National Health Strategy for Zimbabwe, 2009

4.2 Partnerships For Health 127 REFERENCES 131 PAGE 4 The National Health Strategy For Zimbabwe 2009 - 2013 Abbreviations ACT Artemisinin based Combination Therapy AFRA Africa Regional Cooperative Agreement For Research AIDS Acquired Immunodeficiency Syndrome ANC Antenatal care ARI Acute Respiratory Tract Infections ART Antiretroviral Therapy ARV Antiretroviral Drugs AU African Union BCG Bacillus Calmette-Guérin BMI Body Mass Index BSS Basic Safety Standards CBNCP Community Based Nutrition Care Programme CBDs Community Based Distributors CBR Community Based Rehabilitation CCZ Consumer Council of Zimbabwe CDR Crude Death Rate CDC Centers for Disease Prevention and Control (USA) CHDs Child Health Days CMAM Community Based Management of Acute Malnutrition CMED Central Mechanical Equipment Department CMR Child mortality rate COMESA Common Market for East and Southern Africa CSFP Child Supplementary Feeding Programme CSO Central Statistics Office CWGH Community Working Group on Health DDT Diethly-Dichloro-Triethyline DOTS Directly Observed Treatment Short course EDLIZ Essential Drugs List of Zimbabwe EHTs Environmental Health Technician EPI Expanded Programme of Immunisation ESP Expanded Support Programme EU European Union FDC Fixed Drugs Combination FSAB Food Safety Advisory Board GBV Gender Based Violence GDP Gross Domestic Product GF Global Fund HBC High Burden Country HIV Human Immuno-deficiency Virus HOSPAZ Hospice Association of Zimbabwe HRH Human Resources for Health IAEA International Atomic Energy Agency ICT Information Communication Technology IDD Iodine Deficiency Disease IEC Information Education and Communication ILO International Labour Organisation IMCNI Integrated Management of Childhood &Neonatal Illnesses IMR Infant Mortality Rate INFOSAN International Food Safety Authorities Network IPR Intellectual Property Rights IRHS Indoor Residual House Spraying ICT Information and Communication Technology ITN Insecticide Treated Nets KAPB Knowledge, Attitude, Practice and Behaviour LEB Life Expectancy at Birth Equity And Quality In Health: A People's Right PAGE 5 MCAZ Medicines Control Authority of Zimbabwe MDGs Millennium Development Goals MDR TB Multiple Drug Resistance Tuberculosis M&E Monitoring and Evaluation MIMS Multiple Indicator Monitoring Survey 2009 MIS Management Information Systems MNH Maternal & Newborn Health MOHCW Ministry Of Health and Child Welfare MOU Memorandum of Understanding MRI Magnetic Resonance Imaging NAC National AIDS Council NCPA National Action Programme for Children NCDs Non Communicable Diseases NGOs Non Governmental Organisations NUST National University of Science NatPharm National Pharmaceutical Company of Zimbabwe NCDs Non Communicable Diseases NDTPAC National Drug and Therapeutics Policy Advisory Committee NHIS National Health Information System NHSP National Health Strategic Plan NIDs National Immunisation Days NMRL National Microbiology Reference Laboratory NPAC National Programme of Action OIs Opportunistic Infections OVCs Orphans and Vulnerable Children PASS Poverty Assessment Study Survey PFMS Public Finance Management System PHC Primary Health Care PHHE Participatory Health and Hygiene Education PLWHA People Living With HIV and AIDS PMTCT Prevention of Mother To Child Transmission of HIV PWDs People With Disabilities PSIP Public Sector Investment Program RBM Results Based Management RBZ Reserve Bank of Zimbabwe RDC Rural District Council RHC Rural Health Centre RPAZ Radiation Protection Authority of Zimbabwe RTA Road Traffic Accident SADC Southern African Development Community SAFE Surgery, Antibiotic therapy, Facial cleanliness, Environmental improvements SARS Severe Acute Respiratory Syndrome SCMLT State Certified Medical Laboratory Technician STHs Soil Transmitted Helminthes STIs Sexually Transmitted Infections SP Sulfadoxine and Pyrimethamine TB Tuberculosis TBRL Tuberculosis Reference Laboratory THP Traditional Health Practitioners TM Traditional Medicine UNAIDS The Joint United Nations Programme on HIV/AIDS UNESCO United Nations Education, Scientific & Cultural Organisation UNFPA United Nations Population Agency UNICEF United Nations Children's Fund UZ University of Zimbabwe VIA Visual Inspection With Acetic Acid Solution VCT Voluntary Counseling and Testing VEN Vital, Essential and Necessary Drugs PAGE 6 The National Health Strategy For Zimbabwe 2009 - 2013 VHW Village Health Worker VIDCO Village Development Committee WADCO Ward Development Committee WHO World Health Organisation XDR TB Extremely Drug Resistance Tuberculosis ZDHS Zimbabwe Demographic Health Survey ZDF Zimbabwe Defence Forces ZEPI Zimbabwe Expanded Programme of Immunisation ZimVAC Zimbabwe Vulnerability Assessment Committee ZINQUAP Zimbabwe Quality Assurance Programme ZNASP Zimbabwe National HIV and AIDS Strategic Plan ZNCR Zimbabwe National Cancer Registry ZNFPC Zimbabwe National Family Planning Council Equity And Quality In Health: A People's Right PAGE 7 Executive Summary T he National Health Strategy (NHS, 1997 – 2007) set the agenda for launching the health sector into the new millennium. Recognizing that improvement in the health status of the population would not depend on health • HIV prevalence continues at an unacceptably high level of 13.7% (15 – 49 year age group) with only 180,000 of an estimated 400,000 persons requiring treatment actually receiving antiretroviral therapy (ART) by mid year 2009 sectoral actions alone, it sought to pull together all • TB remains a leading cause of morbidity with a national efforts which had potential to enhance notification rate of 434 out of 100,000 health development into a promising new era. • Child health status indicators are worsening, with infant mortality and under five mortality Whilst the situation analysis carried out at that rising from 53 and 77 per 1000 live births in time showed a worrying decline in health status 1994, to 60 and 86 per 1000 live births indicators, the optimism associated with the dawn respectively in 2009 (MIMS) of a new era provided hope and conviction for • The nutritional status of children indicators improvement. Similarly, the identified weaknesses are unacceptably high with stunting increasing in the performance of the health system were from 29.4 in 1999 to 35% among children thought to be temporary, in the hope that the under 5 years old holding capacity of the economy to support a • Maternal mortality levels are at an robust health system would improve. unacceptably high level of 725 deaths per 100,000 births (Zimbabwe Maternal and On the contrary: the challenges facing the health Perinatal Mortality Study, 2007) sector continued and in fact got worse. During the • Cholera epidemics, exacerbated by a country second half of the implementation period of the wide breakdown of sewage and water supply National Health Strategy (1997 – 2007), and treatment systems, claimed 4,269 lives out Zimbabwe experienced severe and escalating of a total of 97,469 cases by end of April economic challenges which peaked in the year 2009 2008. The economic decline resulted in a sharp • It is estimated that over five million people are decrease in funding for social services in real terms. at risk of contracting malaria annually This directly contributed to an unprecedented • Outbreaks of rabies and anthrax continue deterioration of health infrastructure, loss of being reported in some parts of the country experienced health professionals, drug shortages • There is continued and increasing public health and a drastic decline in the quality of health significance of chronic non-communicable services available for the population. conditions such as diabetes and hypertension (Zimbabwe STEPS survey, 2005) Health Status • Life expectancy at birth has fallen from 63 in 1988 to 43 years in 2005/6 Based on data from the Zimbabwe Demographic and Health Survey 2005/6 (ZDHS), Multiple Service Delivery Indicator Monitoring Survey 2009 (MIMS), Maternal and Perinatal Mortality Study and other The various studies and surveys carried out in stidues, the NHS has identified that Zimbabweans Zimbabwe over the last three years point towards are dying from easily preventable and treatable inadequacies in the six health system building conditions e.g. HIV and AIDS, TB, Diarrhoea, blocks (human resources; medical products, Acute Respiratory Infections, Malaria, vaccines and technology; health financing; health Malnutrition, Injuries, Hypertension, Pregnancy information; service delivery and leadership and Related and Perinatal complications, Mental governance) that are prerequisites for a functional Health disorders etc. The health status of health delivery system. Zimbabweans can be summarized as follows: PAGE 8 The National Health Strategy For Zimbabwe 2009 - 2013 There is gross underutilization of public sector incidence rate has also been declining; the National institutions, due to non-functionality of the health Immunization and Child Health Days have been a care system for various reasons: great success resulting in high immunization coverages for selected antigens; occurrences of • Public sector Human Resources for Health vaccine preventable conditions have fallen to vacancy levels (December 2008), are at insignificant levels; all primary care clinics have at unacceptable levels of 69% for doctors, 61% least one primary care nurse; the Village Health for environmental health technicians, over 80% Worker programme is back on course and the for midwives, 62% for nursing tutors, over Parliament Portfolio Committee on Health has 63% for medical school lecturers and over continued to lobby for more resources for the 50% for pharmacy, radiology and laboratory health sector. All of these successes indicate that personnel. with an injection of appropriate resources, health • Health management has weakened as a result workers can be productive and produce tangible of high attrition rates of experienced health improvements in the health and quality of life of service and programme managers. This has an Zimbabweans. It is worth noting that even during impact on supervision and monitoring and is these difficult economic times, Government, evidenced by reduced quality of service through the Ministry of Finance, has continued to provision. give priority to the health sector, • Health professionals cannot provide services without adequate medicines and equipment. The Ministry of Health and Child Welfare Access to essential drugs and supplies has been remains committed to the vision of ensuring the greatly reduced with stock availability ranging highest possible level of health and quality of life between 29% and 58% for vital items and for all citizens of Zimbabwe. This will be attained 22% and 36% for all categories of items on through the combined efforts of individuals, the essential drugs list in 2008. Vital items communities, organizations and the government, should always be 100% available. which will allow them to participate fully in the • Medical equipment, critical for diagnosis and socio-economic development of the country. To treatment is old, obsolete and non-functional. achieve this vision, the Ministry of Health and • The majority of physical health infrastructure Child Welfare has developed this National Health is in a state of very serious disrepair. Fixed Strategy which has thirty three areas for action and plant and equipment such as laundry machines, implementation over the next five years. The areas kitchen equipment and boilers are also non- identified go beyond the boundaries of the health functional. As a result very few public health sector and are thus the responsibility of the institutions are able to meet basic hospital government as a whole, as exposure to some socio- standards for patient care and infection control economic and environmental risk factors increases measures. the disease burden of communities. • As a result of serious shortage and disruption of transport and The Ministry realizes that with the current socio- telecommunications several programs economic environment it is unrealistic, with its including patient transfer, immunisations, limited financial and human resources, to malaria indoor residual spraying, drug implement the entire five year agenda at once. As a distribution, supervision of districts and follow up to this strategy, a “Three Year Rolling rural health centres have been compromised. Plan” will therefore be developed. This plan will • The health system is grossly under-funded. The cover priority key performance areas where current revised budgetary allocation works out improvements must take place in order to, at the to approximately US$7 per capita per annum very least, maintain those activities that are keeping against the WHO recommendation of at least the health sector “ticking” and also prevent a US$34. complete collapse of the health system. This “Three Year Rolling Plan” will form basis of the Besides this gloomy picture of health status and Health Sector Investment Plan health system, the remaining health professionals have continued providing some limited services In the first year of the Three-Year Rolling Plan, with support from both Government and a priority will be placed on resuscitating the ailing number of health development partners. The health system and making it more functional, in combined effort of the Ministry of Health and order for it to be able to address the main health Child Welfare, communities, development partners diseases and conditions with the greatest impact and the private sector, has seen a reduction of on the health of the nation. HIV prevalence in the 15-49 years age group from 29.3% in 1997 to 13.7% in 2009; the malaria Equity And Quality In Health: A People's Right PAGE 9 The main strategy that will be used to address 1. Provision of adequate, skilled and well these diseases and conditions will be the Primary remunerated Human Resources for Health. Health Care Approach. Zimbabwe, in 2008, joined Efforts will be made to:- the rest of the world in re-committing itself to a. Retain health workers at work by giving Primary Health Care by signing the Ouagadougou them a living income that can be sustained Delcaration. The Primary Health Care Approach by the current economy. will assist the Ministry in not only addressing the b. Increase productivity and professionalism health needs of this nation, but will also steer the of health workers by providing them with country towards attainment of the Millennium adequate tools of the trade as listed below Development Goals. In 2004, Zimbabwe officially c. Reduce the overall vacancy levels through adopted the Millenium Development Goals as the halting and reversing brain drain, recruiting, nation's 2015 development vision and since then training and retaining qualified health staff. Zimbabwe has been working towards meeting the The role played by community health MDG targets. From a regional perspective, this workers, as evidenced by their actions document has incorporated some elements of the during the cholera epidemic, should not be Africa Health Strategy. Based on the diseases and underplayed as one looks at the human conditions mentioned above, the following priority resources for health. programmes will be scaled up: 2. Continuous supply of medicines and medical supplies:- There will be need to improve the • HIV, AIDS, STI & TB Programme availability of medicines, medical sundries and • Nutrition Programme other hospital supplies, to a level that will • Environmental Health and Hygiene enable institutions to provide at least basic Programme. services as defined for each level of care. • Maternal Health and Family Planning 3. Provision of functional Equipment (Fixed and Programme movable) and Infrastructure:- There will be • Child Health Programme need to improve the availability and • Malaria Control Programme functionality of diagnostic and treatment • Non-Communicable Disease Programme medical equipment in critical departments • Epidemic Preparednes and Response Control (Theatre, Laboratory, Casualty, Maternity, X- Programme ray & renal departments). Water supplies and • Mental Health Programme provision of generators at health facilities shall • Oral Health Programme be given high priority. • Eye Care Programme 4. Provision of Transport:- There will be need to • Heath Promotion Programme, including the improve the availability of reliable School Health Programme transportation and telecommunication systems to improve and strengthen the referral system. Priority will also be placed on revitalizing the 5. Ensuring a sustainable and predictable Health Care delivery system based on Primary Financial Base:- There will be need for Health Care including an effective, efficient, advocating and lobbying for a sustainable and referral system and Emergency Services. The health predictable financial resource base, to ensure care system covers issues such as the management the provision of high quality services to the of common illnesses, emergency services, oral population. health services, and mental, oral, eye, disability and 6. There will also be need to address the issues of rehabilitation services amongst other health leadership and governance at all levels, disease services. surveillance and health information for decision making including strengthening Health System Strengthening coordination of health sector players. Adequate resources and an appropriate enabling environment are critical prerequisites for the These critical success factors are addressed in this successful scaling up of the above mentioned strategy under the six pillars of a health system as programmes. The Ministry has identified the defined by the World Health Organisation critical success factors for the successful scaling up (WHO). of health programmes and these are:- PAGE 10 The National Health Strategy For Zimbabwe 2009 - 2013 Inclusive Implementation And Monitoring to provide leadership and more importantly, stewardship, in harnessing and nurturing these The thrust and theme of the National Health efforts and contributions. Maintaining sustainable Strategy is naturally focused on promoting and partnership frameworks will be an ongoing improving the quality of services and ensuring negotiation process, promoted within an ambit of equity in the delivery of these services. This will be co-operation and with promotion of equity, achieved primarily through the meaningful quality and access to health care being the focus. participation and involvement of local Key to implementation of this strategy will be communities. In the past, community partnerships with Public Health Providers participation has been interpreted as the provision including Missions and Local Authorities; the of free labour by communities for the construction private sector; traditional international of physical facilities such as clinics and water development partners including the United points. Communities value services when they play Nations Family and bilateral donors; regulatory a role in their design and development. Relative to bodies of the health professions; institutes of their asset base and given the decline in formal higher learning and other ministries and sectors. health sector funding, communities are likely to be Intersectoral collaboration will be based and providing a large share of support to health related focused on the common goal i.e. doing those programmes in their areas through cash and in- things which improve the quality of life of the kind contributions in the form of labour. This population, together. Existing district and contribution should be officially recognized and provincial structures in the form of Provincial evaluated. During the next five years, communities, Councils, Provincial Development Committees and through health centre committees or community District Development Committees will support health councils, will be actively involved in the taking forward the operational agenda of this identification of health needs, setting priorities strategy. and mobilizing and managing local resources for health. Overall structure of strategy The action points for the next five years include Based on the situational analysis above, the strategy areas outside the boundaries of the health sector. is divided into four thematic areas. It is anticipated The current environment in Zimbabwe that successful, coordinated implementation within (characterized by poor and inadequate water these four areas will lead the nation towards the supplies; breakdown in the sewer systems; national vision for health. inadequate sanitation in both urban and rural; poor waste management practices; inadequately • Determinants of Health: addressing the supervised food preparation processes; and factors outside the health sector which have an inadequate control of vector borne diseases, impact on health coupled with increased urban unplanned • Diseases affecting Zimbabweans: addressing overcrowded settlements and poor enforcement of the burden of specific diseases and conditions laws and regulations that protect health) has affecting Zimbabwean's increased the exposure of the nation to hazardous • Health System Strengthening: supporting the factors in water, air, food and in some cases soil. overall health system context in which services The picture presented by the top ten outpatient must be planned, delivered and monitored conditions that include diarrhoeal, eye, and skin • Inclusive Implementation: acknowledging and diseases including asthma and tuberculosis is a enabling the actions of a wide range of reflection of increased exposure to hazardous stakeholders towards realising the health of the agents within the environment. Inter-sectoral nation coordination and collaboration will be necessary to address these major contributors to illness, The strategy develops trends, current status and disability and death in the country. key issues then articulates goals, objectives and implementation strategies within each of the four Improvements in the health status and quality of thematic areas. A total of thirty three goal areas life of the population do not depend solely on have been identified under these four thematic interventions within the health sector. It takes the areas, reflecting the comprehensive nature of an efforts, contributions and participation of a approach required for full health sector revival. myriad of stakeholders involved in both financing This strategic approach is summarized in the and direct provision of health services. It figure below, with goals, objectives and nevertheless remains the responsibility of the state, implementation strategies detailed in the tables through the Ministry of Health and Child Welfare, that follow: Equity And Quality In Health: A People's Right PAGE 11 PAGE 12 Zimbabwe's National Health Strategy 2009-2013: Strategic Approach VISION OF THE MINISTRY OF HEALTH & CHILD WELFARE: To have the highest possible level of health and quality of life for all citizens of Zimbabwe MISSION OF THE MINISTRY OF HEALTH & CHILD WELFARE: To provide, administer, coordinate, promote and advocate for the provision of equitable, appropriate, accessible, affordable and acceptable quality health services and care to Zimbabweans while maximising the use of available resources, in line the Primary Health Care Approach. Disease & Population Inclusive Determinants Health System Specific Goals Implementation of Health Goals Goals Goals The National Health Strategy For Zimbabwe 2009 - 2013 Socio-economic Dynamics Maternal & Child Health Health Service Delivery Community Participation Health & The Environment Nutrition disorders Human Resources For Health Partnerships for Health Health Promotion Communicable Diseases Health information Non Communicable Medical Products, Vaccines Diseases & Conditions & Technologies Mental Health Health Financing Disability & Rehabilitation Governance & Leadership Older persons Objectives for each goal Implementation Srategies for each objective 2009 -2013 Zimbabwe National Health Strategy Part 1: Determinants Of Health Goals Objectives SOCIO-ECONOMIC DYNAMICS 1. To increase national Advocate for improvement in socio-economic status and living awareness on the impact of conditions of the population. socio-economic factors Strengthen inter-sectoral coordination and collaboration with such as resource allocation, relevant sectors and other organizations, towards improving income, poverty, adult health and quality of life of the population. literacy, housing, food availability and working Increase awareness on and advocate for action by relevant conditions, on the health ministries and other stakeholders on the major determinants of and quality of life of the health such as water, sanitation, food, hygiene, education and population gender amongst others. HEALTH AND THE ENVIRONMENT 2. To contribute towards the Increase access to safe water and sanitation. creation of a safe and Increase national awareness and understanding on the impact of healthy environment environmental factors and living conditions (settlement, factories, through strengthening agriculture industry, mining, sewage, waste disposal, toxic waste Environmental Health deposal, radiation hazards) on the health and quality of life of the Services in particular, population. promotion of safe water, appropriate and adequate Promote rural and urban development and housing within an sanitation, food and environment where pollution from various types of waste (solid, personal hygiene liquid, chemical, noise, radiation) is reduced to an acceptable minimum. Reduce air, water and terrestrial pollution by strengthening mechanisms including regulations that will control and minimize contamination of the environment. Strengthen public health measures that ensure food for sale to the public meets standards and is sold and prepared in a manner and in premises that comply with public health regulations. Increase awareness on clean and hygienic living conditions HEALTH PROMOTION 3. To promote positive Promote positive health behaviours (lifestyles) in 80% of targeted behavioural change through health promotion audiences by 2010. health promotion Equity And Quality In Health: A People's Right PAGE 13 2009 -2013 Zimbabwe National Health Strategy Part Two: Disease and Population Specific Goals Goals Objectives MATERNAL & CHILD HEALTH 4. To reduce the Maternal Increase the availability and utilisation of youth friendly Family Mortality Ratio from 725 to Planning and HIV prevention services. 300 deaths per 100,000 Increase the availability and utilisation of quality focused live births by 2015 antenatal care including PMTCT services. Improve access to skilled attendance at delivery; including EmONC. Improve access to quality PNC including PMTCT services. Strengthen the capacity of the health system for the planning and management of MNH programmes. Improve the policy environment for provision and utilization of quality and equitable MNH services. 5. To reduce the Under Five Scale up high impact child survival interventions (Immunization, Mortality Rate from 86 per IMCI, etc.). 1000 live birth to 43 by Improve coordination and strengthen multi-sectoral approaches 2013 to addressing child health conditions. Advocate for increased resource allocation to child health programmes. Strengthen monitoring and evaluation of child welfare activities and programmes. NUTRITION DISORDERS 6. To reduce the incidence improve the sustainability of nutrition related programmes. and prevalence of nutrition Create awareness on the impact of nutrition on health and quality disorders of life through information, education and communication (IEC) on dietary habits. Monitor nutritional status of the population for early detection of malnutrition. Improve household food security. Develop a national programme on control of vitamin and mineral deficiencies. Improve the nutritional status and quality of life of people infected and affected by HIV and AIDS. Improve nutritional management of malnutrition. Improve Infant and Young Child Feeding. COMMUNICABLE DISEASES 7. To have halted, by 2015, Prevent and control HIV and STI transmission. and begun to reverse the Reduce the impact of STI, HIV and AIDS on the individual, spread of HIV and AIDS community and society. (MDG) Improve coordination and strengthen multi-sectoral approaches to addressing the HIV and AIDS epidemic. Advocate for greater resource allocation for STI/HIV and AIDS interaction (extra-budgetary). Strengthen STI/HIV and AIDS surveillance and improve research and programme effectiveness. PAGE 14 The National Health Strategy For Zimbabwe 2009 - 2013 COMMUNICABLE DISEASES (cont.) 8. To reduce the mortality, Expand and enhance provision of high quality DOTS. morbidity and transmission Enhance coordination and implementation of TB/HIV of tuberculosis in line with collaborative activities. the Millennium Development Goals and Effectively prevent, control and manage multi-drug resistant TB. the Stop TB Partnership Contribute towards the strengthening of health systems. targets Promote partnerships with other care providers and stakeholders at all levels of the health system. Empower people with TB and their communities. Promote operations research. 9. To have halted, by 2015, Achieve universal access to malaria prevention and personal and begun to reverse the protection. increasing incidence of Improve diagnosis and treatment of uncomplicated and severe malaria (MDG) malaria. Improve detection and timely control of malaria epidemics. Strengthen community and other stakeholder participation to maximize achievement of universal access to malaria control interventions. Improve coordination, management and monitoring for achieving universal access to malaria control interventions. 10.To improve timely detection Strengthen timely detection and control of all epidemic prone and control of epidemic diseases through use of Integrated Disease Surveillance and prone diseases (Cholera, Response. dysentery, rabies, anthrax, Strengthen prevention and timely control of zoonotic diseases. plague, pandemic influenza, meningococcal Prevent cholera and other diarrhoeal diseases. meningitis, viral Strengthen detection and control of Viral Haemmorrhagic Fevers haemorrhagic fevers (VHF) (VHF). etc. Strengthen detection and control of outbreaks. Reduce morbidity due to schistosomiasis and soil transmitted helminthes. 11.To reduce morbidity due to Establish the incidence and prevalence of Schistosomiasis schistosomiasis and soil Establish the incidence and prevalence of soil transmitted transmitted helminthes by helminthes year 2015 NON COMMUNICABLE DISEASES & CONDITIONS 12.Improve the prevention and Reduce the burden of non communicable diseases by between management of priority 15 and 20% by 2013 Non-Communicable Protect women and children against all forms of abuse and Disease (NCDs) violence. Increase community participation and responsibility in the promotion of healthy lifestyles and responsible behaviour. Research on the social impact of lifestyles on health. Increase access to services for clients with NCDs. Reduce morbidity and mortality due to cancer. Reduce and prevent the incidence of blindness. Reduce the incidence of oral health problems. Equity And Quality In Health: A People's Right PAGE 15 MENTAL HEALTH 13.To reduce the incidence of Increase access to appropriate and effective mental health mental illnesses through services, with an emphasis on access; and to reduce the strengthening and incidence of mental illness. promotion of mental health Improve the capacity of all levels to achieve national goals. programs Improve outcomes for those with mental illness through the use of proven, effective treatments. Create an environment that promotes the mental well being of individuals. Strengthen and coordinate forensic services. DISABILITY & REHABILITATION 14.Improve the functionality, Increase access to quality medical rehabilitation services to all that independence and quality need them. of life of people with disabilities OLDER PERSONS 15.Improve the quality of life Promote the well being and quality of life for older persons. of older persons PAGE 16 The National Health Strategy For Zimbabwe 2009 - 2013 2009 -2013 Zimbabwe National Health Strategy Part Three: Health System Strengthening Goals Objectives HEALTH SERVICE DELIVERY 16.To increase coverage, Improve the functionality of Primary Health Care clinics and the access and utilization of referral hospitals (district, provincial and central referral hospitals). affordable, comprehensive and quality preventive and Improve the quality of care provided in health facilities. curative health services 17.To increase availability of Increase availability of transport at all levels. transport to at least 75% Increase availability of a reliable communication package at all and communication levels. systems to 100% of the requirements levels 18.To increase physical access Increase the availability of functional infrastructure in underserved of the population to areas including deliberate emphasis on developing appropriate health farm/resettlement area health facilities. infrastructure for each level Regulate the establishment of health facilities. of care Upgrade and rehabilitate health infrastructure. 19.To ensure the delivery of an Improve the quality of clinical and public health laboratory effective, efficient, service provision. accessible, equitable, and affordable national quality assured network of tiered laboratory services 20.To improve on the quality Improve the quality of laboratory diagnosis. of the national analytical Improve the capacity of the Government Analyst Laboratory. laboratory services for food, water, toxicology/clinical Strengthen the administration of the Food and Water Safety and and industrial Quality Regulations to ensure availability of safe food and water inputs/products analysis to the public. Improve information collection, gathering and dissemination as National CODEX and INFOSAN Contact Points, SADC, COMESA and FSAB substantive member and secretariat. To be part of the nucleus of the imminent food control authority. 21.To increase access to high Strengthen the medical imaging services. quality imaging services 22.To reduce radiation Upgrade Radiation Protection Infrastructure &Services through exposure of both human the implementation of the Radiation Protection Act [Chapter beings and the environment 15:15]. Ensure safety and security of radioactive sources and contribute towards the fight against illicit trafficking. Increase national awareness of radiation hazards and risks. Equity And Quality In Health: A People's Right PAGE 17 HUMAN RESOURCES FOR HEALTH 23.To ensure that the health Develop and implement a human resources policy and strategy. system based on PHC has Reduce vacancy levels across all staff categories by 50%. appropriate numbers and categories of Human Strengthen management at all levels. Resources for Health for efficient and effective implementation of the National Health Strategy HEALTH INFORMATION 24.To provide reliable, Harmonise the functions of the Health Information and relevant, up-to-date, Surveillance Systems. adequate, timely and Strengthen Health Information and Surveillance systems. reasonably complete information for health Increase the use of information in decision-making. managers at facility, district, Increase access to information that is ready to use. provincial and national level Increase Human Resource capacity in Health information strengthening. Improve monitoring and evaluation of HIS. 25.To increase utilization of Strengthen and market the National Institute of Health Research health research findings for (NIHR). policy development Strengthen health research capacity at all levels. Conduct Essential National Health Research. Develop and transfer appropriate public health technologies to new resettlement areas. Promote use of evidence based decisions and policies in the development, facilitation and implementation of health programmes. Strengthen national, south-south and north-south research collaborations. MEDICAL PRODUCTS, VACCINES & TECHNOLOGIES 26.To improve overall Increase medicines availability in all health institutions to 100% availability of drugs, for V, 80% for E and 75% for N. medical supplies and other Ensure 100% of all medicines entering the health sector are safe, consumables to 90% efficacious and of good quality. 27.To increase availability of Increase availability of functional medical equipment and functional equipment to technology for diagnosis, treatment and patient monitoring ensure the delivery of appropriate for each level of care. effective curative and Implement a preventive maintenance programme. preventive services 28.To increase access to and Implement the Traditional Medicine Policy and code of ethics in rational use of safe, Zimbabwe. efficacious and quality Promote the proper use of safe, efficacious and quality Traditional traditional medicines Medicines. Educate and train Traditional Health Practitioners (THPs) and Allopathic Health Practitioners (AHPs). Strengthen the Protection of Intellectual Property Rights (IPR) of Traditional Medicine and Indigenous Knowledge. Contribute to production and conservation of medicinal plants. Strengthen the institutional framework for traditional medicine. PAGE 18 The National Health Strategy For Zimbabwe 2009 - 2013 HEALTH FINANCING 29.To increase the levels of Strengthen the Financial Management system at all levels. sustainable and predictable Improve use of existing resources. financial resource base to ensure provision of high Mobilize resources for the health sector including to a sustainable quality services to the financial resource base of at least US$34 per capita. population GOVERNANCE & LEADERSHIP 30.To improve governance and Strengthen management and leadership at all levels of the health management of the health sector. sector Strengthen the decentralization of health service management to local levels. Strengthen the role of regulatory bodies and agencies. Provide clear strategic direction for health development. Clearly define the appropriate regulatory framework to ensure the various stakeholders fulfill their responsibilities in health. Coordinate activities among the different units within the Ministry of Health and Child Welfare. Establish a functional mechanism to ensure transparency and accountability in the health sector. 