiping out life savings, making even trillion-dollar notes worthless and propelling the health and education systems into a vertiginous collapse.

Since then, a power-sharing government has formed after years of decline under President Robert Mugabe, and the economy has stabilized. Zimbabwe abandoned its currency last year, replacing it with the American dollar, and inflation has fallen to a demure 3.6 percent. Teachers are back in their classrooms and nurses are back on their wards.

Barter Exchange Rate  list at Chidamoyo Hospital in Zimbabwe where patients barter goods from their farms for medical treatment.

But a recent United Nations report suggests how far Zimbabwe has to go. It is still poorer than any of the 183 countries the United Nations has income data for. It is also one of only three countries in the world to be worse off now on combined measures of health, education and income than it was 40 years ago, the United Nations found.

For many rural Zimbabweans, cash remains so scarce that the 85-bed Chidamoyo Christian Hospital has continued to allow its patients to barter. Studies have found that fees are a major barrier to medical care in rural areas, where most Zimbabweans live.

“It’s very difficult to get this famous dollar that people are talking about,” said Esther Chirasasa, 30, who hiked eight miles through the bush to the hospital for treatment of debilitating arthritis. Her son, Cain, 13, walked at her side carrying a sack of peanuts to pay for her care.

Chidamoyo Hospital Chapel that been turned into a store home for peanuts and other barter farm produce.

Mrs. Chirasasa said her family of seven was nearly out of the food they grew on their small plot, so she needed to get her pain under control to work in other farmers’ fields to feed her children.

Bartering helps plug some of the holes. A May survey of more than 4,000 rural households found that each of them, typically a family of six, spent an average of only $8 for all their needs in April, the cost of a couple of cappuccinos in New York. To help them get by, more than a third of households surveyed in September 2009 had used bartering.

Still, United Nations agencies estimate that 1.7 million of Zimbabwe’s 11 million people will need food aid in the coming months. And Mr. Mugabe’s continued domination of political life, along with persistent violations of the rule of law and human rights, have deterred foreign aid and investment needed to rebuild the nation’s shattered economy, analysts say.

Here in this rustic outpost with no phone service and often no electricity, the Chidamoyo hospital and the people who rely on it have entered an unwritten pact to resist the tide of death that has carried away so many. Life expectancy in Zimbabwe, plagued by AIDS and poverty, has fallen to 47 years from 61 years over the past quarter century.

Patients provide the crops they grow and the animals they raise — food that feeds the thousands of patients who use the hospital — and the hospital tends to their wounds, treats their illnesses and delivers their babies. Its two doctors and 15 nurses see about 6,000 patients a month and have put 2,000 people with AIDS on life-saving antiretroviral medicines.

Even during the hyperinflation of 2008, when government hospitals ceased to function as the salaries of their workers shriveled, the Chidamoyo hospital stayed open by giving its staff members food that patients had bartered.

“People are helped very well and the staff cares about the patients,” said Monica Mbizo, 22, who arrived with stomach pains and traded three skinny, black-feathered chickens for treatment.

The hospital, founded over four decades ago by American missionaries, from the Christian Church and Churches of Christ, receives limited support from a government that is itself hurting for revenue. The hospital also gets up to $10,000 a month from American and British churches, enabling it to charge patients far less in cash or goods than the fees at most government facilities. The hospital charges $1 to see the doctor — or a quarter bucket of peanuts — while a government hospital typically charges $4, in cash only.

Short of cash like the people it serves, the hospital practices a level of thrift unheard of in the United States. Workers and volunteers steam latex gloves to sterilize them for reuse, filling the fingers with water to ensure against leaks. They remove the cotton balls from thousands of pill bottles to swab patients’ arms before injections. And they collect the tissue-thin pages of instructions from the same bottles for use as toilet paper.

But there are limits to what even stringent economies can achieve. For most of the past year, the hospital did not have enough money to stock blood. Ms. McCarty said women who hemorrhaged after giving birth or experiencing ruptured ectopic pregnancies were referred to bigger hospitals, but often they had no blood either. Eight women died, she said. Just recently, the United Nations has begun paying for blood at the hospital to improve women’s odds of surviving.

Standing over an anesthetized woman before a Caesarean section, Dr. Vernon Murenje recalled how frightening it was to operate without blood in stock. “You’re operating,” he said, “but then at the back of your mind, you’ll be thinking, ‘What if we have significant blood loss?’ ”

As he prepared to make the incision, the hospital was in the midst of almost two weeks without power. Its old generator, already used when the hospital bought it 20 years ago, lacked enough juice to run the X-ray machine or to keep the florescent lights from flickering. It was turned on just before the Caesarean section. The air-conditioner coughed weakly to life in the stifling room.

When a boy emerged, Ms. McCarty cried, “Welcome to Zimbabwe!” But the newborn made no sound. She pounded his back and suctioned his nose until he let out a cry like a quavering baby bird.

“Oh, you finally realized you were born in Zimbabwe,” she said. “He thought he was born in South Africa, and he was happy.”

Postscript: The Community Presbyterian Church of Ringwood, N.J., has raised $24,000, and the Rotary Club of Sebastopol, Calif., contributed $7,000 to buy the hospital a generator.

Copyright 2010 The New York Times Company. Reprinted from The New York Times, International, of Sunday, December 19, 2010.