31.To strengthen capacity to Create an inclusive health policy development framework. formulate, develop and Link health service provision to national social development implement health policies objectives. and regulations Define role of local authorities in health services development and provision. Coordinate activities among the different units within Ministry of Health and Child Welfare. Identify and clarify policies which affect and promote the protection of the population’s health. Strengthen the health policy development framework through coordination, dialogue and collaboration with sectors impacting on health and quality of life. Review existing health policies, legislation, and regulations so that they are consistent with changing circumstances. Monitor and evaluate the impact of policies on access, equity, efficiency and community satisfaction. Equity And Quality In Health: A People's Right PAGE 19 2009 -2013 Zimbabwe National Health Strategy Part Four: Inclusive Implementation Goals Objectives ENHANCING COMMUNITY PARTICIPATION & INVOLVEMENT IN IMPROVING HEALTH & QUALITY OF LIFE 32.To enhance community Make available to all Zimbabwean information on the health participation and status of the nation including determinants and risk factors for involvement in improving health. health and quality of life Create an enabling environment and encourage individuals to and in health development take responsibility for their own health and secure the health of the others. Establish methods for seeking broad based national consensus on priorities to be addressed. Make individuals, families and communities aware of their rights and responsibilities. Re-vitalize and strengthen the role of the village health worker and other community health workers. Provide an enabling implementation framework for community participation. Empower communities and ensure their involvement in the governance of health services. PARTNERSHIPS FOR HEALTH 33.To enhance collaboration Strengthen partnerships with public health providers. with both local and Increase and strengthen private sector involvement in the health international development sector. partners Increase and strengthen intersectoral collaboration and coordination in health development. Strengthen partnerships with local and international health partners. Strengthen partnerships with health related stakeholders. PAGE 20 The National Health Strategy For Zimbabwe 2009 - 2013 Context For The National Health Strategy Equity And Quality In Health: A People's Right PAGE 21 INTRODUCTION In pursuing this mission, the Ministry of Health and Child Welfare is committed to the following Good health and quality of life do not derive only values: - from the health sector, but are influenced by a myriad of other factors which are outside its direct • Equity in health status and health care influence. All sectors of the economy impact on • Comprehensive quality services the health and quality of life of all citizens • Cost effectiveness (value for money) and through their direct influence on the social efficiency determinants of health. • Client and provider satisfaction • Transparency and accountability The Ministry of Health and Child Welfare plays a • Ownership and partnership in health stewardship role in safeguarding the health of the • Monitoring and evaluating the performance of population of Zimbabwe, as well as in direct the health service to ensure accountability and provision of health services. The Ministry operates adherence to national standards and policies. within the functions mandated to the office of the Minister of Health and Child Welfare (Restricted: In broad terms, the mission of the Ministry of Hand-book on the Functions of the Minister of Health and Child Welfare will be pursued through: Health and Child Welfare, March 1993) as well as the provisions of the Public Health Act (Chapter • Continuously reforming the Health Sector in 15:09) and the Health Service Act. line with changing needs. • Strengthening the Primary Health Care VISION OF THE MINISTRY OF HEALTH Approach as the main strategy for health AND CHILD WELFARE development. • Increasing partnership in health services and The Government of Zimbabwe desires to have the care whilst maintaining the principle of three highest possible level of health and quality of life ones (one national plan, one coordinating for all its citizens, attained through the combined mechanism and one monitoring and evaluation efforts of individuals, communities, organizations mechanism). and the government, which will allow them to • Ensuring resource availability and sustainability. participate fully in the socio-economic development of the country. This vision will be Underpinning the Ministry of Health and Child attained through guaranteeing every Zimbabwean Welfare mission is the need to: access to comprehensive and effective health services. Guided by its mandate and in line with • Achieve equity in health by targeting resources the Results Based Management framework, the and programmes towards the most vulnerable Ministry of Health and Child Welfare has and needy amongst the population. therefore defined the following Key Result Areas • Maintain the Primary Health Care approach as (KRAs): the leading strategy for health development. • Focus on health as a key component in overall • Improving the health status of the population national development policies towards • Improving the quality of care improving the quality of life of all citizens. • Health systems strengthening • Identify priority health problems and target resources accordingly. MISSION OF THE MINISTRY OF HEALTH • Develop innovative and new approaches in AND CHILD WELFARE management and delivery of services in ways which enhance access, community satisfaction To provide, administer, coordinate, promote and and local accountability. advocate for the provision of equitable, • Aim at high quality health services. appropriate, accessible, affordable and acceptable • Give priority to disease prevention, health quality health services and care to Zimbabweans promotion and protection. while maximizing the use of available resources, in • Widen the participation of stakeholders in the line with the Primary Health Care Approach, development and implementation of policies for better health and • Establish wider awareness on the impact of social determinants of health. PAGE 22 The National Health Strategy For Zimbabwe 2009 - 2013 The Ministry will therefore ensure that There is a close relationship between socio- Zimbabweans enjoy the highest possible level of economic development and the population growth health and quality of life, in line with the vision rate. Improved socio-economic development goes described above. This aim can be further hand in hand with improved health status and articulated as: quality of life, which are in turn associated with a falling birth rate. • To keep as many people as possible in good health in the Community (A) through health Zimbabwe is a landlocked country situated in protection, health promotion and disease Southern Africa. The country covers an area of prevention strategies 390,759 km2 and is divided into 10 • To provide appropriate quality services for administrative provinces that include Harare and those needing care in the community (B) Bulawayo. The other 8 provinces are mainly rural (Primary Care services) and and are made up of a total of 62 districts. • To provide high quality hospital services at the appropriate level for those few requiring that Zimbabwe's population increased from 10.4 form of treatment and care (C) (secondary, million in 1992 to 11.6 million in 2002 (Central tertiary and quaternary care). Statistics Office). In 2008, the population was 12,121,565 (Inter-Censal Demographic Health Survey – ICDHS - 2008). The annual population A B growth rate was 1.1 between 1992 and 2002. C According to the 2008 ICDHS, the average rate of natural increase has declined to 0.7. The male/female ratio in 2008 was 0.93, meaning there are slightly more females than males in the DEMOGRAPHIC DYNAMICS AND total population, whilst the dependency ratio has HEALTH STATUS dropped to 0.81 (ICDHS 2008) from 0.94 in 1992. This means that for every 100 adults in the Demography helps to define those population age group 15 – 64, there are 81 children and groups in potential need of health services and elderly people who should be looked after. those who are vulnerable and at risk. It provides the denominators for comparison of the health status of the same population or against other populations. Table 1: Selected demographic indicators. Indicator 1982 1988 1992 1999 2002 2005/6 2008 CSO ZDHS CSO ZDHS CSO ZDHS ICDHS Crude birth rate (CBR) 44 - 34.5 30.8 30.3 31 25 Total Fertility Rate (TFR) 6.2 5.5 - 4 - 3.8 3.3 Crude death rate (CDR/1000) 10.8 - 9.5 - 17.2 - 20 Infant Mortality Rate/1000 86 53 65 58 - 55 63 Life expectancy at Birth 57.4 63 61 - 45 43 43 Annual growth rate 1969-82= 3 - 1982-92= 3 - 1.1 1992- 1.1 0.7 Sex ratio: 2002 = male-Female 96:100 - 95 - 94 - 93 Rural/Urban population R74%:U26% - R69%:U31% - R65%:U35% - R74/U26 Dependency ratio 101:3 (103.7) 94.4 87.4 80 - 81 Equity And Quality In Health: A People's Right PAGE 23 The age structure of the population has remained ICDHS 2008 surveys reported the fertility rate to young, with 41% of the population aged below 15 have further declined to 3.8 and 3.3 births years. Both in the 2002 Census and 2008 ICDHS, respectively. The table below shows trends in 41% of the population was below 15 years of age, current fertility rates based on successive ZDHS 55% was between the ages 15 and 64 years, and a reports. Fertility declined by 1.7 births between very small proportion (4%) was 65 years of age or 1988 and 2005-6 surveys. more. Table 2: Trends in total fertility rates, Zimbabwe 1984- 3.6% of the population were under one year old in 2006 1992, with a figure of 3.3% in 2008, according to projections from the 2002 census. The proportion Age Group 1998 ZDHS 1994 ZDHS 1999 1984-1988 1991-1994 ZDHS 2005-06 ZDHS 2008 ICDHS of 5-14 year olds has remained stable at the 1992 1996-99 figure of around 30%. For planning purposes it is TFR 15-49 5.5 4.3 4.0 3.8 3.3 important to note that there is a large dependent proportion of the population (45%) made up of The 2003 Poverty Assessment Study Survey children under 15 years (41%) and those over 65 (PASS) reported that nationally, 30% of all years (4%). It is also important to note that children aged 0 to 17 years were categorized as women and children comprise over 70% of the Orphans and Vulnerable Children (OVCs), of population. whom 75% were orphans. The study estimated the overall prevalence of orphans within the same There has been a drastic decrease in the Life population to be 22% giving a total of 1,207,645 Expectance at Birth (LEB) from above sixty years children below the age of 18 years. According to in 1990, to 41 years for males and 46 years for the ZDHS 2005/6, close to a quarter of children females according to the Inter-Censal under the age of 18 years were orphaned, that is, Demographic Health Survey (ICDHS). one or both parents were deceased. A dramatic . increase was noted in orphan-hood on comparing Population structure the 1994 and 2005/6 surveys with the proportion of children orphaned more than doubling between Zimbabwe has a broad based population pyramid the two surveys, from 9% to 22%. The proportion and a narrow top, reflecting a youthful population of all children with both parents deceased also with a large proportion of children. This youthful more than doubled, from <1% to 6%. The 2003 population results from a relatively high fertility study also noted that orphans, particularly double and increased adult mortality. However, the orphans, had a higher prevalence of being structure of the 2005/6 population pyramid is underweight (23%) as compared to non-orphans consistent with a population experiencing a decline with the 2005/6 ZDHS confirming the same in fertility. The number of children under five is (21% of OVCs underweight, compared with 16% less than the number aged five to nine years, a of other children). Urban OVCs, particularly those finding that is consistent with a recent fertility living in Harare, were particularly disadvantaged decline. with respect to their nutritional status compared with the rural children. The most recent study, Figure 1: Zimbabwe population pyramid10 MIMS found, 37% of all children aged 0 to 17 years were categorized as Orphans and Vulnerable Age 80+ Children (OVCs), with 25% of all children being 75-79 70-74 orphans. It can therefore be concluded that there 65-69 60-64 are a great number of Orhans and Vulnerable 55-59 Male Female 50-54 Children in Zimbabwe, who are generally more 45-49 40-44 vulnerable to poverty, food insecurity, malnutrition 35-39 30-34 and HIV & AIDS. 25-29 20-24 15-19 10-14 10-14 The population living in urban areas has increased 5-9 <5 from 26% in 1982, to 31% in 1992 and 35% in 10 8 6 4 2 0 2 4 6 8 10 2002. With an area of 390,757 km2, the Percent ZDHS 2005-2006 population density of the country was 29 persons per square kilometre (2002 census); an increase The total fertility rate has been declining over the from 27 persons per square kilometre in 1992. years, from 7.9 children per women in 1969 to 6.5 The highest population densities are found in the in 1984. It further declined from 5.5 to 4.3 in the cities, with the lowest density being in period 1985 to1994 and the ZDHS 2005/6 and Matebeleland North due to national parks which PAGE 24 The National Health Strategy For Zimbabwe 2009 - 2013 are sparsely populated. However, recent internal Key demographic issues considered in the migration has resulted in a change in the development of this National Health settlement patterns and therefore population Strategy were thus: densities. This has a bearing on service provision and utilization, as well as the basic determinants of • 70% of the population lives in the rural areas health. • Over 70% of the population is made up of women and children An unplanned rural–to–urban drift has negatively • 41% of the population are children under 15 affected the environment of urban local years of age authorities. Urban infrastructure, specifically the • Older persons make up 4% of the population maintenance of environmental standards including • A very large and increasing number of for housing, safe water, sanitation and refuse orphans and vulnerable children within the disposal, is deteriorating. There is also increasing total population of all children. pressure for expansion and creation of new • Unplanned peri-urban settlements without infrastructure in the rural growth points and rural social services service centers, as well as the high density areas of • Resettled farmers without social services towns and cities. Urban health care thus requires specific focus and attention. Raising awareness about the relationship between population Burden of disease dynamics and health will continue to be a major Morbidity and mortality trends in Zimbabwe show challenge for the future. that the population is still affected by common preventable and treatable diseases and conditions The PASS suggests that an additional urban-to- including nutritional deficiencies, communicable rural migration of specific populations could be diseases, pregnancy, childbirth and new born due to job loses or HIV and AIDS as the jobless, related conditions. retired and critically ill tend to move back to rural areas. Mortality Mortality figures are key indicators for assessing From 2000 there was also a rural-to-farming area the quality of life of a population. Despite the migration due to the land reform programme, earlier recorded successes of the early 1990s, most which saw people moving into designated farms health indicators have either remained unchanged where there were no social amenities. At the or have deteriorated. Multiple factors have national level, 3.2 percent of the population affected the capacity of the public health sector to migrated out of the country. maintain the achievements of the first decade since Independence. It must be noted that besides the urban – rural differences in some indicators, such as access to Crude Death Rate health services, there are also differences within the The crude death rate dropped from 10.8 in 1982 urban and rural areas themselves. There are sub- to 6.1 in 1987 and then rose to 9.49 in 1992. The areas within the rural areas that are particularly far overall crude birth rate for the country was from health facilities; others have high incidences estimated at 17 deaths per 1000 population in the of specific conditions, whilst others are hard to 2002 census and 20 deaths per 1000 in 2003. The reach for reasons of geography and infrastructure. 2008 Inter-Censal Demographic Health Survey Of particular note is the growth in the number of (ICDHS) gives a crude birth rate of 25. The unplanned peri-urban settlements without water, Crude Death Rate decreased from a high of sanitation, health and other amenities. These issues 20.1/1000 population in 2003 to 17.2/1000 need to be considered in programme planning. population in 2007. TheICDHS (2008) gives a crude death rate of 20. Figure 2: Crude Death Rate Trends Estimated Crude Death Rates (CDR), Zimbabwe, 1980 - 2007 25 CDR (per 1000) 20 15 10 5 0 1 3 5 7 9 1 3 5 7 9 1 3 5 19 19 19 19 19 19 19 19 19 19 20 20 20 8 8 8 8 8 9 9 9 9 9 0 0 0 Year Equity And Quality In Health: A People's Right PAGE 25 The HIV and AIDS epidemic has greatly affected • HIV, AIDS, STI & TB Programme the national crude death rate. The crude death rate • Nutrition Programme is expected to rise in tandem with an expected rise • Environmental Health and Hygiene in the age specific death rates of the 15-45 year Programme. olds and the under-fives, due to HIV and AIDS. • Maternal Health Programme • Family Planning Programme Causes of Illness and Death in Zimbabwe • Child Health Programme The main causes of illness and death in Zimbabwe • Malaria Control Programme have been identified through the routine National • Non Communicable Disease Programme Health Information System (NHIS) data as well • Epidemic Preparednes and Response Control as various studies as: HIV and AIDS; TB; Programme Diarrhoea; Childhood Illness; Malaria; • Mental Health Programme Malnutrition; Injuries; selected non-communicable • Oral Health Programme diseases; and Reproductive Health & Pregnancy • Eye Care Programme related conditions, as shown in Figure 3. • Heath Promotion Programme including the School Health Programme Figure 3: Causes of death 2008 Addressing The Burden Of Signs, Symp & ill-defined conditions Disease: The Primary Health Nutritional Deficiencies Care Approach Malaria The main strategy that will be Meningococcal & other Meningitis used to address these diseases Diagnosis Cer. Conditions orig. Per period and conditions, scale up the HIV related/AIDS priority programmes and ensure Intestinal Infections Pulmonary TB quality institutional care will be Other viral Diseases the Primary Health Care ARI Approach (PHC). This implies a healthcare delivery system 0 200 400 600 800 1200 1400 1600 Number of Deaths based on Primary Health Care with an effective and efficient Source: National Health Profile 2008 referral system including Emergency Services, and critical health systems Gains have been made in the fight against the support. In 2008, the Government joined the rest above mentioned communicable and non- of the world in reaffirming its commitment to the communicable diseases. However, problems related PHC approach as signatory to the Ouagadougou to health transition in Zimbabwe (the shifting of Declaration on PHC and Health System in Africa: disease burden from infectious disease to chronic Achieving better health for Africa in the new illness in line with industrialized countries) have millennium. continued to increase the burden against a backdrop of limited resources (Human Resources Meeting The Millennium Development Goals for Health, material, equipment and technology). Critically, the Primary Health Care Approach will also steer the country towards attainment of the Of advantage today is the huge knowledge base of Millennium Development Goals. In 2004, ‘what works’. Experience over the last ten years has Zimbabwe officially adopted the Millennium made the health sector aware of high impact and Development Goals as the nation's 2015 low cost strategies that can be used to combat the development vision and since then Zimbabwe has diseases and conditions responsible for most illness been working towards meeting the MDG targets. and deaths in communities. It is therefore logical From a regional perspective, this document has not to re-invent the wheel but immediately also incorporated some of the elements of the implement those good practices or interventions Africa Health Strategy. that represent good value for money in terms of impact on health status. The priority diseases and conditions were selected on the basis that they together are responsible for Priority Programmes For Scale Up 70% of illnesses and deaths; most are the MDG Based on the diseases and conditions mentioned related target diseases and conditions; furthermore above, the following priority programmes will be effective cost effective evidence based interventions scaled up over the next five years: to reduce the burden of illness and deaths are already known. Operationalising the eight PHC PAGE 26 The National Health Strategy For Zimbabwe 2009 - 2013 elements and focusing on the MDG targets will PHC and MDG goals which are complementary thus address most of the disease burden in and aligned with Zimbabwe's disease burden and Zimbabwe. It therefore follows that a major thrust programme priorities, as shown in the table below: of the new national health strategy is meeting the Table 3: Relationship Between Priority Diseases, MDGs and PHC elements PRIORITY PROGRAMMES BASED ON BURDEN OF DISEASE Priority diseases Millennium Development The 8 Primary Health Programmes Goals Care Elements HIV, AIDS,TB, STI MDG N°6: Halt / reverse Education concerning the HIV, AIDS & the spread of HIV/AIDS, diagnosis, prevention and TB Programme Malaria, TB control of locally prevalent Heath Promotion health problems Programme Nutritional deficiencies, MDG N°1: Eradicate Food supply and security Nutrition Programme hunger extreme poverty and (nutrition) Diarrhoeal diseases MDG N°7: Ensure Drinking water and sanitation Environmental Health environmental sustainability Programme Maternal illneses and MDG N°5: Reduce maternal Maternal and Child Health Maternal Health conditions mortality ratio by care including family planning Programme three quarters; Family Planning Programme Child Health illness MDG N°4: Reduce under Immunization against major Child Health (Acute Respiratory five child mortality rate infectious diseases Programme Infections) by two thirds; Malaria and other MDG N°6: Halt / reverse the Prevention and control of Malaria Control epidemic prone diseases spread of HIV/AIDS, locally endemic diseases Programme Malaria, TB; Epidemic Preparednes and Response Control Programme Health Information and Surveillance Programme Non Comminicable Appropriate treatment of Provision of health diseases including common diseases and injuries care services Injuries and disabilities including Emergency Services Non Communicable Disease Programme Oral Health Programme Eye Care Programme Mental Disorders Mental Health Programme SUPPORTIVE HEALTH SYSTEMS PROGRAMMES All above mentioned Provision of essential drugs Essential Medicines diseases required Programme treatment Health information system Implementation of best National Health information National Health practices (IBM) system information system Research for health Implementation of best All elements National Health practices (IBM) research agenda NOTE: Zimbabwe incorporated three essential elements of mental health, oral health and NCDs to the original eight elements of the Alma Ata declaration of 1998 and reaffirmed by the Ouagadougou declaration 2008 on PHC and Health Systems: Achieving better health for Africa in the new millennium. From the available data (DHS 2006; census 2002, following measures need to be taken into account VAS 2003), programme evaluation and annual in the fight against communicable and non- profiles 1998 – 2006, there is clear evidence that communicable conditions. Specific objectives of programme management can be improved. targeted diseases and conditions need to be Programmes need to be based on health needs. The developed where they do not exist. Equity And Quality In Health: A People's Right PAGE 27 Key issues around disease burden 1. Health Workforce: Provision of adequate, considered in development of this National skilled and well remunerated Human Health Strategy were thus: Resources for Health 2. Medicines and Supplies: Continuous supply • Ensuring that health programmes are based of medicines and medical supplies on health needs and problems as evidenced by the National Health Profiles 3. Equipment and Infrastructure: Provision of • Identifying new cost effective approaches functional equipment (fixed and movable) and for tackling morbidity and mortality, arising infrastructure from existing and re-emerging 4. Transportation: Provision of Transport communicable and Non Communicable Diseases (NCDs) 5. Financial Resources: Ensuring a sustainable • Adequately training all health care staff for and predictable financial base various roles in health promotion, disease 6. Governance and Leadership: At all levels prevention, case management, follow up and rehabilitation However, various studies and surveys carried out in • Promoting environmental health measures Zimbabwe over the last three years point towards that will reduce the transmission of diseases the inadequacies of the six health system building • Encouraging individuals, families and blocks (human resources; medical products, communities to be more responsible for vaccines and technologies; health financing; health their own health and care information; service delivery; and leadership & • Preventing the spread of diseases through governance). Challenges and constraints include: early detection, effective case holding and adequate treatment of all cases • Inadequate funds allocated for service delivery • Strengthening and equipping both public • Poor access to health care, especially by health and clinical laboratories vulnerable groups • Ensuring availability of emergency • Dilapidated infrastructure for the delivery of medicines and commodities health services • Improving the quality of life of chronic • Frequent stock outs of essential supplies patients through a continuum of care after • Poor quality of care in both public and discharge private sectors • Improving health protection programmes • Low salaries for health staff in the public • Promoting and encouraging multi-sectoral sector and lack of incentives to work in approaches to disease prevention and remote areas control, health promotion and protection • Inadequate capacity for management and • Strengthening a functional health leadership information system that will monitor health • Inadequate capacity in human resources status and services to ensure that the development, including training and information collected is used in decision personnel management making at all levels • A weak health delivery system in terms of • Strengthening information, education and planning, budgeting and management communication strategies • Poor inter-sectoral action and partnership in service delivery SERVICE DELIVERY AND HEALTH • Poor community participation and SYSTEM STRENGTHENING involvement in health issues. • Poor availability of costing data for some Adequate resources and an appropriate enabling aspects of the plan. environment are critical prerequisites for the successful implementation of all health The current status in the Ministry indeed presents programmes and thus delivery of services. The major challenges that require to be addressed Ministry has identified six critical success factors within a resource constrained environment. This for successful scaling up of health programmes as may require that the nation does “business unusual” follows: but always keeping sight the beacon provided by the National vision described above (pg 22). As such, the health sector must strive to increase its capacity in the areas of Human Resources, Medicines, Medical Supplies and Medical PAGE 28 The National Health Strategy For Zimbabwe 2009 - 2013 Equipment, Infrastructure, Transport and Key issues around health system communication, Governance, Health Information strengthening considered in the and Financial Resources. The current status of development of this National Health each of these enabling factors is not encouraging Strategy were thus: due to the socioeconomic challenges being faced by the country (pg 33). However, improvement and • Health Workforce: Efforts will be coordinated application of the enabling required to: environment will lead towards effective prevention - Retain health workers at work by giving and management of the priority diseases and them a living income that can be health conditions eventually leading to the sustained by the current economy. reduction of morbidity and mortality in the - Increase productivity and country. Implementing vertical programmes professionalism of health workers by targeting the disease burden in isolation will not providing them with adequate tools of result in widespread health improvement, as the the trade as listed below underlying health delivery system will remain - Reduce the overall vacancy levels ailing. Furthermore, addressing only one of the through halting and reversing brain enablers will not solve the current crisis in the drain, recruiting, training and retaining health sector: all of the identified priorities need qualified health staff. The role played by to be addressed. community health workers, as evidenced by their actions during the cholera epidemic, should not be underplayed as one looks at the human resources for health. • Medicines and Supplies: Improvement of the availability of medicines, medical sundries and other hospital supplies, to a level that will enable institutions to provide at least basic services as defined for each level of care. • Equipment and infrastructure: Availability and functionality of diagnostic and treatment medical equipment in critical departments (Theatre, Laboratory, Casualty, Maternity, X-ray & renal departments) will need to be improved. Water supplies and provision of generators at health facilities shall be given high priority. • Transportation: Availability of reliable transportation and telecommunication systems to improve and strengthen the referral system will need to be improved. • Financial resources: There will be need to advocate and lobby for a sustainable and predictable financial resource base, to ensure the provision of high quality services to the population. • Governance and Leadership: There will be need to address the issues of leadership and management at all levels, disease surveillance and health information for decision making including strengthening coordination of health sector players. Equity And Quality In Health: A People's Right PAGE 29 INCLUSIVE IMPLEMENTATION AND Role Of MoH&CW Provincial Level MONITORING ARRANGEMENTS There is need to distinguish between the Provincial Implementation of the Five Year Strategy will be Medical Director's office from the Provincial the responsibility of all stakeholders under the Hospital: leadership of the Secretary for Health and Child Welfare and the Top Level Management Team. • The Provincial Medical Director's office is the local representative of the Ministry of Health Institutional Arrangements of MoHCW and Child Welfare and is therefore accountable Overall, the National Health Strategy will be to the Ministry and Government in ensuring operationalised, monitored and evaluated in the that health services in the province are delivered context of the regular Ministry of Health and in accordance with the national health Child Welfare activities. The overall responsibilities priorities. of the different levels of care in the management • The Provincial Hospital is one of the of this plan are clearly defined. operational areas. Role of MoH&CW Head Office The Provincial level has to make sure that all stake- By facilitating in the development of the National holders in a Province are fully aware of the Health Strategy, the head office has assumed one National Health Strategy and their roles in making of its key functions of setting policy and it a success. Whilst all plans must comply with the guidelines based on the information generated by National Health Strategy guidelines, the provincial the operational level. office has to ensure that “specific area peculiar concerns” receive due attention and resources are The Secretary for Health and Child Welfare shall provided. appoint a committee that will oversee the implementation and monitoring of the 5 Year Role of MoH&CW Operational Level (Central, Plan. One of the immediate tasks of this Provincial and District hospitals) committee will be to disseminate the National The success of the 5 Year Plan will to a large Health Strategy for Zimbabwe as widely as extent depend on the commitment of the possible and develop a comprehensive Monitoring operational level. It is at the operational level and Evaluation strategy so that everybody is aware where practical implementation of the 5 Year Plan of: is organised and managed. • The proposed roadmap towards revitalization Once the resource envelope is known, the of the health sector (3 year plan and targets) operational level should prepare a detailed • The roles of the different stakeholders in implementation programme with special emphasis making it a success. on the first year of the 5 Year Plan. The Secretariat of the Committee to monitor the The MoH&CW Planning System and Guidance implementation of the National Health Strategy For Implementation And Monitoring will be the Policy, Planning Monitoring and The Ministry of Health and Child Welfares' Evaluation Division (PPMED) whose main planning guidelines will continue to be used. The functions will be to monitor concrete achievements MODO or National Planning Forum will also be through annual assessment of plans, programmes used to monitor implementation progress. and projects and to give inputs to the Top Management Team and other senior managers The National Planning Forum shall continue to through quarterly reports, minutes of meeting, meet twice per year. The Mid Year National feedback, follow ups and other relevant documents. Planning Forum shall focus on performance review More specifically, the role of PPMED in the of the first six months of the year and decide on context of the 5 Year Plan is to:- what activities to roll out until the end of the year. At this forum, the bottlenecks in the • Devise and design clear mechanisms for implementation process will be identified and ways accountability and ensure they are adhered to in which they can be dealt with suggested. The • Co-ordinate the planning, monitoring and product of the Mid Year MODO shall be an evaluation process of all health activities agreement of the priorities for the next 6 months proposed in this strategy of the year. • Co-coordinate capacity building in planning, monitoring and evaluation. The second National Planning Forum for the year • Develop and apply monitoring instruments and (to be held in November) shall focus on what ensure timely submission of reports GOZ has allocated to the health sector and what PAGE 30 The National Health Strategy For Zimbabwe 2009 - 2013 our development partners pledge and will give to communicating and contributing to the nationally the health sector so that the Ministry can decide identified priorities outlined in the strategy. Of list of activities for implementation in the necessity, different elements of this strategy will coming year. The product of the November require prioritization by Government and National Planning Forum shall be a contract Ministry depending on resources available. between Ministry of Health and Child Welfare Critically therefore, stakeholders should also use and the operational levels as to how the allocated this plan to work with Ministry to identify gaps funds will be used in addressing the annual and thus focus support on addressing unfulfilled plans. implementation areas of the strategy. It is now a requirement, in line with Results Key issues around inclusive Based Management, that a contract be signed implementation arrangements between the operational level and the province or considered in the development of this head office in the case of central hospitals. The National Health Strategy were thus: contract will specify what activities will be carried out, when, where, how and at what cost. Included • The need to inform and mobilize all in the contract will also be monitoring and review stakeholders in the health sector processes. Indicators for monitoring will also be around the National Health Strategy included in the contract. • The need to foster, encourage and facilitate meaningful community Role of Communities participation in the health sector One of the key elements of the Primary Health • The need to strengthen mechansisms Care approach is community participation. In the for partnership, collaboration and past, community participation has been funding of health sector activities to interpreted as the provision of free labour by implement the wide National Health communities for the construction of physical Strategy facilities such as clinics and water points. However, during the next five years, communities, OVERALL STRUCTURE OF STRATEGY through health centre committees or community health councils, will be actively involved in the Based on the situational analysis above, the identification of health needs, setting priorities strategy is divided into four thematic areas. It is and mobilizing and managing local resources for anticipated that successful, coordinated health. implementation within these four areas will lead the nation towards the national vision for health. Role Of Other Stakeholders • Determinants of Health: addressing the The importance of inclusive participation by all factors outside the health sector which have an stakeholders for successful implementation of impact on health this strategy cannot be over-emphasised. • Diseases affecting Zimbabweans: addressing Stakeholders may include, but are not limited to: the burden of specific diseases and conditions • Community (see above) affecting Zimbabwean's • Health Services Board • Health System Strengthening: supporting the • Urban Local Authorities overall health system context in which services • Mission Hospitals must be planned, delivered and monitored • Civil Society (local and international Non- • Inclusive Implementation: acknowledging and Governmental Organizations) enabling the actions of a wide range of • Business sector stakeholders towards realising the health of the • Private medical services nation. • Training Institutions The strategy develops trends, current status and • Bilateral and multilateral donors key issues then articulates goals, objectives and • United Nations Family implementation strategies within each of the four • Regulatory bodies thematic areas. A total of thirty three goal areas • Other Government Sectors have been identified under these four thematic Stakeholder representatives will be included in the areas, reflecting the comprehensive nature of an Implementation Monitoring Committee approach required for full health sector revival. A described above. All stakeholders will also be deliberate effort has also been made to make each responsible for familiarizing themselves with the chapter as comprehensive as possible and as a National Health Strategy and ensuring their result some recurring themes will be noted in plans, activities and results are aligned, most sections as “Key issues to be addressed”. Equity And Quality In Health: A People's Right PAGE 31 Part 1: Determinants Of Health PAGE 32 The National Health Strategy For Zimbabwe 2009 - 2013

1.1 — SOCIO-ECONOMIC DYNAMICS aggravated poverty (a known negative determinant

1.1 SOCIO-ECONOMIC DYNAMICS aggravated poverty (a known negative determinant of health) within the population. Trends and current status Good health and quality of life are influenced by This is significant as the poor tend to have more several factors, including but not limited to food health problems and poorer access to care. availability, security, housing, safe water and According to the 2003 Poverty Assessment Study sanitation, hygiene and employment. Most of these Survey (PASS), poverty in Zimbabwe increased variables are outside the normally understood considerably between 1995 and 2003. The study boundaries of the health sector. However, it is the found that the proportion of households below responsibility of the health sector to identify and the Food Poverty Line (very poor) increased from inform both the general public and our policy 20 percent in 1995 to 48 percent in 2003, makers of the factors that affect health and quality representing an increase of 148 percent. The of life: the social determinants of health. It is proportion of households below the Total therefore crucial that such factors are considered Consumption Poverty Line (very poor and poor), and included in the planning and implementation increased from 42 percent in 1995 to 63 percent of government-wide strategies to promote and in 2003. improve the health and quality of life of the population. The PASS also found that proportionally, urban area households were increasingly becoming Poverty poorer, due to the deteriorating macroeconomic Zimbabwe has been experiencing an economic environment. Although there has been a higher downturn over the last ten years, escalating over the increase in poverty incidence in urban areas, rural recent past due to recurring droughts, floods, households have remained worse off. absence of balance of payment support, withdrawal of lines of credit and disinvestment by During the period 2000 to 2008, the country's foreign firms, foreign currency shortages for the manufacturing, mining, tourism, and commercial importation of raw materials, equipment, fuel and farming sectors were not generating sufficient electricity, and the devastating impact of the HIV employment and were operating below capacity. At and AIDS epidemic. Some of the challenges on the the same time, real wages from formal employment macroeconomic front included hyperinflation and continued to decline. This decline in formal sector low foreign exchange reserves. real wages, combined with sluggish employment growth, translated into a decline in average house- The decline in the economy impacted negatively hold incomes in real terms and an increase in the on the well being of the population both directly percentage of households living below the poverty and indirectly. Directly, the economic downturn line, and therefore exposed to more health meant less revenue generation therefore decreased problems. funding for most Government programmes. Recently, real decreases in public health Food Insecurity expenditures and other resources have contributed Coupled with the recurrent droughts, which towards a drastic decline in the quality of public occurred in 1990/91, 1994/95 and 2000-2002, health services, from which the heath system is yet the decline in economic performance led to food to recover. insecurity in the population. This, in turn, led to high levels of malnutrition. The Zimbabwe Indirectly, one of the major hindrances to Demographic and Health Survey showed that the increasing the achievement of better health is the underweight prevalence for under-fives increased increasing level of poverty. From a public health from 13 percent in 1999 to 16.6 percent in point of view, poverty becomes an impediment 2005/6; and the prevalence of stunting, the when individuals or groups become unable to enjoy chronic form of under nutrition, rose from 26.5 in the minimum standard of living. Closely linked to 1999 to 29.4 in 2005/6. poverty is unemployment, whose consequences lead to increased vulnerability in the absence of Education properly targeted safety nets. Both unemployment Education is a basic human right which enables a and poverty are strongly linked to economic population to make informed decisions about its development. The economic contraction economic, social and political well-being. It is one culminated in unemployment and inflation rates of of the areas where Zimbabwe has made great over 80% and 231 million percent respectively by achievements, with a literacy rate of well over 2008. The high inflation rate grossly eroded the 95%. The more literate people become, the more purchasing power of the Zimbabwe dollar, and they understand health and their responsibilities in coupled with the high unemployment rate, securing their health and that of others. Equity And Quality In Health: A People's Right PAGE 33 Gender Issues and Violence Against Women The problems of street children, commercial sex The government of Zimbabwe has made work and vagrancy are on the increase as the social remarkable strides in addressing gender inequalities safety net fails to protect a large number of those through legislation and a focus on addressing affected by economic insecurity. adverse socio-cultural norms. In the Health Sector, data capture has for a long time been disaggregated Zimbabwe goes down in history as one of those by sex and age, making it possible to understand countries with clear evidence of a linkage between gender barriers in access to healthcare and develop the health status of a nation and its social, physical gender specific programmes. In 2001 the Ministry and economic environment. The major challenges, developed a strategy for integrating gender linked to economic performance and directly perspectives into the health sector. affecting the health service delivery system can be summarized as follows: Violence against women in the form of domestic violence, sexual coercion and rape, remains Key Issues common in the lives of many women in • Economic decline leading to hyperinflation and Zimbabwe. A number of initiatives to curtail resulting in unaffordable commodities, violence against women have been started by unemployment and rising levels of poverty women's groups and NGOs, providing local safety amongst the general population; nets and counseling services. In addition to these • Increasing negative social health determinants efforts, the health care system should continue to and risk factors for poor health and poverty; create more focus on issues of violence against • Drastic reduction in the purchasing power of women having not adequately focused on these the health budget, resulting in insufficient issues to date, though Ministry of Health and resources to procure essential drugs, including Child Welfare has started working in this area antiretroviral therapy, for people in urgent through training of health workers in the need, as well as basic health services equipment, management of Sexual and gender Based Violence medical and non medical supplies; (SGBV). The Ministry has also reviewed the • The income of health workers does not meet gender and health training manual and Training of their basic needs, resulting in very high Trainers for gender mainstreaming has been done. attrition rates ranging from 20% to 80%. Other initiatives in this area include rape victim • Inadequate foreign currency for health sector friendly clinics. requirements Sexual Abuse and Vulnerable Children The economic challenges the country is An increasingly reported cause of child morbidity, experiencing are adversely affecting the health and though not captured in the official statistics, is quality of life of all Zimbabweans. The health child abuse. The National Programme of Action sector should therefore strive to identify and (NPA) Unit of the MOHCW stated that 2 000 inform both the general public and policy makers children of all age groups and sexes were reported of the socioeconomic risk factors that affect health as being sexually abused in 2005. The perpetrators and quality of life. were reported to be mostly close relatives and neighbours of the abused children. Child sexual abuse carries with it the increased risk of HIV transmission. This increasing phenomenon also indicates the breakdown of child care practices which needs to be attended to in any comprehensive health strategy. PAGE 34 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 1:To increase national awareness on the impact of socio-economic factors (resource allocation, income, poverty, adult literacy, housing, food availability and working conditions) on the health and quality of life of the population. Objectives Strategies To advocate for • Develop and publish a simple-to-understand document spelling out improvement in socio- the adverse effects on health of socioeconomic determinants of and economic status and living risk factors for health. conditions of the • Advocate for increased allocation of resources to activities that will population reduce the adverse effects of socioeconomic determinants on the vulnerable population groups (e.g. social protection safety nets). • Advocate for the incorporation of education on the impact of socio- economic factors at an early stage in schools. • Monitor the impact of changing socio-economic conditions on health. • Institutionalize health equity analysis into the health sector. • Increase awareness among policy makers and other stakeholders on issues of equity in health and healthcare. To strengthen inter-sectoral • Advocate for the inter-sectoral development and strengthening of coordination and regulations and policies tackling the socio-economic inequalities that collaboration with relevant adversely affect women, children (see pg 81) and those in rural areas sectors and other and high-density areas. organizations, towards • Identify and clearly spell out the impact on health and quality of life improving health and quality of policies, plans and activities of outside the health sector and of life of the population advocate for their action to improve health. To increase awareness on • Advocate for the clear definition of the roles and responsibilities of and advocate for action by the various players in reducing the adverse health effects of the relevant ministries and other socioeconomic social determinants on health and advocate for their stakeholders on the major appropriate action. determinants of health such • Advocate for the strengthening of policies that aim to reduce poverty as water, sanitation, food, levels in the country and provide social security services for the poor. hygiene, education and • Promote community participation and involvement in activities that gender amongst others will reduce the adverse effects of major socioeconomic determinants.

1.2 — HEALTH AND THE ENVIRONMENT A review of the legal framework is needed in order

1.2 HEALTH AND THE ENVIRONMENT A review of the legal framework is needed in order to empower law enforcement agencies and local Trends and current status authorities to harness their efforts and support Healthy environments and living conditions are growth of informal sector trading (building essential requirements for a healthy people. The standards etc), in order to safeguard hygiene and current economic decline is now affecting essential healthy living conditions. infrastructure such as housing, transport, water and waste disposal, causing outbreaks of diseases and The provision of safe water and sanitation is other health problems. This economic challenge critical to improving the living standards of the has led to the expansion of informal sector population. It also contributes significantly to the manufacturing industries as a survival strategy for reduction in morbidity and mortality from most in the population. Food production in diarrhoeal diseases. Zimbabwe invested and made unregistered premises and consumption of unsafe great progress in water and sanitation programmes, foods including meat, meat products and milk, are post independence. According to the Labour Force on the increase. This makes it difficult for the few Survey the proportion of rural households with environmental health practitioners to inspect and access to safe water declined from 75.1 in 1999 to assess these food processing sites, including 66.5 in 2004. The 2008 ICDHS reports that 75 'backyard abattoirs'. percent of households had access to safe water. With the recurrent problems in provision of water and sanitation in urban areas, it has been shown that some of the piped water is not safe. Equity And Quality In Health: A People's Right PAGE 35 Figure 4: Households with access to safe water in rural areas Figure 7.1: Households with Acess to Safe Water, Rural Areas, Zimbabwe 1992-2003 and 2015 MDG Target 2015 MDG Target - 88% 100 90 80 73 75 70 65 63 60 50 Income 40 30 20 10 Year 0 1992 1997 1999 Rate of progress required to achieve MDG Traget Actual Only 42 percent of rural households had access to settlements have recently been established in areas safe sanitation in the form of Ventilation Improved without adequate sanitary and safe water provision. Latrines. 43 percent of households in rural areas According to the 2008 ICDHS 31 percent of did not have any sanitation at all. This percentage households had no toilet facility at all. might now be higher, considering the fact that new Figure 5: Households with access to safe sanitation, rural areas Figure 7.1: Households with Acess to Safe Sanitation, Rural Areas, Zimbabwe 1992-2003 and 2015 MDG Target 2015 MDG Target - 79% 100 90 80 58 56 70 48 42 60 50 Income 40 30 20 10 Year 0 1992 1997 1999 2003 2015 Rate of progress required to achieve MDG Traget Actual Furthermore, in 2000, Cyclone Eline damaged The rapid growth of urban populations calls for many water points and sanitation facilities in some an urgent need to expand or revamp the water and parts of the country, and most have still not been sanitation systems. repaired. According to the 2008 Malaria Indicator survey, most households in rural areas used The frequent power outages have led to water cuts, borehole water (40.9%), or unprotected water thus forcing urban dwellers to resort to alternative sources (22.5%). The bush was the commonest and less safe sources of water. Compounded by the form of sanitation, followed by the Ventilation deteriorating capacity to treat domestic and Improved Latrines (VIPs) (36.0%). Poor industrial effluent effectively, this has resulted in sanitation, hygiene and inadequate safe water increased pollution of rivers and lakes, increasing supplies in rural and peri-urban areas thus remain a the cost of purifying the water for domestic use. matter of great concern, needing priority attention Entrepreneurs have taken advantage of these especially in light of the recurrent cholera shortcomings as evidenced by the proliferation of outbreaks. bottled drinking water and repackaged scarce food A situation where urban coverage was nearly 100% products, some of which have failed to meet for safe water supply and sanitation services is national food and hygiene standards. This, rapidly changing for the worse. There is need to naturally, calls for continuous monitoring and replace and maintain old water and sanitation surveillance by the Government Analyst systems in the cities, towns and peri-urban areas. Laboratory and Environmental Health PAGE 36 The National Health Strategy For Zimbabwe 2009 - 2013 Department of both bottled water and every stage supply and sanitation, contribute significantly to in the 'farm to fork' food continuum (farming, reducing illness and deaths from diarrhoeal manufacturing, processing, packing, labeling, diseases. distribution, retailing and catering). This is not The World Health Organization describes always possible, due to limited availability of staff, environmental health as comprising of those transport and fuel. aspects of human health, disease, and injury that A study on waste management commissioned by are determined or influenced by factors in the the Ministry of Health and Child Welfare in 2007 environment. It is a well known fact that exposing noted that most sewerage reticulation systems and human beings to environmental factors that are treatment works were in a state of disrepair. This hazardous to health is one of the major situation is conducive to the transmission of contributors to the increase in the disease burden. diarrhoeal diseases including cholera. Diarrhoeal Half of the top ten leading causes of illness and disease outbreaks have occurred in a number of deaths in Zimbabwe can be directly or indirectly urban settings. Such situations are a threat to linked to the environment. public health and need rectification as a matter of urgency, especially given the recurrent cholera The current environment in Zimbabwe outbreaks. (characterized by poor and inadequate water supplies, breakdown in the sewer systems, The safe and efficient collection, removal or inadequate sanitation in both urban and rural, disposal of industrial, domestic and medical waste, poor waste management practices, inadequately is one of the most important responsibilities of supervised food preparation processes and local authorities. The same study noted that local inadequate control of vector borne diseases authorities were failing to provide efficient waste coupled with increased urban unplanned management systems, which has resulted in the overcrowded settlements and poor enforcement of non-collection and accumulation of refuse in the laws and regulations that protect health) has Central Business Districts, residential areas, increased the exposure of the nation to hazardous markets, industrial areas and other public places. factors in water, air, food and in some cases soil. These situations have resulted in fly breeding, The picture presented by the top ten outpatient generation of offensive odours and breeding of conditions that include diarrhoeal, eye, skin vectors and vermin including rodents, which are diseases, asthma and tuberculosis is a reflection of known to be responsible for the transmission of increased exposure to hazardous agents within the plague and diarrhoeal diseases. environment. Intersectoral coordination and collaboration will be necessary to address these Lack of decent habitats remains a major concern. major contributors to illness, disability, and death According to 2003 PASS, at national level, a in the country. There is also need to adapt, adopt comparison with the 1995 data revealed that for and implement the provisions of the Libreville all poverty categories, the percentage of Declaration on Health and Environment which households who owned dwelling units had Zimbabwe signed in 2008 and other local, regional increased from 55 percent in 1995 to 69 percent and international initiatives on climatic change. in 2003. In rural areas, the percentage of Key Issues households who owned dwelling units had • Shortage of financial resources to provide safe increased from 67 to 82 percent. water and sanitation, especially water treatment chemicals. In the urban areas, there is however the problem of • Inadequate access to safe water and sanitation, overcrowding. According to the PASS study, in both urban and rural areas. nationally, the average occupation per room was • Mushrooming of unplanned settlements in both 1.89 persons, which is nearly double the the urban and peri-urban areas. recommended average of one person per room. It • Inadequate decent housing especially in urban was however observed that this was a slight areas. improvement from 1995, where the average was • Air and water pollution. 2.1. • Shortage of skilled human resources for health Environmental health services and others in the especially public health practitioners. health promotion and preventive services outside • Weak enforcement of public health regulations. the health sector, such as schools, have played a • Promotion of hygienic practices. major role in increasing health literacy through • Inadequate capacity in waste management. health promotion. Efforts in this area need to be • Natural disasters (droughts and floods). further strengthened, as it is now well-documented • Increased burden of environment related that hand hygiene, together with improved water diseases. Equity And Quality In Health: A People's Right PAGE 37 Goal 2: To contribute towards the creation of a safe and healthy environment through strengthening Environmental Health Services and in particular, promotion of safe water, appropriate and adequate sanitation and promotion of food and personal hygiene. Objectives Strategies To increase access to safe • Strengthen water and sanitation programmes. water and sanitation • Promote simple home treatment of drinking water. To increase national • Advocate for the institutionalization of environmental impact awareness and understanding assessment in national development projects. on the impact of • Intensify awareness and sensitization of communities to reduce environmental factors and environmental pollution. living conditions • Develop and publish a simple to understand document on the impact (settlement, factories, of human activity on the physical environment. agriculture industry, mining, • Strengthen the lobbying and advocacy skills of the health sector in sewage, waste disposal, toxic promoting environmental health. waste deposal, radiation • Strengthen and promote integrated planning, implementation and hazards) on the health and monitoring on environmental health issues. quality of life of the • Strengthen inter-sectoral collaboration and coordination in the area of population environmental health. To promote rural and urban • Advocate for clear definition of the roles and responsibilities of the development and housing various players in reducing the adverse health effects of environmental within an environment where factors and poor living conditions. pollution from various types • Increase compliance with standards in the construction of housing and of waste (solid, liquid, other public facilities that is compatible with healthy living. chemical, radiation and • Intensify health education on the importance of proper safe disposal noise) is reduced to an of solid and liquid wastes, and measures that can be taken at acceptable minimum community and family levels to encourage this. • Strengthen waste management systems (improving safe and efficient collection, removal or disposal of waste including clinical waste). • Identify, support, and strengthen programmes aimed at improving the living conditions of people in rural, urban and commercial farms. • Resuscitate and promote the concept of healthy villages and healthy towns. To reduce air, water and • Review and amend existing public health requirements and regulations terrestrial pollution by to provide the legal backup to enforce control measures. strengthening mechanisms • Institutionalize the International Health Regulations. including regulation that will • Adapt, adopt and implement the provisions of the Libreville control and minimize Declaration on Health and Environment. contamination of the • Review and strengthen the roles of regulating institutions. environment • Enforce the provisions in the Public Health Act and regulations. • Develop appropriate programmes to monitor environmental pollution. To strengthen public health • Strengthen the administration of the Food and Water Safety and measures that ensure food Quality Regulations to ensure availability of safe food and water to the for sale to the public meets public. standards and is sold and • Strengthen inspection food manufacturing, processing and storage prepared in a manner and in premises. premises that comply with • Strengthen food sampling and analysis. public health regulations • Strengthen the capacity of both Government analyst and Public Health Laboratory. • Increase education activities to the public on food safety including correct food handling and storage. To increase awareness on • Strengthen Participatory Health and Hygiene activities. clean and hygienic living • Promote clean and hygienic conditions at home, public health facilities conditions and work places. • Promote community participation and involvement in activities to create a healthy environment. PAGE 38 The National Health Strategy For Zimbabwe 2009 - 2013

1.3 — HEALTH PROMOTION The 2009 Assessment Survey of Primary Health

1.3 HEALTH PROMOTION The 2009 Assessment Survey of Primary Health Care in Zimbabwe (“Health where it matters Trends and current status most”) reaffirms that information is fundamental Education concerning prevailing health problems in disease prevention and control. The assessment and methods of preventing and controlling them is found that people have a reasonable knowledge of one of the pillars of the Primary Health Care common health conditions, but lack the specific approach. knowledge needed to act in an informed way to promote and protect their health, (such as how to The government has shown commitment to make and use Sugar Salt Solution (SSS) to manage increasing health literacy levels through supporting dehydration). The Assessment reaffirms the need health promotion activities over the years. The for communities to have consistent, regular, Health Promotion unit originally organized and specific information flows and recommends that directed from central and provincial levels has been ad hoc and one-off information to communities further decentralized to the district level though needs to be integrated into a more comprehensive the establishment of district health promotion health literacy programme, as is currently being officers. Realizing that health promotion officers implemented in the districts supported by the cannot do everything on their own, the unit has Community Working Group on Health (CWGH). maintained the objective of developing Support for the functioning of Village Health communication capabilities in all health workers to Workers (VHWs) and other community based enable them to disseminate health education in the health workers, person-to-person health most appropriate and acceptable manner in the information and mass media also provide a means community. They have championed the to improved health information flows. The development of support materials across the assessment notes that high levels of radio various health programmes which are used by ownership mean radios are currently an under- health staff in health education. utilised resource for health, also given gaps in transmission coverage and perceived poor quality Areas of documented health promotion success programming. Addressing this and also promoting include HIV and AIDS, condom use, Expanded health information flow through community Programme on Immunisation (EPI), breast newspapers, community radio and schools would feeding, control of diarrhoeal diseases using Sugar- significantly enhance people's role in health if Salt-Solution (SSS), institutional deliveries and appropriately designed and disseminated. utilization of health facilities and family planning. Technologies such as cell-phones are found to be widely available and SMS messages through cell- The reduction in the HIV prevalence in Zimbabwe phones can send specific targeted messages on has been partially attributed to heavy investment in health actions. This was widely used to good effect information, education and communication by during the 2008/9 cholera epidemic. government, NGOs and the private sector. An epidemiological review commissioned by the Information, education and communication have MOHCW , Zimbabwe and published in also been successfully used in Family Planning November 2005 gathered data from several studies services. Knowledge of family planning methods is that supported that the decline in HIV prevalence almost universal in Zimbabwe, meaning that men had started in the late 1990's. This decline was and women in the country have information about further supported by data from the Zimbabwe the options available for regulating births and Demographic and Health Survey of 2005/06 that planning their families. The 2005/6 ZDHS notes showed HIV prevalence was 18.1% in the general that the level of knowledge of at least one modern population (15-49 years). The 2009 ANC HIV method of family planning among all women age Estimates Technical Working Group Zimbabwe 15-49 years is also almost universal at 98 percent, reports a further decrease to 13.71% in the same and for currently married women it is 99 percent. age group. The main conclusions of the epidemiological review were that a decrease in The above examples are overwhelming evidence incidence (occurring mainly due to a change in that health promotion can lead to changes in sexual behavior, specifically a decrease in number population risk factors and prevalence of both of sexual partners and reported condom use) and communicable and non-communicable mortality have combined to contribute to a diseases/conditions. However, more emphasis has decline in HIV prevalence. This is evidence that traditionally been placed on information, the high HIV literacy rate is being translated into education and communication around epidemic action by individuals. prone diseases. Since the risk factors for both communicable and non-communicable diseases are Equity And Quality In Health: A People's Right PAGE 39 known, investing in health promotion can also be Participatory Health and Hygiene activities will go expected to substantially reduce hypertension, a long way in reducing diarrhoeal diseases. cardiovascular disease, diabetes mellitus, dental Workplace health promotion activities are on the caries, liver cirrhosis and accidents (see Non increase but mainly limited to STI, HIV and Communicable Diseases pg 66). Health promotion AIDS activities. can thus play a significant role in reducing morbidity and mortality due to communicable and Key issues non-communicable diseases. It is therefore • Strengthening Participatory Health and imperative that the fight against the underlying Hygiene Education causes of these diseases be given priority for • Obsolete equipment for the development and action. production of IEC materials. • Lack of mobile units equipped with public There are number of missed opportunities for address systems health promotion. The school health programme is • Lack of support to VHW and other a known effective strategy for increasing health community based health workers. literacy. The Child to Child Programme has not • Missed opportunities in utilization of mass gained ground in Zimbabwe. Strengthening media especially radio. Goal 3: To promote positive behavioural change through health promotion Objectives Strategies To promote positive health • Develop a National Policy and Strategy on Health Promotion. behaviours (lifestyles) in • Finalize the development of the School Health Promotion Policy. 80% of targeted health • Develop communication strategy. promotion audiences by • Strengthen the management and coordination of health promotion 2010 activities. • Strengthen health promotion interventions for epidemics and seasonal conditions. • Promote planned health promotion activities at schools, workplaces and health training schools. • Train service providers in interpersonal communication for the improvement of patient care. • Conduct relevant KAPB studies to generate evidence for targeted health promotion interventions. • Strengthen production capacity for multimedia campaign materials. • Mobilize communities for greater involvement and participation in activities that promote good health. • Coordinate health promotion activities of all sectors including the private sector. • Strengthen Participatory Health and Hygiene Education. PAGE 40 The National Health Strategy For Zimbabwe 2009 - 2013 Part 2: Specific Diseases Affecting Zimbabweans Equity And Quality In Health: A People's Right PAGE 41

2.1 — MATERNAL AND CHILD HEALTH which sheds some light on a country's health

2.1 In Zimbabwe, the female population and children under 15 years constitute about 70% of the total population. This sector of the population is highly vulnerable to malnutrition, infectious diseases including HIV, reproductive health challenges etc. To address the challenges faced by women and children, the Ministry of Health and Child Welfare, as early as 1983, formulated a comprehensive Maternal and Child Health care programme. The objective of the programme was to provide comprehensive and effective health care to the mothers and children on a continuing basis throughout the entire pregnancy, growth and development. The integrated and comprehensive Maternal and Child Health package was and is still defined to include:- • Care and supervision during pregnancy • Supervision and care of home and institutional deliveries. • Provision of postnatal care. • Child growth and development monitoring. • Surveillance of nutrition status of mothers and young children. • Specific education on care of the nutritionally at risk children 1- 4 years. • Immunization against the six killer diseases. • Provision of Child Spacing and Family Planning advice and services. • Provision of Health Education directed to mothers and school going children. • Provision of referral mechanism by which complicated or serious cases can have access to higher levels of health care specialist • Collection and compilation of basic MCH service statistics for programme monitoring. A number of complementing elements make up the comprehensive health package including the Nutrition programme, Health Education programme, Control of Diarrhoeal Diseases programme, School Health Services, Expanded Programme on Immunization, Community Nursing and Child Spacing and Family Planning services. It is this comprehensive package of Maternal and Child Health care that has seen the health and quality of life of women and children improve over the last 20 years. MATERNAL AND CHILD HEALTH which sheds some light on a country's health status, quality and access to health care delivery services, especially for women. It is influenced by general socio-economic conditions, nutrition, access and coverage of maternal health care services. The 2007 Zimbabwe Maternal and Perinatal Mortality Study (ZMPMS) has for the first time established that mortality levels are at an unacceptably high level of 725 deaths per 100,000 births. Over the last 20 years, there have been six estimates of the national maternal mortality ratio in Zimbabwe. Because these estimates have been analyzed using different methodologies, it has been difficult to give trends on the basis of surveys (although all estimates are unacceptably high). Attempts have been made to track maternal deaths using the ZDHS as shown below: Figure 6: Maternal Mortality Ratio Fig 6: Maternal Mortality Ratio 600 578 500 555 400 MMR 300 283 200 100 1994 1999 2005/2006 ZDHS Based on the Zimbabwe Demography and Health Survey, maternal mortality has been rising from 283 per 100,000 live births in 1994 reaching a peak of 578 per 100,000 live births in 1999. services. However, according to ZMPMS (MOHCW 2007) the maternal mortality rate is now reported to be 725/100 000. The methodologies used to obtain the data are different, thereby making trend analysis difficult. As this situation does not yet give us a trend, it is proposed to repeat the 2007 ZMPMS study after five years as this method is more focused and more reliable. Maternal mortality therefore remains a cause for concern as most maternal deaths are preventable through increased access to antenatal, delivery and post natal care. Furthermore, effective interventions to treat the leading causes of maternal deaths, namely HIV & AIDS,

2.1.1 — MATERNAL HEALTH haemorrhage, hypertension/eclampsia, sepsis,

2.1.1 MATERNAL HEALTH haemorrhage, hypertension/eclampsia, sepsis, malaria and obstructed labour, already exist. The Trends and current status 2007 Zimbabwe Maternal and Perinatal Maternal The maternal mortality ratio (maternal deaths per study further notes that successful prevention and 100 000 live births), is one of the indicators treatment of haemorrhage, PAGE 42 The National Health Strategy For Zimbabwe 2009 - 2013 hypertension/eclampsia and sepsis, the three delays in receiving care. User fees have become a leading direct causes of obstetric deaths, have a significant factor in decreasing use of health potential of reducing maternal deaths by 46%. services by women at risk. The third delay, which looks at receipt of appropriate and effective Whilst HIV and AIDS is a major contributor to treatment once the referral challenge was overcome, maternal deaths, the 2007 ZMPMS noted that contributed to 11% of all maternal deaths only 34% of pregnant mothers had been tested for (ZMPMS 2007). The study noted that the third HIV; furthermore only 1.8% were taking ARVs. delay was caused almost entirely by health system More recently, the 2009 Multiple Indicator deficiencies, the most important being shortage of Monitoring Survey (MIMS) reported that 58% of personnel, lack of skills and inadequate drugs and women aged 15-49 year had been tested for HIV. supplies. Regardless, maternal mortality will remain high, vertical transmission will not be brought down, The Government has made efforts to create an and childhood mortality from HIV will continue enabling policy environment for the to increase unless more women are tested and implementation of various maternal, neonatal and appropriate action taken before, during and after child health programmes. Reproductive Health pregnancy. Policy and Guidelines have been developed. In 2004, the MOHCW carried out a comprehensive Appropriate care during prenatal, pregnancy, Maternal Neonatal Health (MNH) Assessment delivery and postnatal care are important for the whose findings formed the basis for the MNH health of both the mother and the baby. Whilst Road Map (2007-2015). For the successful the 2005/6 ZDHS reported an increase in women implementation of the MNH Road Map, it is attending at least one antenatal care visit from necessary to adopt a multi-sectoral approach, 81% in 1999 to 94% in 2006, the 2007 ZMPMS which includes males as essential partners of the shows a decrease in ANC attendance to 91% MNH programme, mainstreaming gender, (93%, MIMS 2009). Coverage of antenatal care is fostering community involvement and slightly higher in urban areas than in rural areas. participation, and promoting behavioural change. Skilled attendance at delivery declined from 73% in 1999 to 69% in 2006 and has further declined The MOHCW has led several initiatives to to 67% (60% MIMS 2009). Institutional mitigate the human resource issues facing the deliveries declined from 72% to 68% over the health sector. Confronted with the worsening same period (ZDHS 1999, 2005/6) and have “brain drain” of general nurses and midwives, the remained constant at 68.7% (61%, MIMS 2009), Ministry introduced a new generic cadre, the according to in the 2007 Zimbabwe Maternal and Primary Care Nurse. These nurses are trained Perinatal Mortality study. specifically to function at primary health care level. In order to increase the number of nurses who go Both the 2004 Maternal and Neonatal Health for midwifery training, qualified midwives receive a Services Assessment and the 2007 Zimbabwe substantial allowance for their services. These Maternal and Perinatal Maternal Study used the initiatives are being complemented by a strategy “three delay model” (described below) to highlight designed to retain medical doctors at district level. the challenges women face with reproductive health issues. In the 2007 Zimbabwe Maternal and Family Planning Perinatal Maternal Study, the three delays Perhaps the most important intervention to reduce altogether contributed to 72.8% of all maternal maternal and neonatal morbidity and mortality is deaths. to develop and sustain a strong national Family Planning programme, designed to prevent The first delay, identified as the time lost in unwanted pregnancies and to encourage child recognizing the seriousness of the situation and spacing. The Contraceptive Prevalence Rate deciding whether or not to seek medical attention, (CPR), or the percentage of currently married was found to be contributing to 56.4% of all women using a family planning method in maternal deaths (ZMPMS 2007). The second Zimbabwe, has increased steadily from 48% in delay, covering the time needed for reaching a 1994 to 60% in 2006. According to the MIMS health facility or a trained service provider, once a 2009 report, the CPR has further increased to decision was taken to seek care, was found to be 65% (63% of all women were using the modern responsible for 5.3% of all maternal deaths method of contraception whilst 2% were using the (ZMPMS 2007). The study also confirmed that traditional method). The family planning method lack of communication facilities, lack of transport most commonly used was the pill (43% of all and financial constraints were contributing to women). The CPR was higher in urban areas Equity And Quality In Health: A People's Right PAGE 43 (69%) compared to rural areas (63%). This is now Key issues one of the highest rates in Sub-Saharan Africa. • Addressing the three delays in seeking medical The Total Fertility Rate has declined from 4.0 in care, receiving care, referral to the next level of 1999 to 3.8 in 2006 (ZDHS, 2005-6). care, shortages of transport and equipment for emergency obstetric care. Figure 7: • Mobilizing resources for the provision of Essential and Emergency obstetric care services Fig 11: Contraceptive prevalence rate among • Increasing skilled human resources for health married women 15 - 49 years 70% and retain them in the current socio-economic environment. 60% 60% • Increasing physical and financial access to 54% CPR 50% 48% health services (transport, communication, waiting mothers shelters, removing fees) 40% • Reversing the HIV and AIDS epidemic and mitigating its impact on maternal health 30% through HIV testing with the provision of 1994 1999 2005/2006 antiretroviral drugs and other measures. • Maternal malnutrition However, the estimated unmet need for • Negative cultural and traditional practices that contraception has remained static at 13% for the influence health seeking behaviour. period 1999 to 2006 as shown below. • Access to family planning services • Gender and male involvement. Figure 8: • Poor collection of maternal mortality data. Fig 12: Unmet need for Family Planning Services 25% 20% CPR 15% 15% 13% 13% 10% 5% 1994 1999 2005/2006 PAGE 44 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 4: To reduce the Maternal Mortality Ratio from 725 to 300 deaths per 100,000 live births by 2013 Objectives Strategies To increase the availability • Capacity building of health service providers on Sexual and utilization of youth Reproductive Health, Family Planning and comprehensive HIV friendly Family Planning Prevention Services. and HIV prevention • Strengthen gender sensitive youth friendly Sexual Reproductive services Health services provision through training of service providers and production of BCC material on Adolescent Sexual Reproductive Health. • Expanding Community Based Distribution systems. • Integrating STI/HIV/AIDS, and FP programs and services. • Community mobilization to increase demand and use of Sexual Reproductive Health and family planning services. To increase the availability • Capacity development on focused ANC including male and utilization of quality involvement and comprehensive PMTCT (including ART for focused antenatal care treatment eligible pregnant women). including PMTCT services • Promotion of male/female condom use. • Dissemination and facilitating use of updated guidelines and clinical protocols. • Operations research as a monitoring and evaluation tool. • Expansion of the mother/baby friendly hospitals initiative. • Community mobilization to increase demand and use of PMTCT. To improve access to • Community mobilization to increase demand and use of maternal skilled attendance at and neonatal health services. delivery; including EmONC • Strengthening transport and communication systems for effective referrals. To improve access to • Capacity development of facility and community based health quality PNC including service providers in EmONC. PMTCT services • Strengthening the waiting mothers’ shelters. • Capacity development on comprehensive post-natal care including PMTCT. • Promotion of dual protection. • Dissemination of updated guidelines and clinical protocols. • Operations research as a monitoring and evaluation tool. • Expansion of the mother/baby friendly hospitals initiative. • Community mobilization to increase demand and use of PNC and PMTCT services. To strengthen the capacity • RH commodity security. of health systems for the • Availability of skilled human resources. planning and management • Functional health management information systems. of MNH programmes • Improved health management capacity at all levels. • Improved financing of the MNH programme. To improve the policy • Review and dissemination of the RH policy. environment for provision • Development of an SRH strategy. and utilization of quality • Development of a human resource development strategy. and equitable MNH • Establishment of partnerships to advocate for increased demand for services and supply of quality services, and the funding for MNH services. • Lobbying for increased government expenditure for MNH. • Advocacy for integrated SRH services and linkages with the HIV and AIDS strategies. • Implement the findings of the 2007 Maternal and Perinatal Mortality study. Equity And Quality In Health: A People's Right PAGE 45

2.1.2 — CHILD HEALTH 1000 live births compared to 82 in 2005. The rise

2.1.2 CHILD HEALTH 1000 live births compared to 82 in 2005. The rise in mortality is mainly attributed to the direct and Trends and current status indirect impact of the HIV and AIDS epidemic The child mortality rate is a sensitive indicator of and the concomitant rise in poverty levels. the level of socioeconomic development of a country. The under five mortality rate (<5MR) Figure 9: Trends in Infant and Child Mortality Rates rose from 77 per 1 000 live births in 1994 to 102 120 per 1 000 live births in 1999 and thereafter 100 102 decreased to 82 per 1 000 live births in 2005. The 80 77 82 65 infant mortality (IMR) followed the same trend. 60 53 60 The neonatal mortality rate decreased from 29 per 40 40 27 34 24 1000 live births in 1999 to 24 live births per 20 24 29 24 22 1000 in 2006. The perinatal mortality rate was 29 0 1994 1999 2005 2015 (>MGG) per 1000 live births, a figure that is higher than the NMR estimate of 25 per 1000 live births reported in the IMR Zimbabwe Demographic and Health Survey report CMR <5MR of 2005/6. The MIMS survey (2009) reports an increase in the under five mortality rate to 86 per Source: ZDHS and World fit for Children Table 4: Zimbabwe IMR and CMR 1978 – 1990 Zimbabwe IMR and CMR 1978 – 1990 Infant Mortality Rate Child Mortality Rate Year Rural Urban Total Rural Urban Total 1978 88 64 83 40 25 37 1981 85 59 79 38 22 34 1984 77 50 69 33 17 28 1986 72 47 64 30 15 25 1988 69 46 61 28 15 23 1990 71 55 66 30 20 26 1999ZDHS 65.3 47.2 59.7 36.7 22.8 32.5 2005-06 51 47 22 18 According to the Child Health Situation Analysis reduce the vertical transmission of HIV with the Study conducted in 2006 consequent rise in childhood mortality from HIV (MOHCW/UNICEF/WHO), it is reported that infection. Furthermore, child care practices in the the decline in <5, NMR and infant mortality rates country are currently not optimal because of could be linked to the overall decrease in HIV household constraints (lack of income, food prevalence, increased access to opportunistic insecurity, lack of mosquito nets, lack of access to infection treatment for children using safe water and poor access to effective health cotrimoxazole, the prevention of acute services). malnutrition, and the scaling up of Vitamin A supplementation. In addition, the focus of the Up to 78% of all perinatal deaths can be malaria programme on under fives and pregnant attributed to preterm birth, intrapartum asphyxia woman is thought have contributed to this & trauma, and unexplained intrauterine death. In improvement. addition to these three, infections and conditions related to multiple pregnancies are recorded as the However, the unfavourable macro-economic and major causes of death in the neonatal period. Both social trends experienced in recent years are likely the 2006 National Health Profile and the analysis to reverse these positive trends. The 2007 of the 2006 Child Health Situation in Zimbabwe Maternal and Perinatal Mortality study noted a give the major causes of infant and child mortality low percentage of pregnant women who were as respiratory infections, malaria, diarrhoea, AIDS, tested for HIV (34%) with more rural women not tuberculosis and malnutrition. being tested. This presents missed opportunities to PAGE 46 The National Health Strategy For Zimbabwe 2009 - 2013 Table 5 : Causes of mortality 1-4 Years, 2007 Rank Disease / Conditions Deaths 1 Nutritional Deficiencies 258 2 ARI 140 3 Intestinal Infections 123 4 Other viral Diseases 37 5 Pulmonary TB 35 6 HIV related / AIDS 31 7 Malaria 28 8 Anaemias & Blood forming Organ Dis. 26 9 Oral Cavity & Digestive System 22 10 Endocrine & Metabolic Dis. & Immunity Dis. 21 Source: MOHCW 2007 Health profile Over the years, the Ministry of Health and Child gradually increased between 2001 (BCG at 60% Welfare has adapted and adopted a number of and DPT3 at 30%) to 2006 (BCG at 75% and high impact and low cost strategies aimed at DPT3 at 70%), before declining to less than 60% reducing the unacceptably high rates of childhood as shown in the graph (figure 10) The 2005/6 deaths. One such intervention is the Integrated ZDHS confirms that 21% of children in the 12- Management of Childhood and Neonatal Illnesses 23 months age group had not received any (IMCNI), adopted and institutionalized in 1999 vaccinations at all, while the 2009 MIMS Survey to address child health problems and ensure recorded only 49% of children aged 12-23 maximum development of the child. The overall months being fully immunized. objective of the strategy is to contribute towards the reduction of child morbidity and mortality. Figure 10: Immunisation coverages 120 100 IMCNI, as an integrated approach to child health, 90 100 combines improved management of common 80 70 80 % coverage childhood illnesses with aspects of nutrition, 60 60 50 immunization and other important factors 40 40 influencing child health, including maternal health. 30 20 20 It has three components, covering health worker 10 0 0 skills development, health systems performance 2000 2001 2002 2003 2004 2005 2006 2007 2008 improvement and a third component involving the BC Years household and community in child survival issues. G The implementation of the IMCNI strategy The reported decline in routine immunization followed the WHO guidelines which included an coverage has been mitigated through Child Health introductory phase, early implantation phase and Days (CHDs) that have been conducted twice a expansion phase. Implementing the strategy year since 2005. Those who are missed by both required collaboration between programmes and routine immunization and by the CHD are usually between different levels of the health system. netted through National Immunisation days Prevention of the major childhood killer diseases (NIDs) that are held periodically for poliomyelitis through immunization is another key strategy of and measles. NIDs have been held every four to reducing childhood morbidity and mortality. The five years, starting in 1998 and aim at vaccinating Zimbabwe Expanded Programme on those not reached by routine immunization, and Immunisation (ZEPI) was introduced in 1982, also to boost overall vaccination coverage as part with the aim of increasing coverage of all ZEPI of the strategy to reach the eradication and vaccines to 90% by the year 2000. elimination goals. NIDs held in June 2007 achieved an immunization coverage rate of 80.4% Despite the economic hardships immunizations for children between 6 – 59 months. The coverage were given a priority by the Ministry of Health of selected antigens was also very high with BCG and Child Welfare and the community. recorded at 96.5%, DPT 96.7%, Measles at Immunization coverage for various vaccines 92.3% and vitamin A supplementation being Equity And Quality In Health: A People's Right PAGE 47 85.5%. Vitamin A supplementation was integrated established at Harare and Mpilo Central into the EPI programme in 2002. It is however of Hospitals. Other initiatives towards improving concern to note that vitamin A supplementation child health practices include the Kangaroo has also declined in the past three years, according Mother Care, the expansion of comprehensive to the MIMS 2009 report. services to prevent vertical HIV transmission (PMTCT – Prevention of Mother to Child The occurrence of vaccine preventable conditions Transmission); the Baby-Friendly Hospital has fallen to insignificant levels over the years, due Initiative; the promotion of exclusive breast feeding to sustained high immunization coverage rates. No in the first six months and the Child epidemics of EPI target diseases (except measles in Supplementary Feeding Programme. Furthermore, the mid 1990s) were reported due to timely public a Child Welfare Health Unit was established at the health interventions that include Child health days, national level. National immunization days, community participation including VHW programme and However the programme has faced difficulties in high health literacy rate on immunization. The its implementation due to fragmentation of investment in the ZEPI has led to the elimination responsibility among major stake holders. There is of maternal and neonatal tetanus and polio. need to redefine the roles, and responsibilities of the various stakeholders and strengthening of Until the current economic problems, the EPI coordination and collaboration mechanisms. programme was almost fully funded by Government. However, since 2001, most of the Key issues programme commodities (vaccines, cold chain • Ensuring universal immunization against all equipment and gas), which require foreign child killer diseases. currency, have been funded by partners with • Limited outreach activities due to transport personnel and running costs being financed by shortages, unreliable vehicles and lack of fuel. government. • Problems and erratic gas supplies for refrigerators to maintain the cold chain. The ZEPI programme faces its own challenges. • Reversing the HIV and AIDS epidemic, as well The Child Health Situation Analysis (2006) gives as reduce the incidence of other child killer a picture of resource constraints which can be diseases such as acute respiratory infection, generalized across the country. There are problems malnutrition, malaria and diarrhoeal diseases with outreach activities due to transport shortages, and pulmonary tuberculosis. unreliable vehicles and lack of fuel. Gas supplies • Reducing vertical transmission of HIV. for refrigerators to maintain the cold chain have • Reducing Malnutrition including the also been erratic. resourcing of child-feeding programmes. • Ensuring education of the girl child and The commitment by Government to the welfare of ensuring access to information on childcare for children is demonstrated through the re- all mothers. designation of the Ministry to include the Child • Provision of safe drinking water and adequate Welfare component. A National Plan of Action sanitation. (NPA) for children was developed covering the • Reducing adolescent pregnancies. decade 1990 – 2000. Children's hospitals were • Training and retaining a skilled health workforce. PAGE 48 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 5: Reduce the under five mortality rate from 86 to 43 by 2013 Objectives Strategies To scale up high impact • Increase under five immunization coverage through routine child child survival interventions health days and outreach services. • Strengthen surveillance of vaccine preventable disease. • Increase availability of vaccines (including new & underutilized vaccines),cold chain equipment, gas supplies, Vit A , essential drugs including ARVs. • Increase exclusive breast feeding rates. • Improve diagnosis and case management of under five conditions through training and capacity building. • Expand, strengthen and enforce the use of all components of the IMCNI strategy. • Increase number of institutions with child friendly clinics. • Increase access to comprehensive HIV prevention and care services for women including ART and ARV prophylaxis to prevent vertical transmission of HIV. • Improve availability of essential paediatric drugs including ARVs. • Increase provision of safe water and sanitation. • Strengthen the diarrhoeal disease control programme (IEC, home use of ORS, case management training and re-training, ensuring availability of supplies and other commodities). • Improve household security. • Strengthen supplementary feeding programs. To improve coordination • Develop a comprehensive child survival strategy. and strengthen multi- • Strengthen community surveillance. sectoral approaches to • Improve collaboration between departments (governmental and addressing child health non-governmental). conditions • Ensure implementation of EPI and IMCI communication strategy. • Strengthen the implementation of community IMCI. • Ensure the implementation of the maternal and neonatal steering committee. • Increase the human resource base for the care of abused children. • Increase community participation in child care. To advocate for increased • Advocate for human resource management. resource allocation to child • Plan and mobilize resources. Health problems • Advocate for more funds allocation to child health programmes from the national budget. To strengthen monitoring • Monitor the observance of children’s rights. and evaluation of child • Monitor the quality of care. welfare health activities • Conduct surveys/ researches.

2.2 — NUTRITION nutritional issues are considered as essential aspects

2.2 NUTRITION nutritional issues are considered as essential aspects of human well being. Trends and current status Malnutrition (a composite indicator for both acute High levels of malnutrition depict food insecurity and chronic under nutrition) remains a common in the country. Despite achievements in nutrition problem and leading cause of many deaths improvement that have been made in the past including those related to HIV. Limited progress through food security, much of this progress has will be made in reducing illness and death unless been eroded by recurrent droughts, poor economic environment and HIV & AIDS. Equity And Quality In Health: A People's Right PAGE 49 Figure 11: Nutrition Trends The trends show a general increase in malnutrition Nutrition Indicator Trends in Under fives: 1988-2008 in women, as measured by the prevalence of a Body 35 30 Mass Index (BMI) of less than 18.5 points, from 25 1999 to 2005/06. This is an indication of Percentage 20 15 increasing chronic food insecurity. 10 5 0 The increasing levels of malnutrition are associated 1988 1994 1999 2006 2007 Underweight Stunting Wasting with the continuing economic downturn, accompanied by increasing levels of poverty, Sources: Demographic and Health Surveys 1988, 1994, 1999; Ministry of Health 2003; ZDHS results 2005-06, Zimbabwe adverse weather patterns, food insecurity and the National Food security Assessment 2007 Note: Values for 1988 and 1994 represent children 3-35 months impact of HIV and AIDS. A tragic outcome of old. Values after 1999 represent children six months to less than the HIV and AIDS pandemic is the growing five years old. orphan crisis. HIV and AIDS has left over one million children without parents, resulting in The under-weight prevalence for under fives increased vulnerability to neglect and abuse. As increased from 13 percent in 1999 to 16.6 percent indicated above (pg 24) orphans, and particularly in 2005/6; the prevalence of stunting, the chronic double orphans, were reported in the PASS study form of under nutrition, rose from 26.5% in 1999 to have a higher prevalence of underweight (23 to 29.4% in 2005/6, and the prevalence of percent), followed by maternal and paternal wasting, the acute form of under nutrition, stayed orphans (20 percent) as compared to non orphans. stable at about 6 percent. More recent data from Urban OVCs, particularly those living in Harare, the Zimbabwe National Nutrition and Food were particularly nutritionally disadvantaged Security Assessment of October 2007 shows that compared with rural children. The increasing the prevalence of underweight has slightly frequency of diarrhoeal disease epidemics has not increased to 17.4 percent. Wasting is given as 4.1 helped the situation either, as these are also percent and stunting as 28.9 percent. The MIMS associated with acute malnutrition. 2009 survey shows reductions in underweight and wasting (12% and 2% respectively) but an increase To address child malnutrition, there is a Child in stunting (35%). Supplementary Feeding Programme (CSFP) that goes back to the early 1980s, and has been A more detailed analysis of the National Nutrition resuscitated as and when needed. With the and Food Security Assessment report reveals that prolonged droughts of the 2000s, CSFP has been both acute and chronic forms of malnutrition are almost continuous since 2002, though it might increasing with some parts of the country more have been suspended at certain times of the year, affected than others. The situation in the current such as immediately after the harvest. To ensure economic environment has been worsening. The quality is maintained and children are protected, all Zimbabwe Vulnerability Assessment Committee the food that is distributed in the CSFP is tested. (ZimVAC) found that the food security situation In conjunction with CSFP, Community Based for the majority of the urban population in high Growth Monitoring has been promoted in most density and peri-urban areas has been worsening feeding centres. The slight decrease in wasting for a number of reasons. The ZimVAC 2009 observed in the ZDHS 2005/6 could be urban food security assessment found 33% of the attributed to the CSFP since districts that assessed households to be food insecure compared conducted CSF recorded lower levels of wasting. to 24% in November 2006. For severely malnourished children who require Malnutrition is also manifesting itself in adults as more intensive support, there is a therapeutic evidenced by the Body Mass Index (BMI) that feeding programme which is carried out at health measures the thinness or fatness of adults and also facilities. Hospitals are encouraged to make their by the levels of anaemia. own therapeutic milks from raw ingredients (milk, water, cooking oil and cereal) based on a standard Figure 12: Body Mass Index recipe and similar to F-75 and F-100. The only Comparison of BMI<18.5 in women 15-49 years (ZDHS) imported component needed to make hospital- 20 prepared therapeutic milk is Combined Mineral 15 and Vitamin mix (CMV). However, hospitals are % 10 finding it difficult to obtain the raw ingredients, 5 0 the most difficult of which has been milk. ay o e ar d C E W go N S nd s ar an M h vi at M la w H al as as as h n M at la ic h M as id Bu an M M M M Province 1994 1999 2005 A Community Based Nutrition Care Programme PAGE 50 The National Health Strategy For Zimbabwe 2009 - 2013 (CBNCP) has been established in 8 districts, 2 from 7 % of all live births occurring in health major cities and 3 central hospitals, with the first institutions in 1990 to 8.4% in 1992 and to 11.5 phase of implementation being the introduction % in 1995. There was a peak in low birth weight of Community Based Management of Acute in 1998 after which the trend was maintained Malnutrition (CMAM), as an entry point to the between 12.4% in 2000 and 10.9% in 2003. wider, more preventative CBNCP. The main aim of However, in the ZDHS in 2005/6, the magnitude CMAM is to decentralise treatment of acute of Low Birth weight recorded was very low. malnutrition, so that clients are able to access treatment without having to stay for long periods Low birth weight can be attributed to the poor in hospitals. Only cases with complications are nutrition status of the mother before and during admitted to the wards. pregnancy. Under nutrition can also manifest as anaemia resulting from chronic infection and Partly through the Baby Friendly Hospital malaria. HIV and AIDS related opportunistic initiative, exclusive breast feeding for infants below infections have recently become the most common six months has been widely promoted. Studies have causes of recurrent infections in the mother. It is shown that exclusive breastfeeding reduces the risks also worrying to note that iron supplementation to of diarrhoeal diseases. The benefits of pregnant women, a critical component of breastfeeding in early infancy even extend for up to comprehensive maternal and child health care 2 years. In 1999, exclusive breast feeding for (pg 42) has decreased from 59.7% to 42.9%, infants below 4 months was 40% and the 4 – 6 during the period between 1999 and 2006. months was 6.2%. Exclusive breast feeding below 6 months was 22% in the 2005/6 ZDHS, with the The elimination of iodine deficiency disorders is June 2007 National Nutrition and Food Security one of the successes of the health sector in Assessment again showing 22%. In general, Zimbabwe. Following a 1988 national goitre exclusive breast feeding has declined from the 1999 survey that showed severe iodine deficiency in the levels of 46% to 22% in 2007. form of goitre in over 50% of the 50 districts surveyed (MOHCW , 1988), a universal salt In recognition of the specific needs of people iodisation programme was established in 1992 living with HIV and AIDS (PLWHA) a nutrition resulting in the elimination of IDD by 1999 and HIV programme has been established. (National Micronutrient Survey, 1999). Partnerships have been built so that the programme works closely with the national ART Table 5: Trends in Urinary Iodine and Households rollout programme, together with the National accessing Iodised Salt AIDS Council. Guidelines on nutrition for people living with HIV have been developed and Year Median µg/L Proportion of published. A strategy on nutrition and HIV is in households accessing the process of being finalized. iodised salt 1991 240 - Low birth weight, an indicator of maternal under 1993 228 - nutrition and foetal development, (real pre-term 1995 430 93 % and small-for-gestational age) influences the 1996 450 - chances of survival of the baby. In 1987, according 1999 245 97 % to a recent, Maternal and Child Health report, the 2002 230 87 % national average was 5.1%. Facility based data, 2005 220 89 % through the National Health Information System, 2007 210 94.6 % showed a consistent deterioration of the situation The proportion of households accessing iodised Figure 13: Low Birth Weight by years salt ranged between 87% and 97% between 1995 and 2007 despite the unavailability Trends of Low Birth Weight by Year 16 of salt in the formal market. There 14 13.3 was a rapid increase in urinary iodine 10.9 12.4 12 12.5 11.4 11.2 from 1993 to 1995 due to the 10 11.5 11.2 11 10.9 introduction of mandatory % LBW 8.4 8.6 8 6 7 6 iodization of salt nationwide. The 4 2.3 increase resulted in reports of 2 transient hyperthyroidism and 0 90 19 19 92 94 95 19 97 99 00 01 02 because of an efficient monitoring 20 /6 91 96 19 03 20 19 19 93 19 19 19 98 19 20 20 20 system, the problem was quickly 05 Year Equity And Quality In Health: A People's Right PAGE 51 identified and adjustments made to the level of The goal of nutrition programmes will be to iodation from 33 to 99ppm to the current 25 to improve health and quality of life by reducing the 55ppm. The urinary iodine levels decreased from incidence and prevalence of nutrition disorders. 450 to 245µg/l between 1996 and 1999 and have Provision of food supplements to vulnerable continued decreasing to 210µg/l in2007. The children under the age of five years and medically current levels are now approximating the WHO selected groups, including pregnant and lactating recommended level of 100 to 200µg/l and mothers, will continue. showing adequate iodine nutrition in the population. Key issues • Increasing levels of both acute and chronic The 1999 National Micronutrient Survey showed malnutrition. a prevalence of vitamin A deficiency of 35.8% in • Continued droughts/flooding are increasing children between 12 – 71 months and 7% in food insecurity. women of child bearing age. Starting in 2002, • Increasing economic challenges and poverty. vitamin A supplementation using capsules given to • Promoting exclusive breast feeding. children aged between 6 to 59 months has been • Addressing malnutrition with limited resources integrated into the EPI programme as a short term under the HIV and AIDS pandemic. strategy. The long term strategy is to fortify commonly consumed foods with vitamin A. The MIMS 2009 report notes a decline in Vitamin A supplementation, with 23% of children aged 6-59 months receiving Vitamin A compared to 47% in the ZDHS 2005/6. PAGE 52 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 6: To reduce the incidence and prevalence of nutrition disorders. Objectives Strategies To improve the • Assess the nature, magnitude and extent of nutrition problems as sustainability of nutrition well as their causes, and recommend or take appropriate action. related programmes • Strengthen on-going nutrition programmes by having them planned and managed by communities. • Revive and capacitate the multi-sectoral Food and Nutrition Committees at all levels. To create awareness on the • Develop programmes to address nutrition concerns of specific impact of nutrition on target groups (nutrition in pregnancy, nutrition in school children health and quality of life etc). through information, • Strengthen existing programmes in addressing nutrition at different education and points in the life cycle. communication (IEC) on dietary habits To monitor nutritional • Strengthen the monthly monitoring and reporting system. status of the population for • Strengthen clinic and community based growth monitoring. early detection of malnutrition To improve household • Advocate for food and nutrition security strategies. food security • Strengthen port health food surveillance and inspection activities. • Strengthen community based food and nutrition programmes. To develop a national • Regularly assess the magnitude of micronutrient deficiencies in programme on control of Zimbabwe. vitamin and mineral • Conduct KAP study to inform the development of a communication deficiencies strategy. • Document food consumption patterns in Zimbabwe. • Develop and set quality control system for food fortification in Zimbabwe in line with regional international standards. To improve the nutritional • Build capacity on Nutrition Care and Support for PLWA at all status and quality of life of levels. people infected and • Motivate males and significant others in maternal, infant and Young affected by HIV and AIDS child Feeding and HIV. • Develop an Integrated Communication Strategy on Nutrition and HIV & AIDS. • Standardize the data collection tools and reporting format for Nutrition and HIV & AIDS. • Conduct operational research on nutrition and HIV & AIDS. To improve nutritional • Build capacity for the management of acute malnutrition. management of • Initiate supplementary feeding programme to all under 5s in areas malnutrition with Global Acute Malnutrition of 7% and above. • Establish local production of Ready to Use Therapeutic Food (RUTF). • Evaluate and revise strategies for the management of malnutrition. To improve Infant and • Develop Comprehensive Policy and Strategy on Infant and Young Young Child Feeding Child Feeding. • Integrate HIV and Infant Feeding counseling into pre-service Nursing, Nutrition , HFSS and Medical training. • Increase exclusive breast feeding rates for infants. • Strengthen the Baby Friendly Hospital Initiative in the context of HIV in all institutions offering maternity services. • Integrate EBF monitoring into routine nutrition surveillance. • Develop strategies to address maternal malnutrition. Equity And Quality In Health: A People's Right PAGE 53

2.3

2.3 COMMUNICABLE DISEASE However, a total of 1.2 million (adults and PREVENTION AND CONTROL children) are currently estimated to be living with HIV. Of these, about 343,460 adults and 35,189 In this document, communicable diseases are children aged less than 15 years of age are in presented in four parts, namely 1) STI, HIV and urgent need of life saving ARV drugs. However, AIDS; 2) TB; 3) Malaria; and 4) other Epidemic only 110,000 were receiving treatment at the end Prone diseases. The goal of the communicable of 2008. diseases programme is to reduce morbidity, disability and mortality due to selected high The National Response dates back to 1987 when profile diseases. the National AIDS Control Programme was established within MOHCW. The Programme's Applicable to all the communicable diseases is main tasks were to increase public awareness about the need to: AIDS, monitor the spread of the disease and • Strengthen health promotion, disease strengthen HIV screening services at the Blood prevention and control activities Transfusion Services. • Strengthen disease surveillance • Increase availability of medicines and other HIV prevention has been the mainstay of the medical commodities National Response to fight HIV and AIDS. Early • Strengthen case management skills prevention interventions included Behaviour • Strengthen community involvement Change Communication focusing on youth, • Strengthen inter-sectoral collaboration women and People Living With HIV and AIDS • Strengthen the health System (PLWA); prevention and treatment of Sexually Transmitted Infections (STIs); condom promotion and surveillance of the epidemic. The declining

2.3.1

2.3.1 STI, HIV and AIDS trend of HIV prevalence can be largely and directly attributed to this approach which Trends and current status continues to date. HIV and AIDS remains a significant public health problem in Zimbabwe, threatening the socio- Through a broad consultative process begun in economic fibre of the country and placing a 1997, the national HIV Policy was developed and tremendous strain on the capacity of the health eventually launched in 1999.The need to broaden sector to respond to the health needs of the the National Response beyond the Health Sector population. gave rise to the creation of the National AIDS Council (NAC). The objective of NAC was to lead According to 2007 National HIV and AIDS and coordinate the country's multi-sectoral Estimates , from a prevalence of <1% in 1986, response to AIDS in a more concerted and unified HIV prevalence in Zimbabwe peaked at 29.3% manner. Through an Act of Parliament, NAC was around 1997, before gradually declining to 26.5% established in 1999 and became operational in in 2001, 23.2% in 2003, 19.4% in 2005 and 2000. 15.6% in 2007. The 2009 ANC HIV estimates the HIV prevalence in the age groups 15 to 49 An intensive Information, Education and year olds to have further dropped to 13.71%. It is Communication campaign, involving all sectors, also estimated that new HIV infections peaked at has been and continues to be carried out across the 5.6% in 1993 and have since then continued to country. The National AIDS Council is now at the decline to the present 0.4%. This information is fore-front of coordinating this effort and recently summarized in Figure 14 below. launched a Behaviour Change Communication Strategy for the prevention of sexual transmission Figure 14: Trends in HIV&AIDS Adult Prevalence and of HIV (2006 – 2010), providing guidance to all incidence (1980-2007) stakeholders on their contributions to behaviour change promotion. Trends in the estimated adult (age 15 to 49 years) HIV and AIDS prevalence and incidence, Zimbabwe, 1980-2007 35 Voluntary Counseling and Testing (VCT) centres 30 25 were established across the country from 1998. Percent 20 15 10 Intensive multimedia campaigns were used to 5 0 increase access and uptake of these Voluntary 19 19 19 19 19 19 19 19 19 19 20 20 20 20 80 82 84 86 88 90 92 94 Year 96 98 00 02 04 06 Counseling and Testing services. By the end of Adult prevalence Adult prevalence 2007, more than a million people had utilized these services across the country and an increasing PAGE 54 The National Health Strategy For Zimbabwe 2009 - 2013 emphasis was being placed on encouraging routine a significant amount of resources from the NATF offer of HIV testing by healthworkers in health (AIDS Levy), have been critical and sustainable institutions. At the same time, condoms have been sources of funding for the ART programme. made widely available at affordable prices in public However, the sector has also received much health institutions, workplaces, formal markets and support from bilateral partners, the Global Fund, other places. UN Agencies, NGOs and the private sector. The training of health workers to improve their The government remains committed to ensuring STI diagnostic and management skills has that PLHWA have access to social services and continued at Genito-Urinary Centres (GUC) in that they are protected from human and social Harare and Bulawayo, while on the job training in rights abuse. This is well enunciated in the syndromic management, targeting mainly nurses, National AIDS Policy and this commitment is also continues at facility or service delivery levels. further strengthened by various pieces of Various treatment guidelines/ algorithms were legislation. Furthermore, through NAC, different developed during this period and have been support services are available for PLHWA such as distributed widely. STI drugs are available at low BEAM (for OVCs), CHBC, food and nutritional cost through the National Pharmaceutical support programmes and psychosocial support Company of Zimbabwe (NatPharm) and various services. ZNNP+ and groups affiliated to it, are partners. To ensure patients were exposed to safe well supported and recognized by the Government. and efficacious treatment regimens, periodic STI To further show this commitment, Meaningful drug resistance studies have been carried out and Involvement of People Living with HIV and the results guided the recommendations of the AIDS (MIPA), was established by NAC in 2004. National Drug and Therapeutics Policy Advisory Other social support activities are well supported Committee (NDTPAC) on treatment and by various AIDS service organizations, NGOs, management of STIs. UN Agencies etc, with full government backing. In 2004, the Ministry of Health and Child Welfare From the initial three pilot sites in 1999, the launched the National Home Based Care PMTCT programme has expanded to more than Standards, to harmonise activities of NGOs across 1300 Family & Child Health sites across the the country. Other important strategic plans that country, with a target of all health facilities (1415) have been drawn up to improve programme to be providing PMTCT services by 2010. coordination, include the Draft National PMTCT and Paediatric HIV and AIDS Strategic Plan; An important statutory instrument (SI 202 of National Plan for Orphans and Vulnerable 98), was developed and passed in 1998, to improve Children (OVC); National Behaviour Change and provide a conducive environment, free from Strategy (2006 – 2010) and the Zimbabwe stigma and discrimination, at workplaces. National HIV and AIDS Strategic Plan (ZNASP) – 2006 -2010. The Domestic Violence Act of 2007, Criminal Procedures and Evidence Act (Amended) and the The Business Council on AIDS has been Sexual offences Act, were also enacted to curb instrumental in mobilizing resources for HIV and sexual abuse and gender based violence. AIDS within the workplace, to complement Government efforts as well as influence business In 2002, Government declared AIDS an attitudes, towards those infected / affected – Emergency in order to mobilise and increase especially the workforce. The introduction of efforts to make the treatment of AIDS a reality. workplace HIV and AIDS Programmes, which This, together with the development of generic offer VCT, PMTCT, OI, ART, as well as support formulations of ARVs, and decreased prices of activities, has taken some strain off Government ARVs globally, made it possible for MOHCW to programs and hence public expenditure, while also establish systems to introduce ART in Zimbabwe. assuring the country of a constant and healthy Opportunistic Infections (OI) clinics were labour supply. Awareness programmes, coupled established in 2003, in preparation for the with school health programmes, have meant that introduction of ART. ART was introduced in the youth are targeted early, imparting positively on 2004, in a phased approach, from 5 initial sites, to labour supply from the various schools and all central and provincial hospitals and has now training institutions. been expanded to a number of mission and district hospitals. By the end of 2008 110,000 patients The Zimbabwe National HIV and AIDS strategic were on ART countrywide. The introduction of a Plan (ZNASP) 2006 -2010, was developed and budget line item for ARVs and the commitment of launched in July 2007, by His Excellency, the Equity And Quality In Health: A People's Right PAGE 55 President of the Republic of Zimbabwe, Child Welfare, together with the University of Cde R. G. Mugabe, following recommendations Zimbabwe and the Africa University are involved made at the June 2004 National HIV and AIDS in vaccine trials. One of the recent research conference. The strategy gave focus to Zimbabwe's findings in the area of global HIV prevention is commitment to the “ Three Ones”, Universal the significant impact of adult male circumcision Access, evidence and results based strategies among on prevention of HIV transmission; the Ministry others. of Health have therefore been developing plans to scale up this intervention country wide as another There has been an ongoing programme to train component of a comprehensive HIV prevention and capacitate staff in order for them to deal with response. various issues related to HIV and AIDS, in such areas as advocacy and lobbying. Furthermore, a Key issues number of sensitization workshops have been held • Increasing access to essential medicines, for politicians, policymakers and planners on the including ARVs in a foreign currency effects of the AIDS pandemic, with successful constrained environment. buy-in from the targeted audiences. • Meeting the needs of a growing number of orphans. Government has supported the commissioning of • Shortage of skilled health professionals. various research studies on vaccines, traditional • How to sustain the behaviour change medicines, infant nutrition etc and some studies momentum. are currently ongoing. The ministry of Health and PAGE 56 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 7: To have halted, by 2015, and begun to reverse the spread of HIV and AIDS Objectives Strategies To prevent and control HIV • Increase preventive counseling services (including PMTCT). and STI transmission • Promote safer sexual behaviour through an intensive IEC campaign to be implemented by all sectors. • Make condoms widely available. • Promote male circumcision. • Prevent vertical transmission of HIV (see pg 43, 48). • Improve diagnostic and management skills of health workers to prevent complications and improve their management. • Ensure STI Drugs are available at all times. • Monitor STI drug resistance. • Create awareness on sexual abuse and rape and provide for stiffer penalties for offenders. To reduce the impact of • Provide access to treatment, case and psycho-social services for STI, HIV and AIDS on the PLWHA. individual, community and • Protect Human Rights and social services for persons infected and society affected by HIV. • Implement National Action Plan for OVCs. • Strengthen political commitment for affective action by leaders at all levels. • Universal access to HIV prevention and treatment. To improve coordination • Implement the Zimbabwe National Strategic HIV and AIDS and strengthen multi- strategic Plan (ZNASP) 2006-2010. sectoral approaches to • Implement the “three ones” principle. addressing the HIV and AIDS epidemic To advocate for greater • Earmark greater resources specifically for STI/HIV and AIDS resources allocation for intervention in the National Budget. STI/HIV and AIDS • Promote local manufacturer of ARVs and explore the role of interaction (extra- traditional medicines. budgetary). To strengthen STI/HIV and • Build research capacity. AIDS surveillance and improve research and programmed effectiveness

2.3.2 — Tuberculosis heavily influenced by HIV, continued to increase

2.3.2 Tuberculosis heavily influenced by HIV, continued to increase to 402/100 000 in 2000. In 2007, the country Trends and current status reported 138,866 cases of tuberculosis (new and The National Tuberculosis Programme was relapse), and had an incidence of all cases of 1136 established in the sixties. In 1983, the government per 100 000 population (WHO, 2008). As shown developed a policy of integrating all TB activities in fig.15, TB case load expanded exponentially, into the general health services. The National mainly as a result of the high HIV burden but Tuberculosis Programme officially adopted the indications show that the TB epidemic may have Directly Observed Treatment Short-course passed its peak i.e. the incidence rate for 2005- (DOTS) strategy in 1997. Staff training continues 2006 period showed a decline of 6.8%. HIV in order to improve diagnostic and case affects up to 80% of all TB patients. There were management skills. an estimated 1 390 000 people living with HIV and AIDS in 2005, with these people having an Tuberculosis, once thought to be on the decline, annual risk of 5-10% for developing TB. It is almost trebled in incidence from 96.9/100 000 in probably likely that even more cases of TB should 1990 to 267.5/100 000 in 1995. This trend, be diagnosed than is currently the case. Equity And Quality In Health: A People's Right PAGE 57 Figure 15: Trends in estimated number of TB cases Just as HIV, the reproductive and economically productive age group is most affected by the Trends in the estimated number of TB cases, disease and is also the same age group bearing the Zimbabwe, 1980-2007 burden of HIV. Number of TB cases 100,000 80,000 The notifications of TB rose markedly during the 60,000 40,000 nineties, from less than 5,000 to a high of over 20,000 50,000 in the late nineties. From then on, the 0 19 19 19 19 19 81 83 85 87 notification rate has been on the decline. 19 19 19 19 89 91 93 95 19 20 20 2097 99 01 03 05 Year Figure 17: Case Detection Rate over years Tuberculosis, thus, remains a major public health New Smear Case Detection Rate (%): problem for Zimbabwe, a member of the 22 so- 2002 - 2007 called high burden countries responsible for 80% 45% 40% of the Global TB caseload. TB is the second 35% 30% leading cause of death nationally and is among the 25% top five leading causes of hospital admission and 20% 15% outpatient consultation (Health Information 10% 5% Department, 2004). Patients with HIV and 0% AIDS-related conditions occupy up to 70% of all 02 20 03 20 04 20 20 05 06 20 20 07 hospital beds, constituting the majority of hospital deaths. TB is the commonest cause of death among PLWHA. The parallel relationship between Estimated case detection of smear-positive cases AIDS cases and TB cases is shown in the graph was only 42% in 2006 and has remained stagnant below: over several years (see fig 17 above). However, no nationally representative TB prevalence survey has Figure 16: AIDS and related conditions ever been conducted to validate the TB case estimate by the WHO. Similarly, over the past 25 AIDS and Related Conditions Nationally 1995 - 2006 years, no tuberculin surveys were ever conducted 170 1000 and therefore data on estimates of annual risk of 150 900 TB infection could be inaccurate. A lot of work AIDS: ARC: TB Cases 130 800 700 STI Episodes 110 90 70 600 500 will be required to improve case detection to meet Thousands Thousands 400 50 30 300 200 the global benchmark standard of 70%. 10 100 -10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 AIDS new cases ARC STI Episodes TB new cases The treatment success rate has gradually declined over the years and is almost stagnant (see fig.18). Zimbabwe is currently in the process of The low rate of treatment success (Global strengthening the integration of TB and HIV Benchmark -- 85%) is an indicator of activities in health care settings. In 2006, a programmatic inadequacy and the impact of the committee on TB and HIV Collaborative activities HIV disease burden. The implications are a high was formed to report to the National HIV and risk of MDR generation and transmission. AIDS partnership forum. The National TB manual was finalized in 2006, to incorporate TB Figure 18: Treatment success rate trends and HIV collaborative activities. The New Smear Case Detection Rate (%): implementation of provider initiated testing and 2002 - 2007 counselling in health care settings started in July 90% 2007 in 10 learning sites. It is envisaged that all 80% 70% TB patients will be offered an HIV test, while 60% 50% suspected and confirmed TB cases will also be able 40% to access HIV testing. 30% 20% 10% Age and sex specific notification data for 2004 0% 02 03 04 05 06 07 indicated that TB affects more men than women. 20 20 20 20 20 20 PAGE 58 The National Health Strategy For Zimbabwe 2009 - 2013 The country has had reasonable stocks of TB The proposed strategies for the 2008-2013 drugs at all times. FDCs (Fixed Drug National TB Control programme are based on the Combinations) are being introduced in a phased WHO recommended New Stop TB Strategy, manner to replace single dose regimens. The TB introduced in 2006. The vision is to have a TB free manual was thus revised in 2007 to include FDCs. Zimbabwe with the following targets:- DOTS remains the primary strategy being used by the TB control programme. A good laboratory • By 2010, detect at least 70% of new sputum network for TB diagnosis is well established but is smear-positive TB Cases and cure at least 85% not fully utilized, due to shortages of manpower, of these cases. reagents and functional equipment. • By 2010 all TB patients should have access to comprehensive HIV care and support services The monitoring of TB drug resistance continues including HIV testing, cotrimoxazole therapy to be carried out at the TBRL (Tuberculosis and ART. Reference Laboratory) in Bulawayo. The laboratory • By 2012, reduce TB prevalence and death rates is in the process of being strengthened so that it by 50% relative to1990. can monitor cases of MDRTB (Multiple Drug • By 2030, eliminate TB as a public health Resistance Tuberculosis) and XDR TB (Extremely problem (<1 case per million population). Drug Resitance Tuberculosis). In line with DOTS, sputum smear microscopy is being used as the Key Issues primary TB diagnostic test at district, provincial • Resources for the National TB programme and central hospitals. activities have remained inadequate. • The case detection rate of new smear-positive The Government is the major funder of all cases is still only 42%, just above half the activities. Significant support is provided by global target of 70%. bilateral agencies such as CDC in the area of • There is over-reliance on chest x-rays for laboratory strengthening and TB and HIV diagnosis. collaborative activities, whilst the European Union • Inadequate availability of, access to and use of supports the provision of first line anti-TB drugs. diagnostic facilities e.g. inadequate capacity at Two main sources of multilateral support come as National TB laboratory. management and technical assistance, from WHO • Inadequate management and supervision due to and programmatic support from the Global Fund, human resources shortages. with a Round 5 Grant worth US$ 9.2 million with • There is still no national external quality further substantial funding expected from a Round programme in most public laboratories. 8 grant recently awarded. • The national treatment success rate of 67% is very far from the global target of 85%. Equity And Quality In Health: A People's Right PAGE 59 Goal 8: To reduce the mortality, morbidity and transmission of TB in line with the Millennium Development Goals and the Stop TB Partnership targets. Strategic Objectives Strategies To expand and enhance • Increase political commitment for increased and sustained provision of high quality financing. DOTS • Improve diagnosis of TB cases through quality assured bacteriology. • Develop and enhance mechanisms for patient support. • Strengthen procurement and supply management systems for TB drugs and other commodities. • Strengthen M/E systems and Impact measurement. • Strengthen Human resource capacity for TB. To enhance coordination • Scale up TB/HIV collaborative activities. and implementation of TB/HIV collaborative activities To contribute towards the • Introduce the Practical Approach to Lung Health. strengthening of health systems To effectively prevent, • Prevent and control MDR TB. control and manage multi- • Address TB in high risk groups i.e. prisoners. drug resistant TB • Strengthen infection control of TB. To engage all care • Develop and enhance collaboration for TB control with all providers in TB control stakeholders. include Public-public mix, Public-Private mix approaches To empower people with • Strengthen ACSM activities. TB and their communities • Strengthen Community based TB care and DOTS. To enable and promote • Implement relevant Identified research priorities. operational research

2.3.3 — Malaria spraying (IRHS), increased use of insecticide

2.3.3 Malaria spraying (IRHS), increased use of insecticide treated nets (ITN) and improved treatment Trends and current status regimes. Malaria remains a major public health problem in Zimbabwe, with over five million people estimated Figure 19: National Malaria Incidence rates to be at risk of contracting the disease annually. It is estimated that 50% of the country's population National Malaria Incidence Rates: 2000-2008 resides in malarial areas. 180 160 Incidence Rate/1000 140 155 Since 2004, malaria incidence has been declining 120 100 136 137 154 117 108 with a decrease in the number of reported cases 80 102 60 95 from 1.8 million cases in 2006 to 1,315,132 in 40 81 68 2007. This has been mainly attributed to changing 20 0 weather patterns (drought), use of DDT (Diethyl- 2000 2001 2002 2003 2004 2005 2006 2007 2008 2010 Reporting Year Dichloro-Triethyline) in indoor residual house PAGE 60 The National Health Strategy For Zimbabwe 2009 - 2013 The number of malaria deaths declined from 1 200 as promoting the adoption of personal protection to 1 000 during the same period as shown in figure measures. Epidemic preparedness committees have 20 below. Improved malaria case management also been very effective in malaria and other training for health workers continues to play an epidemic prone disease control activities in important role in reducing malaria case fatality rate. districts such as Binga in Matebeleland North Province. Figure 20: Malaria deaths and CFR 2002-2007 The involvement of other state agencies such as Malaria Deaths and CFR 2002-2007 the Zimbabwe Defence Forces (ZDF), Local Government, Rural District Councils (RDC) and 2500 0.16 the private sector, especially in IRHS, should 0.14 2000 0.12 create a formidable partnership that will go a long 1500 0.1 way in ensuring the success of malaria control 0.08 1000 0.06 programme. The pooling of resources such as fuel, 0.04 vehicles and technical expertise, to complement 500 0.02 those provided within the health sector, will 0 0 2002 2003 2004 2005 2006 2007 achieve economies of scale. Private companies also continue to play a significant role in providing Deaths/T9 CFR drugs, IRHS chemicals, training and other commodities. Voluntary Service Organisations Specific programmes to improve health worker (VSO) have been very active at the community and management of malaria cases include Integrated district hospital levels. Technical and financial Management of Childhood Illness (IMCI), support continue to be received from the UN Integrated Disease Surveillance and Response family. (IDSR), the Basic Epidemiology course, as well as the inclusion of malaria case management in pre- The decentralization of malaria control activities service training. IDSR has strengthened the use of to the district level was successfully implemented epidemic thresholds at the Rural Health Centre level in the past decade, resulting in greater program and has also led to an increase in outbreak detection efficiency as the roles of each level are now clearly rates. defined. The shortage of resources and brain drain, among other challenges, continues to negatively In vivo sentinel studies have been carried out each affect the smooth running of the malaria control year to determine malaria drug efficacy. As a result, programme, despite all the effort that has been put malaria treatment guidelines were reviewed twice in towards its re-organization. Successful applications the past 10 years, transitioning from the use of to Global Fund under round 1, 5 and more chloroquine only to the use of the free recently 8, are largely expected to ease these combination of chloroquine and Sulfadoxine and challenges. Pyrimethamine (SP), and now to fixed combination of artemether and lumefantrine (co- Despite the economic challenges experienced in the artemether), an artemisinin based combination last few years, Treasury allocations for malaria therapy (ACT). Bioassays continue to be done to control have continued to increase each year. ascertain the effectiveness of chemicals used for However, due to hyperinflation and other macro- indoor residual house spraying (IRHS). DDT, economic difficulties, coupled with crippling which has been found to be very effective against foreign currency shortages, these allocations predominant vector mosquitoes, has been re- remain insufficient to meet the obligations of the introduced into the malaria spraying programme programme. with good results. A malaria indicator survey (MIS) is planned for the year 2008. The results of The referral system plays an important role in the MIS will indicate the progress that has been reducing malaria deaths and can only function made in the malaria control programme in the past optimally where there is adequate and efficient decade. transport and telecommunications. Health promotion campaigns, particularly during Community participation in malaria control is now commemorations of key malaria health calendar considered as an integral part of malaria control days, continue to be carried out to raise activities and therefore needs to be actively community malaria awareness. Intermittent promoted. This needs to be strengthened with Presumptive Treatment (IPT), using SP, is an greater involvement in the IRHS programme, bed integral part of ante-natal care (ANC). This is nets production and larviciding and environmental actively promoted for all pregnant women in manipulation to reduce mosquito breeding as well malaria transmission areas. Equity And Quality In Health: A People's Right PAGE 61 Key issues • IEC Materials and drugs availability. • Human resources. • Improving the communication and transport network. • Sustainable funding. Goal 9: To have halted, by 2015, and begun to reverse the increasing incidence of malaria Objectives Strategies To achieve universal access • Reduce the transmission of malaria by scaling up effective vector to malaria prevention and control interventions (IRS and ITNs) to 90% of the population. personal protection • Achieve at least 85% of intermittent preventive treatment (at least IPT2) in pregnant women attending antenatal care in all medium to high transmission areas of Zimbabwe. To improve diagnosis and • Provide access to malaria treatment within 24 hours of onset to treatment of 85% of fever cases. uncomplicated and severe • Confirm and correctly treat all malaria cases. malaria To improve detection and • Detect and effectively manage at least 95% of malaria epidemics timely control of malaria within two weeks of onset. epidemics • Increase malaria free zones in Zimbabwe. To strengthen community • Increase community participation and competence on correct and other stakeholder malaria prevention and control measure to 85%. participation to maximize • Strengthen the participation of other stakeholders in malaria. achievement of universal access to malaria control interventions To improve coordination, • Strengthen malaria surveillance, monitoring, evaluation and management and operational research. monitoring for achieving • Strengthen planning, partnership building and coordination. universal access to malaria • Strengthen the management of malaria control programming control interventions through adequate financial and human resource management, logistics support and procurement and supply management.

2.3.4 — Other epidemic prone diseases the outbreaks were mostly along the eastern and

2.3.4 Other epidemic prone diseases the outbreaks were mostly along the eastern and northern borders of the country. From the year Other epidemic prone conditions that are a threat 2000 onwards, outbreaks stated occurring in some to public health in Zimbabwe include diarrhoeal urban areas. In 2002, the country reported 3125 diseases such as dysentery and cholera, and cholera cases and 192 deaths. The cases decreased zoonotic diseases such as anthrax, rabies, plague, in 2003 to 1033 and 36 deaths whilst in 2004, avian influenza, influenza A H1N1 and SARS. 125 cases and 9 deaths were reported. In 2008 and 2009, Zimbabwe experienced a very serious Cholera outbreak starting from Chitungwiza and Harare The first recorded case of cholera in Zimbabwe spreading to 55 out of the country's 62 districts, was in 1972. Since then the country has been infecting 99 704 people and killing 4 420. This experiencing sporadic minor outbreaks. Initially outbreak occurred at the height of the economic crisis with a very weak health system. PAGE 62 The National Health Strategy For Zimbabwe 2009 - 2013 Figure 21: Cholera cases CHOLERA CASE BY YEAR: 1976 - 2009 80000 66929 70000 60000 50000 40000 32775 30000 20000 10000 4081 546 234 256 610 820 123 8 1135 330 3 1 883 1911 649 3125 1033 125 206 63 1043 0 1975 1976 1982 1983 1984 1985 1986 1992 1993 1994 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Although cholera spreads rapidly and can have Anthrax high case fatalities, it is probably the simplest The commonest form of anthrax in Zimbabwe is outbreak to control. The control of cholera the cutaneous type which is a zoonotic disease. requires speedy detection and availing of resources This is due to the handling of carcasses during and experienced staff in affected areas. While most skinning and the consumption of infected meat outbreaks were controlled within three weeks, the against public health advice. Drought, lack of 2008/2009 outbreak continued for many months fodder, overstocking, intensive pasture rotation and due to resource constraints, general breakdown in dusty crowded pens, are proven risk factors for water and sanitation systems, and inexperience on animals to contract anthrax. Prolonged droughts the part of health workers in managing cholera induce animals to graze closer to soil, which is outbreaks. potentially infected with infective anthrax spores. Key issues Like all zoonotic diseases, the control of anthrax is • Making key ministries aware of their roles in spearheaded by the veterinary department. Due to Cholera prevention. resource constraints and lack of stakeholder • Improving clean water supply coverage. coordination, anthrax outbreaks that occurred in • Improving sanitation facilities coverage. 2006 and 2007 were prolonged, with human cases • Improving hygienic practices by vulnerable reported. communities. • Regulation of vending practices. Key Issues • Monitoring large gatherings such as funerals, • Vaccination of cattle congregations etc. • Activation of zoonotic committees • Encouraging religious health objectors to protect their own health and that of others. Plague The last reported Plague outbreak was in Gokwe Rabies and dog bites and some districts in Matebeleland North in Since the major 1994 and 1995 outbreak, there 1994, with 554 clinical cases including 48 were sporadic minor rabies outbreaks until 2007, laboratory confirmed and 29 deaths. Whilst no when another major outbreak occurred in cases have been reported since 1994, there is need Mashonaland Central Province. The general to maintain active surveillance so that the disease macro-economic situation since 2000, will not fall into the group of neglected diseases. characterized by crippling foreign currency shortages, resulted in the virtual breakdown of the Key Issues routine public dog vaccination programmes. Anti • Maintain plague surveillance rabies vaccines are imported but against a background of foreign currency shortages, this has resulted in sporadic shortages. Key Issues • Vaccination of dogs • Human anti rabies vaccine • Activation of zoonotic committees Equity And Quality In Health: A People's Right PAGE 63 Goal 10: To improve timely detection and control of epidemic prone diseases (Cholera, dysentery, rabies, anthrax, plague, pandemic influenza, meningococcal meningitis, Vital haemorrhagic fevers (VHF) etc.) Objectives Strategies To strengthen timely • Improve health worker’s capacity to detect and manage outbreaks detection and control of all through training in and utilization of Integrated Disease Surveillance epidemic prone diseases & Response (IDSR) principles. through use of Integrated • Mobilize adequate resources for timely detection and control of Disease Surveillance & epidemic prone diseases. Response • Strengthen the health information system to enable it to support effective surveillance. • Strengthen inter sectoral coordination at national , provincial and district level through Civil Protection Unit structures. • Develop and/or revise disease specific Outbreak Management guidelines periodically. • Develop and/or revise disease specific Standard Operating Procedures for managing epidemics. • Establish Rapid Response Teams (RRT) at national, provincial and district levels. To strengthen prevention • Raise community awareness of zoonotic diseases through and timely control of Information, Education Communication and Advocacy. zoonotic diseases • Re-activate zoonotic subcommittees to integrate/coordinate the prevention and management of zoonotic diseases through integrated Rapid Response Teams (RRT). • Advocate for vaccination of eligible animals e.g. dogs and cattle by Dept of Veterinary Services. • Support the efforts of key ministries in vaccination of animals. To prevent cholera and • Advocate for improvement in water and sanitation coverage. other diarrhoeal diseases • Address Food, Water and Sanitation issues. • Water quality monitoring. • Water chlorination or super chlorination. • Food inspection. • Temporary toilets construction where there are no standard facilities. • Supervise burials. • Establish cholera treatment centres (CTC) or Oral Rehydration Points (ORP). • Promote standard hygiene practices to reduce risks of contracting diarrhoeal diseases e.g. commemorating National Hand Washing days. • Establish Cholera Command & Control Centres (C4) at all levels to direct coordinated response of epidemics. To strengthen detection • Utilise Integrated Disease Surveillance & Response guidelines to and control of Viral timely detect and control VHF. Haemmorrhagic Fevers (VHF) To strengthen detection • Strengthen the health information system with special emphasis on and control of outbreaks surveillance. PAGE 64 The National Health Strategy For Zimbabwe 2009 - 2013

2.3.5 — Schistosomiasis and soil transmitted distribution of STHs in order to plan for their

2.3.5 Schistosomiasis and soil transmitted distribution of STHs in order to plan for their helminthes control. Trends and current status The Government of Zimbabwe has prioritized the The prevalence and epidemiological distribution control of schistosomiasis on its agenda. Given the of schistosomiasis has continued to increase. Since absence of prominence in the program in the last no large scale control programmes followed the ten years a national multi-sectoral team including previous National Schistosomiasis Surveys about UN agencies was set up in 2005. A National Plan two decades ago, the current schistosomiasis of Action for the control of schistosomiasis and prevalence may have increased throughout the STHs was approved in 2006. Due to high country as a result of increase in water inflation, the budgeted funds for activities development projects in response to persistent (including for the baseline survey) failed to enable droughts. implementation. A recent report on a study investigating Little attention has been given to schistosomiasis polyparasitism among primary school children control over the past years in Zimbabwe also due living in rural and commercial farming areas in to the compelling competition from more life Zimbabwe, has confirmed high prevalence of threatening diseases including Malaria, HIV and schistosomiasis (56% and 66%) in Mutare and AIDS, and TB, compounded by floods and Shamva districts respectively (Midzi et al, 2008). droughts that demanded more national funding According to the World Health Organization and human resources leaving schistosomiasis with treatment guidelines, the prevalence reported in little of either. However, the patent on these two areas indicate high level of transmission praziquantel, the only drug of choice for treatment of the schistosomiasis parasite that warrants of schistosomiasis, has expired resulting in reduced regular annual treatment of children in schools and drug costs. This condition will make it feasible for access of the adult population living in these areas large scale procurement of praziquantel and to essential drugs for schistosomiasis treatment implementation of the national schistosomiasis (WHO 2002). control programme. Although some reports from small scale studies indicate occurrence of soil transmitted helminthes Key issues (STHs) in certain parts of Zimbabwe with • Schistosomiasis programme neglected. prevalence ranging from 21-70% (Chandiwana et • Unavailability of schistosomiasis drugs. al 1983, 1989, Midzi et al 2008), data regarding • School health programme neglected. the national distribution of STH is still lacking. • Community participation in environmental There is therefore a need to determine the management. Goal 11: To reduce morbidity due to schistosomiasis and soil transmitted helminthes by year 2015. Objectives Strategies To establish the incidence • Conduct schistosomiasis baseline survey. and prevalence of • Stratify the country using baseline data. Schistosomiasis • Develop treatment policy and strategy. To establish the incidence • Monitor and evaluate program. and prevalence of soil • Conduct soil transmitted helminthes baseline survey. transmitted helminthes • Develop treatment policy and strategy. • Monitor and evaluate program. Equity And Quality In Health: A People's Right PAGE 65

2.4 — NON COMMUNICABLE DISEASES of non-communicable diseases namely diabetes,

2.4 NON COMMUNICABLE DISEASES of non-communicable diseases namely diabetes, AND CONDITIONS cardiovascular diseases, cancers, and chronic obstructive lung diseases have common modifiable Trends and current status risk factors namely tobacco use, obesity, dietary Zimbabwe like several other developing countries factors and physical inactivity; and therefore share and in line with the so-called “epidemiological intervention strategies. transition” is being faced by a triple burden of communicable, re-emerging and non- Evidence exists confirming that a sizeable number communicable diseases and conditions. The of Zimbabweans have adopted poor habits and country has put at lot of emphasis and resources behaviours which affect their health by increasing on the first two. Non-communicable diseases are their risk of developing non-communicable however bringing with them unnecessary demands diseases. The Zimbabwe STEPwise survey (2005) on available health resources that if prevented shows that there is a high prevalence of modifiable would see these resources channeled to other health risk factors of non-communicable diseases. It also needs. reveals that current alcohol consumption and tobacco consumption is very high especially among Whilst evidence exists that there is an increase in males. The survey noted that current alcohol the prevalence of lifestyle related diseases such as consumption was 58 percent in males and 13.5 cardio-vascular diseases especially hypertension, percent in females in the study population. diabetes mellitus, various cancers, avoidable and Tobacco consumption was 33 percent in males and preventable blindness, liver cirrhosis, dental caries, 5 percent in females. Both alcohol and tobacco are injuries and some of the psychiatric conditions, causes of cancer. not much effort is being made in making communities understand the role of social or The prevalence of both diagnosed and personal determinants of health such as lifestyles, undiagnosed hypertension and diabetes mellitus education, culture, behavior and even earnings on was found to be very high in the Zimbabwe health and quality of life. The best that has been STEPwise survey (2005). Other lifestyle factors done is to prohibit smoking in public places, such as overweight and central obesity were also prohibition of under age (18 years) drinking and noted to be high especially in females. Overweight awareness campaigns on the effects of drug abuse and central obesity have not traditionally been to school children and the general public. classified as malnutrition because malnutrition has traditionally been falsely associated with children Of greater concern is the low level of attention and not adults. Strengthening people's ability to directed towards the risk factors associated with understand and cope with these problems and lifestyle diseases, such as excessive alcohol promoting appropriate preventive programmes and consumption, tobacco use, lack of physical protection regulations can reduce these lifestyle exercise, obesity, drug abuse and social related illnesses (pg 38). disintegration. It is worth noting that the majority Figure 22: Out-patient visits for Non Communicable Diseases: 2006 Out-Patient Follow-up, Non-Communicable Disease, 2006 All Ages Cancer Malignant Neoplams 0.0 Disabled / Handicapped 1.4 R.H.D. 1.8 Disease Diabetes 8.3 Psychiatric 0.1 Eplepsy 11.3 Asthma 22.3 Hypertension 54.7 0 10 20 30 40 50 60 Percent PAGE 66 The National Health Strategy For Zimbabwe 2009 - 2013 Currently all levels of care contribute to the There were 148,322 new cases for under five years management of non-communicable, diseases with (2006) giving an incidence rate of 394 per 1000 the lower levels mostly playing the role of (2006). identifying and treating cases as provided in the management protocols, if available. Some 2.4.4 Preventable and avoidable blindness medicines for some non-communicable diseases can only be initiated at high levels of care with Preventable and avoidable blindness remains a lower levels mostly monitoring and re-supplying major public health problem in Zimbabwe. Eye medicines. To that end, it has been the practice that conditions have continued to appear amongst the each lower level health facility keeps a chronic top reasons for OPD attendances in the course of disease register for the purpose of patient tracking, the last decade. Cataracts, trauma and glaucoma are and also ordering of patient specific medicines. the major reasons for eye admissions. It is Non-availability of medicines has seen the collapse estimated that 1 percent of the population is of this best practice of managing some of the blind, with half of these cases due to treatable non-communicable conditions as near the patient cataracts. It is further estimated that some 80% as possible. of the causes of blindness are avoidable. There is however a huge backlog in cataract surgery because

2.4.1 — Cardio Vascular Diseases of few ophthalmologists in the country largely due

2.4.1 Cardio Vascular Diseases of few ophthalmologists in the country largely due to the brain drain. In addition, equipment and Cardio Vascular Diseases are a major cause of supplies need repair and re-supply respectively. mortality in adults. Hypertension accounts for 50% of all cardio-vascular diseases and its The National Prevention of Blindness Committee complications including strokes. In the Zimbabwe provides expert guidance and leadership in the STEPwise survey the prevalence of hypertensions Prevention of Blindness programme. Some of the was found to be as high as 27%, while in 2006 major activities of programme implementation hypertension accounted for 25% of all out- include development of the SAFE (Surgery, patient visits for chronic conditions. Strokes are Antibiotic therapy, Facial cleanliness, responsible for a significant portion of disabilities Environmental improvements) strategy for the and attendances at medical rehabilitation units. elimination of trachoma, training of Effective management of cases, follow-up and ophthalmologists, post basic training of nurses in screening of at risk persons depends on specialist ophthalmology, and ophthalmology outreach guidelines, which are yet to be developed and put services. into wider use. Key Issues

2.4.2 — Diabetes Mellitus • Supply of affordable equipment, technology

2.4.2 Diabetes Mellitus • Supply of affordable equipment, technology and spectacles. Diabetes mellitus and its complications are on the • Human resources. increase. It is among the top five chronic • Improving case management. conditions seen in the outpatients clinics. The • Building national blindness prevention 2005 STEPwise survey noted that the prevalence programmes, with a strong community of diabetes among the adult population is 10%, approach, as well as individual approach to eye with a large number of people not being aware that care. they had raised blood sugar levels. • Improving physical facilities for both service and training at central and provincial levels.

2.4.3 — Chronic obstructive lung diseases There is need to make effective and efficient

2.4.3 Chronic obstructive lung diseases There is need to make effective and efficient use of the available provincial eye care Chronic obstructive lung diseases, especially institutions at Bindura, Gwanda, and Victoria asthma, are one of the more frequently seen Falls. conditions in outpatient clinics. In both adults and children, asthma has become a disease of public 2.4.5 Cancers health concern. Asthma and the Acute Respiratory tract Infections (ARI) contribute Cancer is an increasingly important public health significantly to the high levels of morbidity, problem in Zimbabwe. By 1997, cancers accounted mortality and disability, particularly among the for 2% of OPD follow-ups and 8 -10% of all under 5 years in Zimbabwe. ARI itself is a major hospital mortality. In 2004 cancers accounted for cause of deaths in children under five years. In 0, 4% of OPD visits. In 2005, a total number of 2006, new acute respiratory tract infections cases 4,015 new malignant cancer cases were recorded accounted for 37 percent of all outpatient diseases. among Zimbabweans with 1 762 (43.9%) being Equity And Quality In Health: A People's Right PAGE 67 males and 2 253 being (56.1%) females. Kaposi's ovary (3.2%), liver (3.0%), stomach (2.5%), sarcoma (KS) was the leading cause of cancer oesophagus (2.3%) and non-melanoma of skin among Zimbabwean black men accounting for cancer (2.2%). 26.4% of the new cases registered in 2005. A cancer Age standardized mortality rate of 122 per 100 000 population, for both sexes was This was followed by prostate (11.4%), non- reported in 2004 (WHO). Hodgkin's lymphoma (NHL) (6.8%), oesophagus (6.0%), liver (5.8%), eye (4.2%), lung (3.0%), The advent of HIV and AIDS has seen a striking non-melanoma of skin cancer (3.0%), connective increase in the incidence of certain cancers that are and soft tissue tumours (2.6%) and colon (2.3%). associated with the epidemic. The most notable of these cancers are Kaposi's sarcoma, Non- The most frequent cancers among Zimbabwean Hodgkin's Lymphoma and squamous cell black women were cervix uteri (32.1%), breast carcinoma of the conjunctiva. (11.1%), KS (10.9%), eye (5.4%), NHL (3.9%), Figure 21: Most common malignant cancers: 2005: Males and Females All Zimbabwean males All Zimbabwean women PERCENTAGE PERCENTAGE 0 5 10 15 20 20 30 0 10 20 30 40 Kaposi’s Sarcoma Cervix Uteri Prostrate Kaposi’s Sarcoma Non--melanoma of Skin Breast Non-hodgkin’s Lymphoma Eye SITE SITE Non-Melandoma of Skin Eye Non-hodgkin’s Lymphoma Oesophagus Ovary Liver Liver Lung Stomach Bladder Corpus Uteri Colon The cancer control programme boosts of one of Key Issues the best cancer registries on the African continent, • Funding of the ZNCR and its activities. the Zimbabwe National Cancer Registry. Registry • Human Resource for Health including the is an integral part of the overall national cancer training of oncology specialists in country. control effort and has also become an • Resources for conducting operational research. internationally respected institution that offers • Maintenance of radiotherapy equipment and reliable cancer statistics. Indigenous and drug availability. international researchers and the Ministry of Health and Child Welfare, extensively utilize the 2.4.6 Oral health data produced by the registry for programme planning and management and cancer control Little attention has been given to oral health programmes. Increased funding will enable the outside the school health programme. However, it registry to maintain its high standards, upgrade is known that a lot can be done to reduce its equipment, train personnel, achieve national contribution to the burden of disease through coverage, conduct more research and produce simple preventive measure. Communities have also publications and reports. tended not to seek preventive oral health care, instead waiting until they have a dental problem. The cancer control programme of Zimbabwe has, One preventive measure of high effectiveness that in the last decade, placed emphasis on early is not being given adequate attention is the identification of cancers, and raising awareness and fluoridation of drinking water as a means of training health workers in palliative care for preventing dental caries. The 1995 National Oral advanced cases. PAGE 68 The National Health Strategy For Zimbabwe 2009 - 2013 Health survey revealed that there is an unmet Figure 24: Causes of injuries treatment need for both periodontal related Injuries cases and deaths conditions and dental cavities. The University of 40.0 Zimbabwe (UZ) started the Dental Practitioners 35.0 degree programme to augment the Dental 30.0 Therapists and Technologists programmes run by PERCENTAGE 25.0 the Ministry of Health and Child Welfare. 20.0 Cases Deaths 15.0 Efforts to meet the oral health care needs of all 10.0 Zimbabweans have included: 5.0 0.0 474 2215 455 2809 1599 88 553 • Initiating the process to develop the oral health 1. Motor Vehicle & Road Traffic Accidents 2. Other Transport Accidents 3. Accidental Poisoning 5. Accidents by Fires and Flames 6. Other Accidents 7. Drugs Medicaments Adverse Effects 9. Homicide policy and strategy for Zimbabwe. Cause of Injury • Equitable deployment of Dentists and dental therapists to central hospitals and provinces Key issues around all NCDs and to districts, which has progressed well. • The development of NCDs Strategy including • The inclusion into the PCN Training updating guidelines and protocols, management Regulations of oral health issues and care. of each of the conditions. • Continued efforts towards commencing the • Inadequate human and financial resources training of Dental Assistants. necessary to prevent and control NCDs and • Strengthening the institutionalization of oral their risk factors. health as a component of PHC. • Limited or lack of systematic screening for NCDs or their risk factors at all levels of care. Efforts in this strategy will be further guided by • High prevalence of hypertension, diabetes, the findings of the oral health policy, strategy and obesity in women compared to men. a survey that will be conducted in due course. The • Lack of prioritization of care and management major challenges in oral health are the shortage of of cancers. dental equipment and supplies. • High level of substance abuse. • Inadequate rehabilitation services for patients

2.4.7 — Injuries with complications of NCDs

2.4.7 Injuries with complications of NCDs. • Negative perception of some interventions Injuries are reported to be among the top five targeted at reducing NCDs and their risk causes (Figure 24) of out-patient visits. Injuries factors. account for 50% of all newly reported disabilities. • Increasing awareness in NCD risk factors. Transport accidents and accidents by fires make up • Institutionalising NCDs into the PHC and a significant proportion of all injuries. CHBC activities. Equity And Quality In Health: A People's Right PAGE 69 Goal 12: Improve the prevention and management of priority Non-Communicable Disease Objectives Strategies To reduce the burden of • Develop and implement a national health policy and plans for the non communicable prevention and control of non-communicable diseases. diseases by between 15 • Reduce the level of exposure of individuals and populations to the and 20% by 2013 common modifiable risk factors for non-communicable diseases (namely tobacco use, unhealthy diet, physical in activity, and the harmful use of alcohol) and their determinants. Available international and regional recommendations on the control and management of NCDs (MPOWER package on tobacco, Global strategy on Diet, Physical activity & Health etc shall be referenced to during the development of policy documents). • Protect and safeguard children and minors from the effects of tobacco, alcohol and drug abuse. • Strengthen and maintain an integrated surveillance system aimed at quantifying the burden and trends of NCDs, their risk factors as well as details of some other major determinants. • Strengthen healthcare services for people with NCDs by developing evidence based norms, standards and guidelines for cost effective interventions. • Provide competence and skills to health workers to cost-effectively manage NCDs and their complications. • Institute accident control and prevention programmes aimed at the reduction of all forms of accidents. • Revive and sustain community-based rehabilitation programmes; • Advocate for active involvement of line ministries to initiate and support legislature designed at creating an NCD prevention and control friendly environment. • Strengthen NCD program coordination structures at all levels of care with each level having a minimum level of appropriate staffing and equipment to effectively coordinate and monitor the implementation of all activities. • Promote primary prevention through community based interventions targeted at promoting positive behavioural changes at the community level using integrated multidisciplinary, multi- sectoral and private/public mix approaches (focal sites being schools, workplaces, church organization etc). • Develop and implement a behavioural change communication (BCC) strategy that seeks to reduce NCDs risk factors as well as increasing awareness towards health life styles and promoting the health seeking behaviour for regular measurement of blood pressure, screening through pap smear, testing and assessing severity of haemophilia, detection of proteinuria etc. • Define and implement a minimum package of cost effective clinical preventive screening interventions such as urinalysis, measurement of blood pressure, blood sugar, body weight and height as well as screening for some common and easily detectable cancers, mental illnesses, blindness and chronic respiratory diseases in health facilities, in schools and workplaces as a strategy for early case detection. • Facilitate treatment, care and support beginning at community level and move up the ladder of the health care delivery system using an effective bidirectional referral system ( reintroduce clinic registers to facilitate targeted supply of medicines that are normally not kept at that level). PAGE 70 The National Health Strategy For Zimbabwe 2009 - 2013 • Develop and implement strategies that will help people with non- communicable diseases manage their own conditions better, and provide education, incentive and tools for self management (include supporting organized community based associations for the management of NCDs e.g. Diabetic Association, Haemophilia Association). • Promote and preserve traditional norms that are compatible with the maintenance of healthy lifestyles. • To assess the role efficacy and safety of traditional medicines in the management of non-communicable diseases. To protect women and • Contribute to the prevention and reduction of domestic violence children against all forms of and sexual abuse, support victims and stiffer penalties for offenders. abuse and violence • Train health workers and specialist agencies in the identification of abuse of women and children and what to do about it. • Increase awareness in the population of agencies that can assist the victims of abuse and violence. To increase community • Intensify health education campaigns on promoting healthy participation and lifestyles. responsibility in the • Organize competitions that highlight the importance of healthy promotion of healthy lifestyles. lifestyles and responsible • Advocate for greater community participation, particularly in behaviour planning and decision-making on issues/matters that promote healthy lifestyles. • Strengthen people’s ability to understand and cope with self- created problems, notably alcoholism, STIs, affluence-related diseases, social disintegration and road traffic accidents. • Develop and introduce clinical preventive services starting with the reintroduction of annual medical examinations for health workers. To research on the social • Strengthen research capacity on the social impact of unhealthy impact of lifestyles on lifestyles. health • Explore why knowledge of risk factors does not bring behaviour change. • Develop and adopt a standard list of health education priorities. To increase access to • Train HCWs to detect NCDs early and treat NCDs effectively services for clients with utilizing available protocols and algorithms and personal cards. NCDs • Acquire equipment and materials for basic diagnostic procedures and investigations. • Ensure NCD vital drugs and consumables availability. • Re-introduce chronic disease registers at the primary care facilities and supply the necessary drugs as per register. To reduce morbidity and • Review the 10 Year National Cancer Control Programme Plan of mortality due to cancer 1994 – 2004. • Review and finalize the oncology care for Zimbabwe manual in line with new EDLIZ 2006 and treatment protocols. • Mobilize resources for training HCWs in palliative care and CHBC in liaison with relevant departments and MAC, HOSPAZ and its members. • Rollout the VIA project to all districts in the country. • Strengthen cervical cancer and prostate cancer screening at district levels. To reduce and prevent the • Determine the magnitude and causes of the burden of eye incidence of blindness conditions (present findings of the survey on common eye conditions in government health institutions). • Develop programmes on common eye conditions. • Implement vision 2020. Equity And Quality In Health: A People's Right PAGE 71 • Develop curriculum on refraction. • Train HCWs/ ophthalmology nurses in refraction. • Develop dissemination IEC material on the prevention of blindness. • Establish school eye health care programme for refraction and squint problems. • Establish eye centres in the remaining provinces and at selected district hospitals. To reduce the incidence of • Develop oral health programmes. oral health problems • Develop an oral health policy with focus individual responsibility for care and treatment. • Disseminate policy to HCWs, stakeholders individuals and families. • Advocate for the in corporation of oral health component into the elements of PHC. • Revamp the school oral health component. • Evaluate the national plan for oral health emphasizing the 16 goals set in 1990. • Develop the oral health strategy based on the findings of the evaluation. • Update IEC material based on information on oral services including HIV and AIDS. • Strengthen surveillance system on oral health. PAGE 72 The National Health Strategy For Zimbabwe 2009 - 2013

2.5 — MENTAL HEALTH Depression is amongst the top five mental health

2.5 MENTAL HEALTH Depression is amongst the top five mental health illnesses seen in public health institutions. For a Trends and current status long time, the breakdown of family structures and The provision of mental health activities is guided social values have been reported as the by the Mental Health Act of 1996, the Mental contributory factor to depression, leading to abuse Health Regulations of 1999, and the National of alcohol and use of illicit drugs (Brudtland health policy of 2005. The Mental Health 2001). programme includes care for the mentally ill, forensic care and care for mentally retarded While it has been believed that Zimbabwe was a (learning disabilities). transit state for illicit drugs/ substances, this is no longer the case as these drugs are now sold and Mental illness remains amongst the major public consumed in the country. Various surveys have health concerns in Zimbabwe. The objective to be shown that the problem of both alcohol and drug achieved over the last ten years was to create an abuse are increasing (WHO, Mental Health environment that promotes the mental well being ATLAS - 2005). of individuals. The last ten years, especially the immediate last five years, have seen the The first point of contact of mentally ill patients development of an environment completely is the primary care level with possible referral working against this objective due to the socio- upwards as and when the need arises. This was economic challenges the country has been going made possible through in-service training of nurses through. and integrating mental health care into primary care activities. Support to the primary level was Stress associated with life in Zimbabwe is more provided by a psychiatric-trained nurse found at pronounced as reflected by increased emotional each district hospital and also by the provincial and mental illnesses resuling from several factors psychiatric nurse. Psychiatrists provided the including: HIV and AIDS morbidity and specialists care of treatment and are found at mortality and the subsequent increase of orphans; provincial and specialists tertiary institutions. socioeconomic challenges with its accompanying Recently this well designed mental health delivery increasing unemployment and poverty levels; and system has not functioned well. effects of natural disasters, in particular the droughts and floods. However no studies have Forensic/detained mentally ill patients are catered been done to show the extent of this stress and the for in Special Mental Institutions, Chikurubi new burden of mental ill health due to the current Prison in Harare, and Mlondolozi Prison in socio-economic environment. Furthermore the Bulawayo and these have been similarly negatively national health information system is not affected to the extent that the Mental Health capturing stress disorders. Review Tribunal and the Special Mental Health Boards were not able carry out their duties In 2004, the commonest causes for admissions in regularly. Psychiatric Institutions were Schizophrenia and Epilepsy. While epilepsy is not a mental illness, it The provision of adequate care and support for is captured together with mental illness. The large the mentally ill requires multi-disciplinary, multi- number of epilepsy patients admitted is the result sectoral, community and corporate involvement of lack of specific services for epileptic patients, in and participation. Many stakeholders support and particular the community or outreach services, complement the ministry's efforts in advocacy and which remain undeveloped and the stigmatization service provision. There is however need to of epileptic patients remains a problem. strengthen partnerships for maximum benefit. There is also need to strengthen community based Figure 25: New Mental Disorders by Type: 2004 mental health services with the aim of reducing the custodial concept of New Mental Disorders by Type in 2004 psychiatric care. Epilepsy 56% Depression Community based psychiatric Conditions Anxiety/Neurotic disorders Other Conditions rehabilitation and Mental Retardation occupational therapy Schizophrenia 39% contributes to the continued 0% 10% 20% 30% 40% 50% 60% care at home and has been Perecentage noted to play a pivotal role in reducing re-admissions. Equity And Quality In Health: A People's Right PAGE 73 However, the existing facilities remain under The main focus of the mental health activities for resourced. The Mental Health and psychiatric the duration 2008 –2013 will be on prevention of services provide expert guidance and leadership in mental illnesses, promotion of good mental health, the care of the mentally ill. Training of Psychiatric provision of curative and rehabilitative services for Nurses, Psychologists, Clinical Social Workers and those already affected by mental disorders, and Psychiatrists is undertaken in country, but there ensuring specialists drug and equipment remains a critical shortage of these cadres with a availability. 50% vacancy rate amongst psychiatry trained nurses and over 90 percent of the available Key issues psychiatry trained nurses employed at Ingutsheni • Review and revision of the Mental Health Act Central Hospital. While the need to train mental no 15 of 1996 and its Regulations. health professionals is clearly essential, empowering • Erratic availability specialist medicines and existing general health professionals with basic equipment. mental health skills is critical. Integration of the • Human resources for mental health care. programme with the mainstream PHC activities • Standards and guidelines for the management remains the best option. of common mental health disorders. • Destigmatization of mental illness and Zimbabwe has participated in the implementation epilepsy. of the WHO – Assessment Instrument for Mental • Mental health services for the children and the Health Systems (WHO - AIMS), a new tool for adolescent collecting essential information on mental health • Specialized institutions for alcohol and information systems of a country. Similarly, the substance abuse implementation of the WHO- Alcohol, Smoking • Reestablishment and integration of community and Substance Involvement Screening Test (WHO based mental health rehabilitation programmes ASSIST V3.0) will enable the country to ascertain including half way homes for the mentally ill. the burden of abusers and to detect the problems early and to intervene promptly. PAGE 74 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 13: To reduce the incidence of mental illnesses through strengthening and promotion of mental health programs. Objectives Strategies To increase access to • Increase the number of institutions offering comprehensive mental appropriate and effective health services. mental health services, • Conduct a baseline survey on the Epidemiology of mental with an emphasis on disorders. access; and to reduce the • Develop treatment protocols and guidelines on management of incidence of mental illness psychiatric and substance abuse conditions. • Improve case management capacity at all levels. • Develop discharge guidelines for patients with mental disorders • Develop psychiatric substances and alcohol policy. • Advocate for appropriate numbers of mental health professionals; i.e. clinical psychologists, psychiatrists nurses, social workers to increase the staff population ratios. • Increase public awareness through mass media, districts and provincial commemorations. • Improve programme management, collaboration and governance by implementation of the acts and regulations. • Resuscitate establishment of treatment and rehabilitation centres for Drug and Alcohol Abuse. • Increase Community Based Mental Health Care program. • Review and strengthen enforcement of the Mental Health Act, Regulations and Policy. • Develop Psychoactive Substance and Alcohol Policy. • Develop mental health services for children and the adolescent. To improve the capacity of • Increase the capability of all levels to provide appropriate and all levels to achieve effective mental health services through training. national goals • Develop community based mental health staff. • Reestablish community based mental health rehabilitation programmes including half way homes for the mentally ill. • Advocate for increase of training schools for Mental Health Personnel. • Increase public awareness of the prevalence of mental health and of risk and preventive factors. To improve outcomes for • Increase the capacity to provide effectively mental health support in those with mental illness response to disasters. through the use of proven, • Promote the detection, early intervention, and treatment of the effective treatments mental illnesses. • Increase consumer and family input and participation in the treatment planning process. To create an environment • Strengthen Mental Health Education on Prevention of Mental that promotes the mental Illness and Substance Abuse, and Promotion of Mental Health in well being of individuals schools. • Design a Mental Health Program specifically for the youths and adolescents. • Address alcohol and substance abuse through IEC strategies. • Establish specialized institutions for alcohol and substance abusers. To strengthen and .• Strengthen the management and coordination of mental health coordinate forensic services services. • Strengthen collaborative approaches with other stakeholders to assure integrated, accessible and effective treatment services for those with serious emotional disturbances. Equity And Quality In Health: A People's Right PAGE 75

2.6 — DISABILITY AND REHABILITATION Injuries are reported to be among the top ten

2.6 DISABILITY AND REHABILITATION Injuries are reported to be among the top ten causes of outpatient visits (pg 69) and account for Trends and current status 50% of all newly reported disabilities. Of The Rehabilitation and Disability Program seeks particular concern are injuries resulting from Road to improve the quality of life for the people of Traffic Accidents, Domestic Accidents and Work Zimbabwe by promoting healthy living and Related Accidents, which constitute 10 - 15% of prevention and management of disabilities and all registered deaths. The most important cause of injuries, through a process of rehabilitation injury related deaths, are road traffic accidents empowerment and inclusion into society. Acute followed by suicide. In children under 5 years, injury care services continue to be provided at all burns are the most common form of injury. health care facilities and rehabilitation care plays a Domestic violence has also become a course of crucial role in the continuum of care in line the concern. There is also an increase in reported PHC approach. violent injuries such as homicide, suicide and rape. According to the Zimbabwe Population Census of Figure 27: Commonly reported disabilities: 2004 2002 (CSO), approximately 350 000 People With Disabilities (PWDs) were identified, a figure Disabilities By Cause 2004 which equates to 29% of the population. This Other figure is further validated by the Poverty Congenita 10% Condition Assessment Study Survey (PASS) 2003 which 5% showed that nationally, 3% of people were Accident at disabled. The rural areas had a slightly higher Disease Home 20% 40% prevalence of persons with disability than urban areas. The main disability found at the national level in the study was difficulty in moving, R.T.A. 20% Accident at followed by difficulty in seeing. About 68% of Work disabled persons were prevented from maintaining 8% significant economic activity or going to school due to the disability. The last decade has seen a change in the epidemiology of disability, from those arising as a result of polio, leprosy, and land mines for example, to those related to birth trauma including cerebral palsy, road traffic accidents, spinal cord injuries, amputations, mental illnesses, age related impairments, multiple disabilities and home accidents, especially among children. Figure 26: Disability by type Hearing Impairment/ Disability By Type Speech 2004 2% Visual Impairment Medical Multiple Disabilities 3% Respiratory 5% 14% Mental Handicap 7% Neurological Burns 53% 16% Source: National Health Profile PAGE 76 The National Health Strategy For Zimbabwe 2009 - 2013 Accidents in the home are significant and affect all Key issues age groups. These are followed by disease related • Inability of Health care workers to disabilities. communicate effectively with persons with hearing disability. Occupational injuries are also significant, with the • Failure to transform existing facilities to highest rates reported in the transport sector Centers of Excellence. followed by the mining and forestry sectors. The • The increasing burden of injuries with limited work environment in both the formal and informal accident control and prevention. employment sectors is causing a range of acute and • Strengthening of / development of efficient chronic illnesses and injuries that are, in some Accident and Emergency Services at all levels areas, not detected, reported or managed. Only a of care. small fraction of occupational diseases are • Increasing collaboration with multi identified. The prevention and management of stakeholders involved in injuries and accidents. home related injuries is generally inadequate, • Limited access to mobility aids such as fragmented and poorly provided for. prosthesis and walking sticks. • Lack of skills by health workers to correctly Rehabilitation services have over the last decade identify and refer clients early for further/ expanded across the country with almost every specialist management. district having purpose built rehabilitation • Non functionality of Rehabilitation Villages as department. Both rehabilitation technicians and centers of excellence. physiotherapist are being trained locally. Zimbabwe • Non ratification of the convention of the has a very strong Community Based Rehabilitation Rights of Persons with Disabilities on the (CBR) programme, which is now constrained by rights to health and rehabilitation (Articles 25 lack of transport in particular motor cycles, which to 26, 2006, UN General Assembly). enable the rehabilitation assistants to get to the • Weak multi-sectoral collaboration among stake hard to reach areas for the purposes of patient holders. screening. • Fragmentation of efforts in dealing with injuries and accidents across sectors and The focus of care is integration, focusing on departments. mainstreaming management of disability into all • Lack of knowledge and information on first health programmes including Community Home aid at home. Based Care, HIV & AIDS, mental health and Reproductive Health programmes, and inclusiveness of People with Disability (PWDs) in decisions and programmes that affect them. There is need to provide Information, Education and Communication (IEC) to meet the needs of specific disabilities including Braille material. There is therefore a need for comprehensively addressing the needs of PWDs, using a human rights' approach. The prevention and early identification and referral of children and persons with disability, coupled with early intervention for conditions such as birth asphyxia, will avoid the development of permanent complications and remain central to care. Equity And Quality In Health: A People's Right PAGE 77 Goal 14: To improve the functionality, independence and quality of life of people with disabilities. Objectives Strategies To increase access to • Conduct survey to determine magnitude, consequences and types quality medical of disabilities in the country. rehabilitation services to all • Contribute towards development of broad based national data on that need them disability and rehabilitation. • Create awareness on the needs of the disabilities among Health Community Workers and general public. • Improve access to health and rehabilitation services to PWDs especially women and children with disabilities. • Update National Community Based Rehabilitation (CBR) guidelines and resuscitate and expand CBR programme to all districts. • Increase awareness on occupational health. • Strengthen mechanisms for early detection such as the “At Risk” programme and early treatment of disabilities. • Promote production of appropriate technology and assistive devices, strengthening training of personnel and equipment for persons with all types of disabilities. • Advocate development of national policy on the provision of assistive devices. • Strengthen accident and emergency services. • Increase awareness on occupational health. • Create awareness on injuries on children in the home, at school and on the road. • Create awareness on work place injuries in the health sector and develop appropriate preventive measures. • Train HCWs to provide appropriate counseling to victims and families. • Identify hazards in the health sector and develop appropriate preventive measures. • Develop and revise protocols and guidelines for management of various RTA and other accident related conditions. • Train HCWs to provide appropriate counselling to victims and families.

2.7 — CARE OF OLDER PERSONS and AIDS epidemic. The vulnerability levels for

2.7 CARE OF OLDER PERSONS and AIDS epidemic. The vulnerability levels for these groups has increased as social structures Trends and current status continue to collapse due to the death of Over the past ten years, the health sector has breadwinners and the rural-urban rural migration, sought to concentrate its focus on specific resulting in the loss of family assets, savings, family population groups, rather than the wider issues of and community support systems. Whereas in the population growth in itself. The Primary Health past when there was a breakdown of traditional Care Strategy adopted by Zimbabwe has had structures, the immediate family usually took care positive results especially for children and the of older persons, this is now not always possible. reproductive age group. However, little has been done to address the growing needs of older The accompanying disintegration of households rpersons. Older persons continue to represent a has also led to the burden of family care, shifting small proportion of the entire population, but to grandmothers and other members of the their health and other needs should be considered extended family (where they still exist), leading in in the perspective of the gradual expansion of some cases to family disunity and child neglect. geriatric services. Priority should now not only be The health consequences that arise include given to infants, children, adolescents, but must emotional deprivation, pscho-social problems, include the well and sick older persons. isolation, maladjustment behaviour, malnutrition and homelessness and its consequences. Nothing has caused more alarm with respect to these groups as the effects and impact of the HIV The harsh economic situation experienced from PAGE 78 The National Health Strategy For Zimbabwe 2009 - 2013 the dawn of the new millennium has wiped out Public hospitals and other voluntary old peoples' coping mechanisms to ameliorate this situation. homes have no capacity to support long term Whilst older persons, who now care for their residential care for the majority of older persons. grandchildren, did not warrant attention ten years They also lack capacity in the area of home-based ago, the situation has substantially changed, care support to the older persons. These increasing their vulnerability and that of the observations bring to the fore the necessity to children they care for and those that are homeless develop a comprehensive, needs driven, policy or living in the streets throughout the country. For framework that takes into account the factors now, the prospect of a secure old age for the enabling older persons to enjoy long and healthy majority of people remains bleak and uncertain. lives. This results partly from the traditional belief that the “elderly will be looked after by their own folk”, Opportunities exist for beneficial collaboration and that they would have purchased medical aid between the government, the voluntary and private cover during their working life. Unfortunately sectors, local authorities, missions and families, to however, medical aid has something to offer only develop and design a living package for the elderly. to a rich minority. Medical Aid Premiums are The inevitability of ageing, as it affects all, should high, and likely to remain beyond the reach of motivate stakeholders to adopt a balanced many older persons, even if prices become more approach towards attending to this need. In this realistic. collaboration, the crucial principle is that both the well and sick older persons should receive the right There are no mechanisms to help those who are care when they need it. “asset rich” but cash poor, with all their “wealth” tied up in the value of their homes and perhaps The main challenge for supporting the needs of livestock. There are also no means to reassure older persons is to design a programme explicitly those who are already old and in immediate need to meet the needs of both the well and sick older of a variety of services. The long-term care needs persons of the older persons are currently provided by the voluntary old people's home system, originally These needs are necessitated by the early death of developed for minority groups. Continuity of care the older person's own children, who traditionally in their own homes is traditionally what older cared and provided for them mostly in the older persons deserve. Exemption from fee payment, at person's rural home environment. the time of need, falls short of this expectation. Key issues There is now need for both the Ministry of • Roles ambiguity among stakeholders. Health and Child Welfare, the Department of • Non availability of both geriatricians and Social Welfare and other stakeholders, to engage on geriatric nurses. this matter. Roles and responsibilities need to be • Lack of resources to support long term clarified. The care of older persons, whether they residential care to the majority of older are sick or not, requires special skills in order to persons. ensure their continuous comfort. As the care of • Lack programme to support home and older persons has not been a priority for reasons community-based care. mentioned above, the training of human resources in this area has also not been a priority. As a result, the country has neither geriatricians nor geriatric nurses. Equity And Quality In Health: A People's Right PAGE 79 Goal 15: To improve the quality of life of older persons Objectives Strategies To promote the well being • Conduct rapid health needs assessment for the older persons. and quality of life for older • Define package of support required by older persons looking after persons orphans. • Develop IEC material on older persons and the services available for them. • Develop formal and short time training programme for HCWs on geriatric care to create awareness amongst HCWs in older persons and their needs. • Establish wellness clinics/Geriatric clinics for older persons where they can attend. • Extend the supplementary feeding programmes to older persons in need (based on the determined inclusion criteria). PAGE 2 The National Health Strategy For Zimbabwe 2009 - 2013 PART 3: Health Systems Strengthening Equity And Quality In Health: A People's Right PAGE 81

3.1 — HEALTH SERVICE DELIVERY The other key community health worker is the

3.1 HEALTH SERVICE DELIVERY The other key community health worker is the Community Based Distributor (CBD). The

3.1.1 — Clinical Care And Quality Of Services Community Based Distributor's main function is

3.1.1 Clinical Care And Quality Of Services Community Based Distributor's main function is to promote family planning services including the Trends and current status re-supply of appropriate contraceptives to eligible The Government of Zimbabwe, in line with the clients. However, only 332 CBDs are in post Primary Health Care strategy of organizing compared to an establishment of 900. In response services, aims at ensuring the provision of quality to epidemics a number of other community health and safe health services that meet the needs of the workers such as the “Chloroquine/SP holders” people through a network of health facilities have also been established. organized to function on the basis of increasing levels of sophistication. Patients with more The primary level incorporates the first point of complex health problems are expected to be contact between the people and the formal health referred up the referral chain. Each level of care is sector, the Rural Health Centre or clinic. This is expected to provide a package of well defined the most peripheral unit of the health delivery services provided by appropriately trained health system i.e. the Primary Care facility. Each Rural professionals. The public health delivery system Health Centre is expected to cover a population of consists of four levels of care: primary, secondary, 10,000 and should be accessible to the community. tertiary and central levels. Core health services The expectation is that no person should be more have been defined for the primary and secondary than 8 kilometres of walking distance of a RHC. levels but have not been costed. Work on defining Both the Access the Health Services Study (2008) the core health services for the tertiary level has and the Assessment of Primary Health Care in started. Zimbabwe (2009) note that physical access to health facilities is still a challenge as some people Primary Level have to travel more than 10 kilometres to reach a The primary level consists of a network of health health facility. The “outreach mobile services” that centres and community health workers. Village used to serve them are no longer functional. Health Workers, the first amongst community health workers, are the key link between the The Rural Health Centres (RHC) provide basic organized village community and the local health but comprehensive promotive, preventive, curative services. The role of Village Health Workers is and rehabilitative care, concentrating on mother fundamentally promotive, educative, and and child care including antenatal care, delivery of preventive, mobilizing the community and the uncomplicated births, family planning, child health individuals for preventive health activities. Village and nutrition, routine immunization for children health workers are the first line health workers for and anti-tetanus immunization for child-bearing treatment of simple conditions, disease women, environmental sanitation, especially in surveillance and for enhancing health information relation to small-scale water supplies and excreta systems. On-going technical supervision of Village disposal systems, control of communicable Health Workers is provided by the local staff of diseases, other specified problems including mental the rural health centres, which keep the village illness, eye diseases and physical and mental health workers supplied with medicines and handicap, and general curative care including oral equipment at government expense. Village Health health. Health and nutrition education form part Workers refer and also encourage communities to of all the above activities. Rural Health Centres seek treatment early from a rural health centre or provide support and supervision for community clinic. The original plan was to have one village health workers. Health centres are staffed by two health worker for every 100 households. The nurses, one of whom should be a midwife and an Assessment of Primary Health Care in Zimbabwe Environmental Health Technician. Unfortunately (2009) notes that less than half of the households midwives are not available in most of these (46%) reported having access to a Village Health primary care facilities. This has compromised the Worker in their wards. Furthermore, they are no quality of care given to expecting mothers. The longer being supplied with basic medicines as the establishment of two nurses at the RHC is no clinics have nothing to give out. With the advent longer adequate given the increase in work load. of new challenges and opportunities in the health Environmental Health Technicians are very few sector, there is need to enhance the training with a high national vacancy rate of over 50%. programme of VHW to embrace community This negatively affects the provision of maternal and neonatal health, cholera, influenza environmental health services. and NCDs. PAGE 82 The National Health Strategy For Zimbabwe 2009 - 2013 Overlooked over years is the role of general has not been possible. Support to doctors in practitioners and nurses in running primary care district hospitals by specialists is limited and in services mostly in urban settings. They concentrate some instances, non-existent. on providing curative services. There is now need to look at the possibility of involving these groups In theory, patients are required to present at the in the provision of selected public health services primary level first and then be progressively over and above TB and immunization. referred to the Secondary, Tertiary or Quaternary levels depending on the complexity of illness. In Secondary Level practice, the experiences of the past decade have Rural health centres refer patients to District shown that the referral chain has broken down, Hospitals (secondary care facilities). Each district with all referral hospitals replicating the work of is supposed to have a district hospital and should the Primary level. At Harare and Mpilo Central save a population of approximately 140,000 Hospitals, it is estimated that about 75% of people. The district hospital provides referral and patients presenting are self referred. This, in itself, supervisory support to the network of clinics and is indicative of the gross misuse of resources in the Rural Health Centres in the district. They also health sector. provide comprehensive preventive and curative services. Patients have their first contact with a This is partly associated with the failure to apply medical doctor at this level within the health administrative measures to enforce the referral delivery system. District hospitals refer to chain. However, more fundamental is the fact that Provincial Hospitals (tertiary care facilities) where availability of funds for maintenance, upgrading patients meet a specialist. There are currently a few and essential supplies have decreased in real terms districts without a district hospital or designated across the system. This, coupled with increases in district hospital. Some of the district hospitals demand, has led to the deterioration of the quality train nurse and midwives. of services, particularly primary care services. The result is that people simply bypass this level Tertiary and Quaternary Level because services are perceived to be of poor Most provinces have a provincial hospital except quality. Whilst in the past, the referral facilities Matabeleland North where the provincial hospital were better resourced hence more functional than is under construction. The provincial hospital level the primary care facilities, the situation has provides referral support to district hospitals. changed. Central hospitals are experiencing the There are a limited number of specialists at the same challenges of limited resources. Basic medical provincial and general hospitals. Provincial equipment and consumables are very often not hospitals refer to Central (Quaternary) Hospitals available. Most of the fixed equipment such as in Bulawayo, Chitungwiza and Harare that provide, elevators, boilers and heating systems have reached together with private for profit hospitals, the more their end of life and are therefore not functional. sophisticated type of services within the country. Specialist professionals in all fields are in short All provincial hospitals train nurses and/or supply. The few staff that are available are midwives. overworked and demoralized. The referral chain works best when the patients In the meantime, teaching at all levels is suffering. referred from the lower levels receive the benefit of The quality of health personnel trained is heavily specialist opinion. In reality, because of the dependent on the clinical activity schedule of the shortage of mid level doctors, a patient referred by institutions. The heavy staff attrition has taken an experienced Government Medical Officer at away experienced manpower leaving recently District Level, or, worse still, by a Specialist from a qualified staff to train students. provincial hospital, is often being seen by a very junior medical officer at the central hospital. This The environment within which heath workers is compromising the quality of care being given to perform their work is key in cementing their patients. relationships with patients. The present state of infrastructure does not create a healthy The planned decentralization of specialist services environment for both patients and staff to enjoy to the provincial level in the 1997 -2007 Strategy the healing process. Both patients and staff expect did not succeeded to a significant extent. that facilities and equipment, essential to support Availability of specialists at the provincial hospitals recovery paths, are up to standard and functioning. would have facilitated the training of intern This is a source of disgruntlement among health doctors and trainee medical specialists at this level. workers, who feel that their work environment does Again, because of the shortage of specialists, this not further their professional growth and job Equity And Quality In Health: A People's Right PAGE 83 satisfaction. On the other hand, patients continue continued to work with various consumer to express disgruntlement over the poor quality of organizations to identify the needs of consumers services arising from this situation. and to educate them about their rights. The patient's charter was one of the first coordinated Communities, patients, their families and staff, are steps towards informing consumers of what to the best placed to judge quality because of their expect. More needs to be done to incorporate the personal or communal experiences. Ignoring this consumer's perception of the quality of care in the and failing to involve them may result in the health process of service delivery. system not responding to the actual needs of the population. In the Access to Health Services Study The MOHCW has been encouraging an (2008), patients and communities rated the service environment in which stakeholders develop and quality they receive at health centres/hospitals as implement a range of quality assurance tools, such satisfactory or fair, whilst in the Assessment of as treatment protocols, management and standard Primary Health Care in Zimbabwe (2009) less operating procedures, clinical audits and reviews than half of households in the study were satisfied that ensure that all communities have access to with the performance of the health system (service quality core health services. The MOHCW has quality and outcomes). People could have been delegated quality assurance responsibilities to reflecting the hardships experienced in 2008. appropriate bodies such as professional bodies and technical agencies, operating from the national, The 2003 Poverty Assessment Study Survey provincial and district levels. However, quality (PASS) revealed, and the 2007/8 Study on Access assurance programmes are not yet an integral part to Health Care Services reaffirmed, that in the of health care. event of illness most people seek treatment from public health institutions. However, communities Health services in Zimbabwe are delivered by a complained about the long waiting time they have multiplicity of players, both public and private, to endure before being treated. They were also involved in direct service provision and financing, unhappy with chronic shortages of supplies and or in some cases, both. This raises the question of drugs, poor water and sanitation services at health how to ensure that their conduct is in the public institutions and lack of electricity, resulting in interest. This has become a concern because of them being requested to bring candles if they need the tensions existing between public interest and attention at night. They also complained of private gain. The work of health professionals is shortages of staff leading to long waiting times, regulated through self regulatory mechanisms, as shortages of food and poor hospital diet, and lack has been the tradition in many countries. The of ambulances services. Even if ambulances were professional councils which regulate their training, available, community members were at times accreditation and professional conduct, are created requested to provide their own fuel for emergency for and run by them. Traditionally, this has been services. They were also very unhappy with what based on the belief that the professionals they view as a much longer and costly referral themselves know best, and are better placed to system, where basic medicines are not available at ensure that standards are maintained based on local peripheral clinics and they have to be referred service or professional ethics, written or assumed. to district or provincial hospitals. Communities The belief amongst health professionals that the wanted to see doctors visiting peripheral facilities, practicing licenses granted to them gives them the so that they can be attended to nearer home and right to pursue professional interests without being avoid high transport costs. questioned should be discouraged. Licensing is in fact the basis of a social contract between society According to the same study, communities expect and health professionals, in pursuance of the to be treated well by committed and motivated public interest and good. This arises out of the staff, with readily available drugs and equipment. acknowledgement of the nature of their They expect good client care, quick service, from relationship with those they serve, in that the latter adequate numbers of staff working in a clean, safe surrender their power of judgment to the and hygienic environment. They also expect respect professional. for confidentiality, as well as the availability of adequate and nutritious food at health institutions. The context has changed. New pressures and Most public health institutions are far from opportunities have emerged over the last few years, meeting these expectations. creating new and perverse professional values which emphasise private gain at the expense of the The Ministry of Health and Child Welfare has public good. Within the public sector, this “cultural” change has been fuelled by policies PAGE 84 The National Health Strategy For Zimbabwe 2009 - 2013 which have encouraged private provision and institutions. The few remaining well trained health subcontracting, in efforts to improve efficiency and professionals are frustrated as they are rendered quality. helpless as they are not able to answer to their callings. It is not possible to provide quality care This has also had the effect of reinforcing the without the tools of the trade. belief and view that public sector provision is inferior to private provision. Human resource Improving the supply side capacity response at all strategies, which focus on individual incentives and levels, in order to improve quality, remains a major private activities, may also influence the shift from activity for the future. The key to success lies in the public sector ethos towards a culture of achieving an appropriate balance between resources individualism. Health professionals will no doubt devoted to Primary Care and hospital services. To find moral justification for this shift in their low this end, the initiative to make hospital services salaries and poor conditions of service, and to a more efficient and responsive to the needs of lower certain extent this is understandable. However, levels and referred patients remains a major goal clearly the current means, in the form of self for the health sector. Secondary and tertiary health regulatory structures, are weak to deal with these facilities need to be revitalized for them to provide pervasive behaviours. the much needed referral, teaching and supervisory services. The utilization of health services is also being affected by the low incomes people are earning. In Key issues a bid to raise funds to purchase vital and essential • Mapping of coverage of RHCs. medicines and supplies, some institutions have • Improving coverage, access and utilization of been charging user fees for services that normally health service delivery. would be free. The Maternal and Perinatal • Institutionalizing quality of care initiatives. Mortality Study (2007), the Health Services Study • Increasing the number of qualified health (2008), the Assessment of Primary Health Care in professionals. Zimbabwe (2009) studies note that user fees for • Strengthening professional ethics through the services are considered unaffordable by the schools and professional councils. community, and are contributing to reduced access • Strengthening professionals associations and to services especially for poor and vulnerable councils. communities. Figure 28 shows this gradual • Strengthening the referral system. decrease in utilisation of services. • Adequately resourcing each level of care and ensuring minimum stock levels at all times for Figure 28: OPD and Inpatient admissions all strategic supplies. • Re-enforcing the Primary Health Care OPD Attendance Approach. 6,000,000 • Strengthening the secondary and tertiary 5,000,000 service delivery. 4,000,000 • Strengthening the health system in a resource Number of Cases constrained environment. 3,000,000 • Redefining core health services for each level of 2,000,000 care. 1,000,000 • Operations research. 0 AD 2004 AD 2005 AD 2006 AD 2007 AD 2008 Year Subsequent sections in this document including those addressing human resources for health, health infrastructure, transport, communications, medical equipment and supplies, highlight the challenges in most health facilities. The major challenge in all the above is the unavailability of funds. Most medical equipment is obsolete and vital medicines are no longer available at health Equity And Quality In Health: A People's Right PAGE 85 Goal 16: To increase coverage, access and utilization of affordable, comprehensive and quality preventive and curative health services. Objectives Activity/Strategies To improve the • Redefine, cost and lobby for the funding of an Essential Package of functionality of Primary Health Services that covers both clinical and public health Health Care clinics and the interventions for each level of care (Core services for each level of referral hospitals (district, care). provincial and central • Revitalize, strengthen and ensure the implementation the referral hospitals) comprehensive Primary Health Care approach. • Revitalize and strengthen referral Health Facilities (district, provincial and central hospitals). • Rehabilitate existing health facilities and only construct new ones in exceptionally needy areas. • Train additional health workers with special emphasis on critical shortage areas. • Increase coverage through involving private health providers. • Train more and equip community health workers with special emphasis on Village Health Workers and Community Based Distributors. • Resuscitate mobile outreach clinics in the hard to reach areas. • Increase the availability of medicines, medical supplies and other health facility strategic supplies. • Adequately equip all health institutions in accordance with the Core health services as defined for each level of the health care system. • Create a transparent and accountable procurement system to achieve value for money. • Ensure the availability of adequate and relevant support service facilities at all levels of the health services including laboratory services. • Strengthen the referral system by providing adequate ambulances and radio or telecommunication means. • Strengthen and enforce compliance with the referral system. • Strengthen supportive supervision, monitoring and reporting mechanism. To improve the quality of • Develop and implement a National Quality Assurance Programme care provided in health in the Health Sector particularly in the areas of infection prevention facilities and control, patient safety and clinical audits. • Develop SOPs for the hospitals and various levels of services delivery. • Review and develop (where necessary) clinical management policies, standards, guidelines and protocols. • Strengthen clinical audits at all levels of care. • Continuously train and update the diagnostic and case management skills of health workers. • Carry out periodic patient satisfaction surveys including operational research. • Review and implement the provisions of the Patients Charter. • Improve efficiency of hospital management teams. • Improve hotel services in hospitals. • Develop a strong information, education and communication programme aimed at improving the attitude and behaviour of health workers towards their clients. PAGE 86 The National Health Strategy For Zimbabwe 2009 - 2013

3.1.2 — Transport And Communications well as the lack of public transport due to poor

3.1.2 Transport And Communications well as the lack of public transport due to poor road networks. Communities are equally concerned Trends and current status about the transport system. The Access to Health Care Services Study (2008), noted that most rural Transport communities feel that because of the importance Transport and telecommunications form the and centrality of health in their lives, the solution essential physical link between the different levels to ambulance problems requires the urgent of care both in terms of the referral of patients, injection of funds from central government. supervision, outreach services and the supply of commodities. Both are important components of In an effort to improve the management of the health care delivery system. The Ministry of vehicles, the ministry de-linked its fleet from the Health and Child Welfare aims at providing a Central Mechanical Equipment Department complete transport and communication package (CMED) to Riders for Health and private garages. for each level of care. To that end, a transport The objective of this transition has however not policy has been defined and is being implemented. been realised as noted by the Access to Health Care Services Study (2008). The study noted that With the aim of meeting the transport standards vehicle repairs and maintenance of the fleet needs for each level of care, a number of ambulances, urgent attention, as there are currently ambulances service vehicles and motor cycles, have been and health programme supervisory vehicles that are directly purchased by the Ministry. The Ministry's off the road because of none repair and lack of efforts have been complemented by partners, who spare parts. have also purchased a number of programme vehicles. However, the Health Service is far from The few available vehicles are paradoxically under- meeting its target of vehicle availability as stated in utilised, due to difficulties in accessing fuel from the policy. Lack of transport has been found CMED and the general shortage of fuel in the through a number of studies to be a major barrier country. To ensure constant availability of fuel for to access and quality of health services. critical services, some institutions installed fuel tanks and purchase fuel direct from NOCZIM, A study on the maternal and neonatal services in when available. Zimbabwe (2004), identified transport and communications as one reason for the delay in Having realized that transport is a key pillar of the reaching treatment centres for pregnant mothers health system, not only for service delivery but also and children, thus contributing to increasing for transportation of health workers, and also morbidity in this group of the population. having noted the breakdown of the public transport system, the Ministry of Health and The 2005 Districts Management Study in 25 Child Welfare has actively been sourcing for buses districts cited transport shortage as a major and vehicles. The major obstacle in fulfilling this obstacle to service provision, contributing to task has been the shortage of foreign currency. breakdown of the referral system and delays in However Government, through the critical staff transportation of commodities (food, vaccine, retention scheme, is complementing the ministry's dugs etc). A child health situation analysis study initiatives by availing vehicles to selected health (2006) indicates that the “referral system, staff, as well as buses for others. supervision and support to lower level health facilities and outreach for community work” have Transport thus remains a major challenge in the all been compromised by the shortage of provision of services. Immunization, malaria transport. The Maternal and Perinatal Mortality indoor residual spraying, drug distribution, Study (2007) noted that only 52% of rural supervision of districts and clinics, have all been women delivered in health facilities compared to compromised due the shortage and poor 94% in urban areas. This difference was caused maintenance of transport and telecommunications. mainly by the difficulty rural women faced in Inadequate ambulances, high maintenance costs, reaching a health facility. erratic fuel supply and poor communication systems in health facilities, limit outreach activities The Access to Health Care Services Study (2008) and contribute to adverse outcomes, particularly in revealed that most people in rural areas, living far maternity care, acute care and emergencies. from health institutions, are using wheel barrows and scotch carts to ferry the sick to health Telecommunication facilities. This is because of the very high A functional health facility connectivity package transport costs (when transport is available), as (telephones, cellular phones, two-way radios and Equity And Quality In Health: A People's Right PAGE 87 internet) is essential for emergency referrals to (2008) and the Vital Medicines and Health higher levels of care. This is essential for the Service Survey. The 2008 study noted that with transmission of important data, epidemic alerts, the exception of very few rural institutions, administrative and management support. Remote telecommunication services are now nonexistent areas benefit from clinical advice communicated and in a state of disrepair due to lack of through various means. maintenance. This has made communication in cases of emergency and referrals extremely In areas where there is telephone connectivity, difficult, with the inevitable unnecessary loss of some telephones have been installed, whilst in areas life in some instances. At many institutions covered without, either radios or cellular communication by the study, phone or radio equipment is available has been provided. At all levels of care, with the but what repair and rehabilitation of the networks exception of Rural Health Centre level, computers is required. have been acquired, thus improving the efficient production of information and its flow through e- Key issues mail. Linked to telephones, some institutions now • Inadequate numbers of ambulances and service have fax machines and access to e-mail and internet vehicles. services through HealthNet. In addition, the • Poor transport management of systems. ministry has established its own web site. • Poor connectivity and communication systems. However, a lot more work needs to be done as shown by the Access to Health Care Services Study Goal 17: To increase availability of transport to at least 75% and communication systems to 100% of the requirements levels Objectives Activity/Strategies To increase availability of • Vehicles and motor cycles procured in line with the transport transport at all levels package for each level care. • Transport management systems strengthened. To increase availability of a • MOHCW IT policy and strategy developed. reliable communication • Radios, phones, computers etc in line with the communication package at all levels package for each level care.

3.1.3 — Health Infrastructure (2008), found that most communities live within a

3.1.3 Health Infrastructure (2008), found that most communities live within a 5km radius of their nearest health facilities, 23% Trends and current status between 5 to 10 km, and 17% over 10km from Distance from the nearest facility is an important the nearest health centre. factor in planning for health care services. Health facilities must be located within a reasonable The Access to Health Care Services Study (2008), distance, and the cost of seeking service should be found that most people walk (85%) to the nearest affordable for equitable health care delivery. In the health facility, whilst a considerable proportion use rural areas where transport is less accessible and a wheel barrows and scotch carts. Very few people higher proportion of people live, the importance use public transport when visiting their nearest of geographical proximity of health services health facility. The study noted that access for cannot be over-emphasized. those living far from health facilities is extremely difficult, due to lack of transport in the rural areas, The standard practice in health infrastructure where most roads are in disrepair. In the Maternal planning and development has been to ensure one and Perinatal Mortality Study (2007), distance to rural health centre per 10 000 population; one a health facility and lack of transport were found district hospital per 140 000 population; and one to be major barriers to access to institutional provincial hospital per province. By 1997, 85% of deliveries. The study recommends the construction the population lived within 8 km of a primary care of “waiting mothers shelters” at strategic health facility. Population movements, as a result of the facilities to overcome these two challenges. agrarian reform programme and natural population growth, have reduced geographic To increase physical access, a number of accessibility in some parts of the country. The just construction projects were initiated over the last completed Access to Health Care Services Study ten years. However, whenever funds have been PAGE 88 The National Health Strategy For Zimbabwe 2009 - 2013 made available, construction activities have been It is worth noting that health infrastructure capital very slow, resulting in some of the projects taking investment has not kept pace with population up to 10 years to complete. There are currently a expansion; notably, a big gap continues to exist in number of projects that have come to a standstill secondary care facilities in urban areas. This as a result of inadequate funding, but also due to situation has resulted in Provincial and Central poor management of contracts. A position of Hospitals being used as first referral centres hospital engineer has been created in the Ministry leading to congestion and a fall in the quality of to address this situation and institutions have also services offered (pg 83). It is in this area that been encouraged to resuscitate commissioning opportunities for Private Sector participation committees to manage new projects. Some should be vigorously examined and exploited. institutions have established their own posts for However, there is also need to construct additional hospital engineers or an equivalent, to oversee the secondary facilities in large urban areas. maintenance and refurbishment of health facility infrastructure including estate management duties. In order to identify the gap in meeting the health infrastructure development standards and improve Resources being allocated for maintenance under physical access to health services for the the “maintenance vote” (budget line item) are underserved, a comprehensive audit of availability grossly inadequate to meet all the refurbishment and condition of infrastructure was undertaken in requirements of the dilapidated infrastructure and the year 2000. Out of this audit, a 15 year health obsolete equipment. This chronic under-funding Infrastructure development plan was developed. for maintenance has resulted in some buildings The infrastructure development plan aims to being abandoned due to cracked and leaking roofs. produce a minimum package of infrastructure per level of care. However, the 15 year health Lack of accommodation has contributed to the Infrastructure development plan is not backed by inability to retain health professionals in most an investment plan. Furthermore, there is need to institutions. To that end, the Ministry has update it. continued to have accommodation constructed on site where possible. Table 5: Public Health Facilities as at 30 April 2006 Provinces Primary 1st Referral 2nd Referral 3rd Referral Total level level level level Harare 45 0 0 7 52 Manicaland 253 36 1 0 290 Mashonaland Central 130 15 1 0 146 Mashonaland East 168 22 1 0 191 Mashonaland West 128 22 1 0 151 Matebeleland North 92 17 0 0 109 Matebeleland South 105 18 1 0 124 Midlands 206 28 1 0 235 Masvingo 170 23 1 0 194 Bulawayo 34 0 0 7 41 Total 1331 181 7 14 1533 Key Primary level = Clinics and Rural Health Centers 1st Referral level = District, Mission and Rural hospital 2nd Referral level = Provincial Hospital 3rd Referral level = Central hospital and infectious diseases hospital Equity And Quality In Health: A People's Right PAGE 89 Challenges Key issues • Brain drain of technical staff for construction • Strengthen management of Public Sector and supervision of projects. Investment Programme (PSIP). • Limited physical access for some communities, • Staff accommodation. especially the newly resettled areas. • Maintenance of existing infrastructure. • Inadequate funding for infrastructure • Improving estate management development. • Poor maintenance and repair services. • Delays in completing infrastructure projects. • Poor contract management. Goal 18: To increase physical access of the population to appropriate health infrastructure for each level of care Objectivess Activity/Strategies To increase the availability • Update data base of available health facilities and their distribution. of functional infrastructure • Construct secondary level facilities in urban areas. in underserved areas • Construct on-site staff accommodation. including deliberate • Complete 50% of all ongoing construction projects. emphasis on developing • Update the data base for training schools and improve facilities at farm/resettlement area training schools. health facilities To regulate the • Develop policy guidelines. establishment of health facilities To upgrade and • Rehabilitate health facilities. rehabilitate health • Perform regular maintenance of facilities. infrastructure To improve availability of • Establish alternative water and electricity supplies for all health water and electricity facilities. services at health institutions

3.1.4 — Laboratory Services personal health care. Public Health Laboratories

3.1.4 Laboratory Services personal health care. Public Health Laboratories mainly focus on disease control and prevention. Trends and current status The major public health laboratories in the Laboratory services are an integral part of the country are the National Reference laboratories, health delivery system, essential in diagnosis, Government Analyst Laboratory, National treatment, monitoring and control of disease. As a Institute of Health Research and the National result of the change in disease pattern, there has Blood Service. Both the private and University been a huge increase in demand for laboratory laboratories provide clinical and public laboratory services to support national programmes including services, and actively support research activities in HIV, AIDS & TB. The laboratory is also required the country. One of the specialized laboratories to provide timely confirmation of outbreaks if especially critical to the health of the nation is the appropriate control measures are to be instituted National Blood Service. The laboratory is early at lower levels of health care service provision. mandated to provide safe blood and blood products to whole health sector. The Laboratory services are comprised of public and private components, and are further The National Reference Laboratories (Specialized differentiated by the type of services they provide. Referral Centres and Services) include the Clinical laboratories, the majority of which are National Microbiology Reference Laboratory found in and managed by health institutions, are (NMRL), the National TB Reference Laboratory the diagnostic laboratory services geared towards (NTBRL), National Virology Laboratory PAGE 90 The National Health Strategy For Zimbabwe 2009 - 2013 (WHO-Polio and Measles Laboratories at the programme. The State Certified Medical College of Health Sciences- Department of Laboratory Technician is expected to provide Medical Microbiology) and the Zimbabwe Quality services for the level of work carried out at district Assurance Programme (ZINQAP), which provides level. The higher laboratory levels (provincial and quality control and quality assurance to all the national) are to be serviced by laboratory scientists. registered laboratories focused on patient clinical and quality care. There has been a general deterioration of laboratory services where the tiered system has Laboratory services are organized to function on failed to provide the standard package of the basis of increasing levels of sophistication. supportive laboratory tests at each level of Each level of care is expected to provide a package healthcare. This has resulted in patients seeking of well defined laboratory services by appropriately services from the private sector where the costs are trained laboratory health professionals. For each prohibitive for the majority of the population. level, minimum standard requirements for However, support from the Global Fund (GF), equipment, reagents and supplies have been Expanded Support Programme (ESP) and other defined. There is however need to finalize and partners have however seen an improvement in the adopt the Zimbabwe Medical Laboratory provision of CD4, chemistry and haematological Standards which have not been implemented, services in some hospitals. despite having been developed in the late nineties. Human resources remain a major challenge, as Appropriate legislation to make participation in experienced Medical Laboratory Scientists and external quality assurance mandatory for medical those graduating from the Department of Medical laboratories needs to be developed and put into Laboratory Sciences at the University of place, to ensure that public, private, research Zimbabwe College of Health Sciences, continue to laboratories etc, can only provide services when leave the country for the region and overseas. their performance is deemed acceptable by the regulatory authority (the Medical Laboratory and The procurement and supply chain management Clinical Scientist Council). This is critical as of laboratory logistics including equipment needs wrong or poor quality laboratory results lead to strengthening. National reference laboratories ( the mismanagement of patients and wastage of National Microbiology Reference Laboratory, the resources. National TB Reference Laboratory and the National Virology Laboratory) need to have their To improve case management at the clinic and activities harmonized so they are responsive to the hospital ward levels, simple diagnostic tests are needs of the MOHCW. being carried out. This has been achieved, for example, through the training of nurses in rapid Key issues HIV and malaria diagnostic tests at rural health • Weak supply chain management of laboratory centre level. The Ministry has also been training logistics and commodities. Laboratory Assistants /Microscopists, and • Unavailability of a framework for the reintroduced the State Certified Medical coordination of laboratory support and Laboratory Technician (SCMLT) cadre in 2007 management. to perform rapid HIV, malaria and TB smear • Absence of policy and strategy. microscopy to service the first point of entry (the • Shortage of human resources. clinic or rural health centre). • Weak service delivery. • Weak monitoring and evaluation of laboratory For the second level, the Ministry of Health has services. re-introduced the State Certified Medical Laboratory Technician (SCMLT) training Equity And Quality In Health: A People's Right PAGE 91 Goal 19: To ensure the delivery of an effective, efficient, accessible, equitable, and affordable national quality assured network of tiered laboratory services. Objects Strategy To improve the quality of • Develop National Laboratory Policy and Strategy. clinical and public health • Revitalize the laboratory health system with special emphasis on the laboratory service provision reference laboratories. • Develop and implement an M&E system for laboratory services. • Define and provide a package of laboratory services for each level of care. • Review and provide guidelines for each level of care. • Strengthen the management capacity and coordination of laboratory services. • Strengthen human capacity development. • Increase the availability of laboratory supplies at each level of care. • Strengthen quality management systems for laboratory services. • Strengthen public-private partnerships. • Strengthen support and supervision of laboratory services. • Increase diagnostic capacity to diagnose MDR and XDR TB and other emerging conditions.

3.1.5 — Government Analyst Laboratory Toxicology, Clinical and Industrial

3.1.5 Government Analyst Laboratory Toxicology, Clinical and Industrial • Post-mortem specimens for toxic substances as The Government Analyst Laboratory (GAL) a service to the Ministry of Home Affairs offers analytical services to the MOH&CW (ZRP) and Forensic Science Laboratory (Environmental Health, Port Health Authority, investigating sudden death cases. Nutrition Unit, Hospitals and National Institute • Clinical samples for therapeutic drug of Health and Research), other ministries and monitoring, emergency toxicology; heavy private sector. The range of services includes metals, pesticides and muti poisoning and for scientific and technical analytical support to Food blood alcohol determination as a support and Drinking Water Safety Programmes, Control service to health care delivery institutions. of Exposure to Toxic and Harmful Substances • Customs samples for tariff classification. Programmes. It has capacity to analyze the food, • Mutilated currency to assist the Reserve Bank drinking and effluent water, industrial products, of Zimbabwe with valuation of its currency agro- products and clinical, anatomical (post claims. mortem) spacemen as listed below: • Pesticides formulations for active ingredient levels. Foods and Waters • Food samples according to the provisions of The laboratory has close links with other the Food and Food Standards Act (CAP 321). laboratories both within and outside the country • Food samples to provide a quality control involved in analytical chemical analysis and service to industry and in cases of suspected research. These include the National Research contamination. Institute, Public Health Laboratories, Standards • Water samples to determine suitability for Association of Zimbabwe, Tobacco Research human consumption and effluent water for Board, Research and Specialist Services, Forensic pollution control. Science Laboratory, Medicines Control • Food and Water samples to provide technical Laboratory, Water Research Laboratory, Harare information on matters related to food Municipality Analytical laboratory, Universities composition, quality, legislation and sources of and others. water pollution and treatment. • Urine and salt samples for iodine levels to The Government Analyst Laboratory is the monitor Iodine Deficiency Disorders. Secretariat to the Food Standards Advisory Board (FSAB) that deliberates on Food Safety issues nationally and participates in regional and international Food Safety Control initiatives such as SADC / COMESA Sanitary and Phytosanitary Measures and CODEX meetings and sessions. PAGE 92 The National Health Strategy For Zimbabwe 2009 - 2013 The challenges faced by the Government Analyst laboratory are adequately described under the laboratory section of this document. Key issues • High workload due to increasing demand for services • Non ISO 17025 compliance. • Poor coordination of laboratory services Goal 20: To improve on the quality of the national analytical laboratory services for food, water, toxicology / clinical and industrial inputs/products analysis. Objectives Strategies To improve the quality of • Analyze submitted samples according to ISO 17025 quality laboratory diagnosis standards timely and proffer expert technical advice that will assist decision making by stakeholders. • Incrementally improve the quality of analytical service delivery from 55% to 90% of ISO 17025 quality standards requirements by 2013. To improve the capacity of • Improve the equipment and instrument base to meet ISO 17025 the Government Analyst standards requirements from 40% to 90% by 2013. Laboratory • Advocate for the improvement of lab infrastructure. • Continuous human resource development. To strengthen the • To review the Food and Food Standards and water Regulations as administration of the Food necessary jointly with FSAB and adhere to international Sanitary and Water Safety and and Phytosanitary Food Safety Regulations. Quality Regulations to • Craft the National Food Safety Policy and steer the FASB activities. ensure availability of safe • To contribute towards the establishment of the Food Control food and water to the Authority. public To improve information • Compile and share analytical and legal information of non- collection, gathering and complying analyses results with the National Taskforce for dissemination as National Contagious and Infectious Diseases and Natural Disasters. Liaise CODEX and INFOSAN with Plant and Animal Health labs, Water Quality Lab, Forensic Contact Points, SADC, Science lab, Regional Drug Control lab, Public Health lab, NIHR, COMESA and FSAB Local Authority labs, Tertiary Institution labs and private labs. substantive member and secretariat. To be part of the nucleus of the imminent food control authority Equity And Quality In Health: A People's Right PAGE 93

3.1.6 — Medical Imaging (Radiography) And Technology (NUST) in Bulawayo, and X-ray

3.1.6 Medical Imaging (Radiography) And Technology (NUST) in Bulawayo, and X-ray Other Support Services operators being trained in provincial hospitals. The public health sector has no single radiologist. Trends and current status These are trained outside the country. The public health sector has a well established medical imaging system that is “available” in all A personnel monitoring service assessing district, provincial and central hospitals. However, individual radiation exposure and catering for both most of the equipment is either obsolete or non- the private and public sectors existed before, but is functional due to the shortage of spare parts. no longer serving the purpose it was created for due to shortage of staff. Because of the need for specialist services, Radiotherapeutic services are centralized in Harare Key issues and Bulawayo. Nuclear medicine, which is only • Lack of personnel monitoring service for appropriate in large referral hospitals is only individual radiation exposure. offered in Harare and Bulawayo. • Inadequate numbers of imaging health professionals being trained. The shortage of imaging professionals is being • Poor maintenance of basic imaging equipment. addressed through the training of radiographers at • Obsolete imaging equipment. Parirenyatwa and National University of Science & Goal 21: to increase access to high quality imaging services Objectives Strategies To strengthen the medical • Update the imaging equipment data base. imaging services • Procure imaging equipment for every district, provincial and central hospital. • Revamp the Radiotherapy facilities in BYO and Harare are fully functional. • Revamp the Nuclear medicine facilities in BYO and Harare are fully functional. • Scale up training and retain staff.

3.1.7 — Radiation Protection Unit • Human health - diagnostic and interventional

3.1.7 Radiation Protection Unit • Human health - diagnostic and interventional radiology, radiotherapy, nuclear medicine, Trends and current status nutrition and isotope molecular techniques in The Radiation Protection Unit has the role of diagnosis and treatment of HIV and AIDS, TB ensuring safety and security of radioactive sources, and malaria. proper management of radioactive waste and the • Agriculture - diagnosis and control of protection of people and the environment from veterinary diseases, tsetse eradication, the hazards of ionizing and non-ionizing improvement of livestock productivity through radiation, through the effective regulation and use artificial insemination, crop breeding, and management of radioactive and nuclear combating desertification. materials for beneficial peaceful purposes. The • Water - dam safety, underground water aquifers Unit has to ensure a balance of the benefits of development, water treatment. radiation uses against the risks of adverse health • Industry - industrial radiography e.g. for non- effects. destructive detection of internal defects or cracks in materials or welds. The country utilizes nuclear and radiation • Sterilization- high intensity radiation sources technologies in the areas of: are used to sterilize medical, blood and pharmaceutical products, insect control or for the preservation of food stuffs • Security e.g. electrically generated x-rays used in airports and other locations to check the contents of packages, mail, baggage etc • Teaching, Research and Development Laboratories and Universities. PAGE 94 The National Health Strategy For Zimbabwe 2009 - 2013 Radiation Protection fell under the Hazardous Loss of institutional memory has adversely Substances Control Act Chapter 322 of 1972 affected progress and implementation of the until August 2004. This Act also provided for the Radiation Protection Act. The initial Radiation safe use of other hazardous substances such as Protection Board that was appointed in 2006 industrial chemicals, their mixtures and could not manage to put in place the Radiation compounds. In order to comply with the Protection Authority of Zimbabwe owing to these International Basic Safety Standards for Protection challenges. The Minister of Health and Child against Ionizing Radiation and for the Safety of Welfare strengthened the Board in May 2008 by Radiation Sources (BSS), a bill was drafted to making new appointments and there are renewed separate ionizing radiation issues from other efforts to see the full implementation of the hazardous substances. Radiation Protection Act. The Radiation Protection Act [Chapter 15:15] The Unit aims to develop structures that will see passed through parliament in August 2004 and the achievement of all five thematic safety areas was operationalised on 1 July 2005. The Act within the next five years. provides for establishment of national regulatory infrastructure for nuclear and radiation safety that Key issues meets international standards as set by the • Setting up of the Radiation Protection International Atomic Energy Agency (IAEA). Authority of Zimbabwe. • Training of Radiation Safety Officers. The Unit has not been spared from the challenges • Creation of synergies with other Governmental affecting the health sector including human Departments that have responsibilities in the resources attrition and dwindling financial safety and security of nuclear and radioactive resources.The activities that the Unit should carry materials. out (authorization, review and assessment, • Radiological protection in occupational inspection and enforcement, development of exposure, medical exposure and environmental regulations and guides, radioactive waste radiological protection. management and personnel monitoring) have been • Emergency preparedness and response to hampered by the prevailing challenges thereby radiological accidents. seriously compromising safety. Goal 22: To reduce radiation exposure of both human beings and the environment Objectives Strategies To upgrade Radiation • Sharpen staff research and technical skills through relevant post- Protection Infrastructure graduate educational and technical programmes. &Services through the • Establish laboratories for research activities and quality control and implementation of the quality assurance. Radiation Protection Act • Strengthen collaborative networks with other regulatory authorities [Chapter 15:15] through participation in AFRA and IAEA activities. • Strengthen cooperation with regional regulatory authorities through exchange programmes. To ensure safety and • Implement robust radioactive waste management programmes. security of radioactive • Train key partners on safety and security of radiation sources at sources and contribute ports of entry. towards the fight against • Source for detection equipment for ports of entry. illicit trafficking • Sign MOUs with strategic partners. • Collaboration with international organizations and partners. To increase national • Increase awareness and understanding on the adverse health awareness of radiation consequences of radioactive substances. hazards and risks Equity And Quality In Health: A People's Right PAGE 95

3.2 — HUMAN RESOURCES FOR HEALTH in hand with higher human resource density

3.2 HUMAN RESOURCES FOR HEALTH in hand with higher human resource density (physicians, nurses and midwives per 1,000 Trends and current status population.) Human resources for Health (HRH) are arguably After the initial successful local production of a the most critical component of a health delivery high quality work force, Zimbabwe's health system. An appropriately trained, skilled and well delivery system has over the past few years been motivated workforce is a critical component hampered by a massive internal and external brain required for the efficient delivery of health and skills drain. This has resulted in the loss of services. The Ministry of Health and Child experienced qualified health professionals from the Welfare has therefore given human resources high public health sector. The remaining health priority, in order to increase access trained human professionals are now spread out thinly, to the resources and to achieve both the National Health extent that some institutions are now staffed by and Millennium Development goals. untrained cadres. This has reduced access for the population to treatment by trained and Zimbabwe has a physician density of 0.16, a nurse experienced health workers. The exodus has also density of 0.72 and an overall density of 1.23 reduced capacity to train and mentor additional health staff per 1 000 population. According to health professional, the World Health Organization (WHO), in order to be able to achieve its MDGs Zimbabwe should Figure 28 below shows the vacancy status from achieve a health worker density of at least 2.5 per 2005 to 2007. For certain categories of staff 1 000 population, i.e. a health worker density of training efforts have been doubled, and show a at least 250 doctors, nurses and midwives per 100 steady increase in the vacancy occupancy rates. 000 population. There is evidence that lower However the newly recruited staff lack adequate maternal, infant and under-five mortality go hand experience to deliver the core health services. Figure 29: Vacancy status Vacancy Status 100% 90% 80% 70% 60% Percentage 2005 50% 2006 2007 40% 30% 20% 10% 0% t en rs se s en t y ac ac y ry n n s er CW oc ur to tio io ag em to N tm m rm ra ra at H ag D ar ar Ph bo ist rm an O an ep Ph a La in fo M M M D Ad In m le p lth m nd og ra ho To ea sa Pr w tH rd he en co rt Re fo nm al iro To t En v Catagory PAGE 96 The National Health Strategy For Zimbabwe 2009 - 2013 The national vacancy status in the table above Whilst recognizing the common “push” factors hides the shortage of critical cadres, for example fuelling the brain drain in various professional midwives and theatre nurses in the nursing groups in Zimbabwe, the lack of recognition of profession, and pathologists and radiologists in the the extra professional burden peculiar to the health medical profession. Central and provincial worker has not been sufficiently understood as one hospitals do not have adequate specialists and of the major factors, despite the creation of the middle level doctors. Out of the 63 specialist Health Service Board as a “pull factor”. The work medical established posts eleven are occupied. The heathworkers do goes beyond merely fulfilling the objective of decentralizing specialist services to basic requirements of a particular job. The provincial and district hospitals through manpower relationships that health workers forge with users development has not succeeded to a significant are qualitatively different from other jobs, where extent. These specialists would have assisted in the interaction between client and service provider further training and supervision of health is less interdependent and intimate. Heath workers professionals at provincial and district levels. across the globe are very sensitive to this lack of Newly qualified doctors deployed to the districts recognition, from both the system itself and the are therefore receiving inadequate clinical and public in general. supportive supervision from specialist doctors. The high vacancy rates of 73% amongst consultants at Zimbabwe is capable of training most of its health central hospitals is affecting the quality of services human resources both at under and post graduate and training programmes. A very high failure rate levels. Training of health professionals is mainly was recorded amongst medical graduates in 2006 done by the Ministry of Education and the and 2007, which can be directly attributed to the Ministry of Health and Child Welfare. There are a shortage of consultants whose additional few private institutions offering training in human responsibilities include training and supervision of resources for health. health professionals. Increasing the numbers of trained health Figure 29 also does not show the existing gross professionals has been one of the strategies of inequitable distribution of health professionals, counteracting the brain and skills drain. In the last both between urban and rural areas and within three years, the vacancy occupancy rate for trained provinces. Staff inducement and retention outside nurses of 40% at the rural health centers has been major cities has remained a challenge since reduced to the extent that approved establishment independence. has been reached. This has been achieved through the scaling up of general nurse training and the Management capacity has been found wanting at introduction of the Primary Care Nurse (PCN) all levels as experienced hospital, ward, and programme. However, the challenge of continuing programme managers have left the health service. to follow this strategy is the lack of both lecturers Figure 29 above suggests an average vacancy rate of and tutors across all fields, with the vacancy rate 81% among the senior positions in the MOHCW. for tutors at a high level of 68%. This cadre is This means that the Ministry of Health and Child critical in the training of nurses and midwives. Welfare, as at December 2007, was operating with This has led to the observed high failure rate in the 19% of its approved establishment of senior nurse training schools particularly in midwifery. management positions. The College of Health Sciences in the University of Zimbabwe in late 2007 had a lecturer vacancy The vacancy levels in the various categories are a rate of up to 57%. Some disciplines, such as cause for concern and have serious implications for anatomy and physiology, had only one lecturer in the ability of the Ministry to meet its mandate. post as opposed to an establishment of between Doctors, nurses and other health professionals have 20 and 25. Similarly the high failure rate of left the health sector for greener pastures, citing students was experienced. poor conditions of service, an unconducive working environment, lack of requisite tools of the The shortage of lecturers and tutors makes it trade and the prevailing compromised economic difficult to increase training output in order to environment. The shortage of staff as a major reduce vacant posts. As a result, the number of concern has been confirmed through key graduates from some training programmes has informant interviews with health workers declined over the years and there will be very few unanimous in citing this as a problem (Access to specialists graduating from the medical school Health Care Services Study 2007). The study during the period of this strategy. Recruitment of noted that many vacancies remained unfilled at the expatriate specialists, as a way of alleviating the district hospital level, with junior personnel shortage of critical specialist skills, will be one way standing in for senior professional cadres. of meeting this challenge. Equity And Quality In Health: A People's Right PAGE 97 Innovative approaches in training have recently With the support of Government and been introduced, including the scale up of generic Development partners, there have been efforts to health worker training programmes such as X-ray manage the brain drain through incentive schemes Operators, Laboratory Technicians, Pharmacy meant to retain health workers. In the last quarter Technicians, Environmental Health Technicians of 2008 most health institutions were reporting an and Primary Care Nurses. This however is being average staff presence of about 50% across the compromised by absence of formal country-to- board, with Harare Hospital reporting the lowest country recruitment agreements. turnout rate of 15% in September/October 2008. Currently however turnout is over 80% of To strengthen the planning and management of expected staff, and is expected to reach nearly human resources, a Human Resources for Health 100% as staff are attracted and assisted to come Policy and Strategy, as well as Personnel back to work by the donor funded health worker Information Systems are at an advanced stage of retention scheme which provides an allowance to development.A Directorate of Human Resources health staff in US dollars as well as the has now been established at national level in order dollarization of government salaries. to coordinate and manage the human resources for health strategy. Key Issues • Failure to contain and manage brain and skills Retention of the remaining skilled health drain. professionals has been a priority for both the • Inequitable distribution of health professionals Ministry of Health and Child Welfare and the within the sector. Health Service Board. In the last few years, the • Unattractive retention incentive measures at all Ministry of Health and Child Welfare, together levels of care and management. with the Health Service Board and the Ministry of • Poor succession planning Finance has been mobilizing resources to provide • Low outputs from specialist training areas. incentives to motivate and retain health • Absence of bilateral/international agreements professionals. The Health Service Board was relating to HRH recruitment. established in 2005 through an Act of Parliament, with the mandate to create, develop and promote a conducive working environment in the public health sector, in order to overcome brain drain from the health sector. PAGE 98 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 23: To ensure that the health system based on PHC has appropriate numbers and categories of Human Resources for Health for efficient and effective implementation of the National Health Strategy. Objectives Activity/Strategies To develop and implement • Finalize the human resources policy and strategy. a human resources policy • Develop a detailed implementation plan for the human resource and strategy strategy. • Develop a monitoring system for human resources. • Strengthen the Human Resources department at all levels. • Establish functional human resources information system (Computerized personal information management system). To reduce vacancy levels • Improve salary levels, working conditions and other non-monetary across all staff categories by incentives to be comparable with the SADC region. 50% • Increase capacity of training schools including support and supervision. • Secure training places for specialties that are not offered locally. • Continue external recruitment for specialist shortages areas. • Scale up cadetship programme. • Decentralize medical specialists, internship and other specialists’ programmes to selected provincial and other hospitals with resources capacity. • Develop and implement a succession planning strategy. • Enter into bilateral/international agreements relating to HRH recruitment. To strengthen management • Adapt the performance appraisal system to fit with clinical work. at all levels • Resuscitate the training and management development programmes for all management professional and technical personnel. • Improve professional ethics. • Develop and implemented an orientation programme for all new employees. • Strengthen clinical audits.

3.3 — HEALTH INFORMATION Information policy but is left to health workers

3.3 HEALTH INFORMATION Information policy but is left to health workers (clinicians) and managers who are charged with the

3.3.1 — Health And Management Information delivery of optimal medical care

3.3.1 Health And Management Information delivery of optimal medical care. System And Research • At the Health Facility level, it serves operational objectives: the information is gathered to optimize A good health information system provides the Clinic and Hospital management as well as information necessary to provide and manage good operational issues of public health management. health services, while it strengthens the The objectives are related to good management of organizational system that provides these services the institution and of the management of the in accordance with the principle of Primary services offered to the community Health Care (PHC). This implies that (epidemiological, public health considerations). information is collected, collated and analysed at Insights gained through information gathered at different levels and used for action at that level. At this level allow health workers to make operational each level it serves specific goals, broadly choices. categorized as follows: • At administrative (District and Provincial) level health information serves a strategic objective: • At the patient level (clinical care): This Where it concerns epidemiology and disease information is necessary for optimal patient control, it may partially overlap and include management, i.e. for individual clinical care of elements of the operational level. Because of the both curative disease episodes as well as preventive larger scale and supervisory responsibilities of the services. This level of health information is often provincial level, the resulting actions are more of a not considered in the development of a Health strategic nature: distribution of resources over Equity And Quality In Health: A People's Right PAGE 99 larger areas (one district versus another), wider Polytechnic, while IDSR and basic epidemiology scope of institutions (support for govt. clinics or courses were introduced for staff at all levels. This council/mission clinics), choices of alternative training was designed to equip staff at these levels resource allocations, etc. These choices involve with skills to enable them to use health calculation (or, more often estimations) of cost- information for decision making. This training has effectiveness. proved to be very useful and has enabled • At National (and international) level, health operational levels to detect and respond to information should also contribute to policy outbreaks early. choices and action which are of a more all encompassing nature than the previous levels. Weekly sentinel surveillance data is being used to a Apart from strictly public health concerns, policy limited extent at the local levels, especially by those will be shaped by additional inputs from policy trained in IDSR and basic epidemiology. Others makers and often rises above the technical cost- are collecting data only for transmission to higher benefit levels of public health interventions. levels. This has resulted in some outbreaks being detected at the provincial or national levels, with From operational through to policy level, data the district or health facilities unaware of the gathered from the levels below is progressively outbreak. This problem has been compounded by more aggregated and complemented with inputs on-going brain-drain, as increasing numbers of from special surveys, scientific research and inexperienced staff take up posts at the operational international best practice and policy experiences. level. Furthermore, completeness of information returns remains a challenge, while no success has Reliable data is required on types of health services been achieved towards monitoring the private provided, coverage of health services, categories of sector. people benefiting from those services, incidence and prevalence of diseases, disease outbreaks, and A lot of effort has gone towards providing availability of human, financial and material Information Technology support for the districts, resources to support the delivery of health services. provincial and National levels. Most NHIS The data should be accurate, timely and complete departments at the various levels have access to in order to guide health managers to effectively computers as well as access to telephone and e-mail plan, implement, monitor and evaluate health facilities. Telephone facilities have however been services according to their level of responsibility. unreliable especially at the rural health centre level. Radio communication equipment linking Rural Trends and current status Health Centres and Districts hospitals, has largely been vandalized and is now unreliable. In response to emerging calls for increased availability of data for planning, implementation Apart from information generated through the and monitoring of health programmes, the NHIS, the ministry also relies on information Ministry of Health and Child Welfare designed generated through research. The National Institute and piloted a national health information and of Health Research (formerly Blair) is mandated surveillance (NHIS) system in 1985. The NHIS to champion this function. system was rolled out nationwide in 1988 followed by a joint evaluation of the system conducted in The institute was active in the first half of the past 1999 by MOHCW and WHO. Some challenges decade, generating research based evidence that has in data collection, analysis, reporting and influenced policy changes, for instance in the drug uniformity were identified and recommendations management of malaria, training of staff at for improving the system were made. Despite provincial and districts levels on operational and these challenges, the NHIS was awarded a SADC health systems research. This latter activity has trophy for being the best surveillance system in the largely died out and due to brain drain, research region in 2004. activities at the provincial and district levels have virtually stopped. A lot of effort has gone towards improving the NHIS in the past ten years. Posts for Health Recognizing the challenges being faced by the Information Assistants were created at district and systems designed to provide information to the mission hospital levels. Data collection tools have health delivery system for decision making, been constantly adapted to suit new information monitoring and evaluation, in 2005, the Ministry needs. Software packages have been developed for with the support of UNICEF, commissioned a data capture and storage. Health Information study to assess the causes of the problems and assistants training was established at Harare identify the most effective rectification measures. PAGE 100 The National Health Strategy For Zimbabwe 2009 - 2013 The assessment noted that the structures required Key issues for the proper functioning of the national health • Inadequate analysis and use of information. information and surveillance systems are in place. • Inadequate focus on performance indicators Generally, the information at the points of and targets. collection - in all types and levels of health facility • Inadequately designed software. - is complete. However, it was noted that the • Lack of access to communication facilities. information is increasingly less complete at • Lack of proper data archival/retrieval systems. District, PMD and headquarters respectively, • Irrelevant details and gaps in data collection. because of failure to update with late returns • Poor selection of sentinel surveillance sites. received at lower levels. The extent of analysis and • Weak human resource and management of use of information was noted to vary from information. programme component to component and facility to facility. The factors affecting the proper functioning of the information system were noted to be multiple and that they were related to management procedures, use of technology and design of the system. Goal 24: To provide reliable, relevant, up-to-date, adequate, timely and reasonably complete information for health managers at facility, district, provincial and national level Objectives Strategies To harmonise the functions • Establishment of a broad-based HIS stakeholders forum. of the Health Information • Selection of core and common health indicators. and Surveillance Systems • Development of the Health Information Strategy. • Operationalisation of the Health Information strategy. • Develop e-health framework and guidelines. • Establishment of a central health information repository. • Development of standard operating procedures (SOP) for data management encompassing both public and private health sectors. To strengthen Health • Adaptation/development of ICT based tools for supporting the Information and business processes of the Ministry of Health and Child Welfare. Surveillance systems • Improvement of data collection tools. • Capacity building in health information management and utilization encompassing both public and private health sectors. • Strengthen disease surveillance system in both the public and private health sectors. • Strengthen health information system operations research strategy. To increase the use of • Promotion of health information utilisation at all levels. information in decision- making To increase access to • Improved information access and dissemination. information that is ready to use To increase Human • Strengthen HR base in line with HIS strategy. Resource capacity in Health information strengthening To improve monitoring and • Regular performance assessment of the HIS. evaluation of HIS Equity And Quality In Health: A People's Right PAGE 101

3.3.2 — National Institute Of Health Research 3. Continued burden of preventable diseases

3.3.2 National Institute Of Health Research 3. Continued burden of preventable diseases The National Institute of Health Research, Malaria formerly Blair Research Institute, is a national During the past ten years various research centre for research, training and service in the fields projects were carried out on both the malaria of disease control, biomedicine and public health. parasite and the vector mosquito. The projects The Institute comprises the former Blair Research covered parasite diagnostics, drug resistance, Laboratory (established 1939) in Harare and the immunology, malaria interactions with other De Beers Research Laboratory (established 1965) parasites, mosquito behaviour, evaluation of in Chiredzi. Both units form the research arm of new insecticides (both synthetic and herbal) the Ministry of Health and Child Welfare. and insecticide resistance. The overall objective of the Institute is to carry Schistosomiasis out scientific research that promotes health The studies conducted focused on finding development to improve the health of the people alternative ways of reducing the disease burden of Zimbabwe through effective disease control and of schistosomiasis. These included biological solving problems associated with health care control of bilharzias using indigenous ducks, delivery. fish and plant molluscicides. Other studies looked at the interactions between The National Health Strategy for Zimbabwe 1997 schistosomiasis and other diseases such as to 2007 stipulated priority areas of health that HIV/AIDS and intestinal worms. required strategizing, including planning for disease management, control and prevention. It is 4. Water and Sanitation the disease control and prevention area that much The Institute embarked on a number of projects of the research conducted at the National Institute related to water and sanitation technology of Health Research focused on. development, transfer and implementation. Selected key performance areas that posed major Key issues challenges and which the Institute's activities • Retention of highly skilled research scientists. covered were: • Unavailability of equipment, chemicals and consumables. 1. Health Sector management and organization • Reduced support from donors. The Institute, through its Health Systems Research • Declining GOZ budgetary allocation (real Unit carried out a number of projects aimed at terms). finding ways of improving the quality of Health • Repositioning of NIHR as a node of research Service Delivery. excellence in the SADC region. • Addressing areas of priority research for 2. High HIV prevalence and AIDS burden informed decision and policy formulation. A number of projects were carried out to find out • Strengthening collaborative links with other more about the prevalence of HIV and AIDS local, regional and international research disease burden and ways of reducing the impact of institutions. the disease on the Zimbabwean population. PAGE 102 The National Health Strategy For Zimbabwe 2009 - 2013 Goal 25: To increase utilization health research findings for policy development Objectives Strategies To strengthen and market • Strengthen the capacity and institutional framework of the National the National Institute of Institute of Health Research. Health Research (NIHR) • Review and create an enabling environment for implementation national health research. • Redesign the NIHR web page and continue to update it. • Design and produce pamphlets to market NIHR’s research activities. To strengthen health • Identify areas of priority health research (including operational research capacity at all research). levels • Develop training modules. • Train various levels of health workers in health research. To conduct Essential • Identify priority health research areas. National Health Research • Develop proposals for approval and funding. • Implement the research projects. To develop and transfer • Develop prototype models of appropriate technology. appropriate public health • Test performance of models and modify accordingly. technologies to new • Develop appropriate public health technologies training modules. resettlement areas • Train communities on how to construct and use the technologies. • Roll out the technologies to new resettlement areas. To promote use of • Present research reports to stakeholders including policy makers. evidence based decisions • Develop policies and programmes based on evidence from and policies in the research. development, facilitation and implementation of health programmes To strengthen, national, • Write collaborative research proposals for research grants. south-south and north- • Run exchange programs that allow training of collaborative south research Institutions’ staff and also technology transfer. collaborations • Strengthen collaborative network through e-groups and e-mail.

3.4 — MEDICAL PRODUCTS, VACCINES became operational in December 2001. NatPharm

3.4 MEDICAL PRODUCTS, VACCINES became operational in December 2001. NatPharm AND TECHNOLOGIES is the major supplier of pharmaceuticals and medical supplies to the nation through the public

3.4.1 — Drugs And Medicines health system. The Essential Drugs List for

3.4.1 Drugs And Medicines health system. The Essential Drugs List for Zimbabwe (EDLIZ) guides NatPharm's Trends and current status procurements. Availability of medicines is an important element in shaping perceptions of the quality of services The performance of NatPharm depends on among users of health services. The aim of all in adequate financial resources, especially foreign the health sector should therefore be to ensure that currency, for it to be able to provide an efficient all health institutions have an adequate and service to public health institutions. The constant supply of safe and efficacious medicines, organization has not been able to obtain the surgical sundries and other supplies such as foreign currency it requires to purchase those diagnostic and laboratory reagents. medicines that are not manufactured locally. The national Government Medical Stores was Medicines and other pharmaceutical supplies are commercialised to form the National sold to public health facilities on a cost recovery Pharmaceutical Company of Zimbabwe basis. NatPharm is the procurement agent for the (NatPharm), with the aim of improving efficiency health sector, with priority being given to public in the supply of medicines and other medical health institutions, who are expected to procure supplies to public health institutions. The from NatPharm in the first instance. Only in cases company, a non profit making organization, where NatPharm does not have the items in stock Equity And Quality In Health: A People's Right PAGE 103 can public institutions approach private suppliers. Foreign Currency allocations to NatPharm The concept of setting up NatPharm was to declined over the years making it difficult for the ensure that the health sector benefits from the company to achieve 100% self reliance in the resulting economies of scale. procurement of pharmaceuticals. The foreign currency shortages also negatively impacted on the This should in turn translate into significant local pharmaceutical industry, which has to savings and mileage for the country's medicines procure raw materials from outside for budget. Such savings are however not being manufacturing medicines and other medical realized due to the very low stock levels at supplies. NatPharm emanating from foreign currency shortages. Institutions therefore continue ordering Currently, NatPharm requires approximately from the private sector at exorbitant prices. For US$65m annually for the public sector. However, example, a mini-survey of prices in the public and in the period 2004 to 2007, Natpharm only private sectors conducted in November 2007 received 3% of this amount. This is far below the indicated that one unit of 1000 aspirins was 56 company's requirements and has crippled the times more expensive in the private sector as company's operations over the years. As a result of compared to NatPharm. The exorbitant prices in the unavailability of foreign currency, stock the private sector resulted from differentials rates holdings had drastically declined to 20% capacity in the purchase of foreign currency. by December 2007. Below is the Average Stock Availability from 2004 to 2008. Table 6: Stock Status of VEN Items at NatPharm 2004 2005 2006 2007 Dec Jan Feb Mar Apr May June Sept 0ct Nov 07 08 08 08 08. 08 08 08 08 08 Vital 63% 72% 82% 42% 22% 29% 35% 32% 36% 38% 42% 52% 58% 42% Essential 21% 56% 62% 23% 16% 16% 18% 16% 16% 28% 34% 34% 38% 40% All drugs 41% 65% 68% 31% 18% 22% 22% 25% 26% 26% 35% 43% 45% 36% Availability for the first half of 2008 shows a declining trend.The VEN stock classification system in the Essential Drug List of Zimbabwe of medicines and surgical sundries was made on the following criteria: Vital items - life saving, non availability may result in serious disability or death, optimum availability to be 100%; Essential items – non availability may result in pain or discomfort to the patient, optimum availability to be 80%; Necessary items – required but of a lower priority than V and N, optimum availability to be 60%. The stock outs of much-needed essential It is worth noting that although the majority of medicines, vaccines and medical supplies in the clients in the study stated that patients should not system have limited the population's access to pay for medicines, almost a third stated that wholesome services, because they cannot afford to medicines should be paid for, to enable health purchase medicines from private sources. The centres to replenish stocks. This attests to a Access to Health Care Services Study (2008) paradigm shift from one that expects all health confirms the unavailability of medicines in the services to be provided for free by Government. country. The study found out that most people get their medicines from health centres (72%) whilst In the private sector, medicines and other medical 27% buy medicines from private pharmacies and supplies including gloves, cotton wool etc, are so one percent from private surgeries. The study expensive that they are generally unaffordable. however further noted that medicines are often not More often than not, the medicines are also not available (52%) at public institutions, where most available as this sector is also affected by foreign communities should conveniently access them. If currency shortages. This has forced some patients available, the medicines are for a fee in most to purchase medicines from across the borders or instances. The fee at most public institutions is from unlicensed vendors, further exposing however often a fraction of the actual cost, themselves to the possible dangers of sourcing although many clients stated that this was still medicines of unproven quality. unaffordable. The study noted that 50% of clients at times go home without prescribed medicines as Support has been extended to NatPharm in the they cannot afford to pay the cost price at health form of occasional capitalization grants. To institutions. improve medicines distribution, NatPharm purchased five delivery trucks to service all public health institutions. Furthermore, NatPharm has PAGE 104 The National Health Strategy For Zimbabwe 2009 - 2013 computerized all its provincial branches and is now efficacious and of good quality.The MCAZ has producing regular availability reports. Support has ensured that all medicines used in both the public also been extended to local pharmaceutical and private sectors are of good quality through medicines manufacturing companies that supply registration of medicines and licensing of generic medicines. One such company is now pharmaceutical premises. Together with the producing ARVs. ministry, the Authority has being enforcing the National Drug Policy. The national drug policy is Zimbabwe has received a lot of support from a an essential instrument for regulating the number of partners in ensuring the availability of importation, production, and distribution of essential medicines, especially at the grassroots essential and other medicines. levels. Since 2002, The European Union (EU), has been providing one third of all medicines and Management of pharmaceuticals at institutions has surgical supply requirements for the public sector also been of great concern. Experienced through NatPharm. Over the years, the proportion pharmacists have left the country for greener of EU supplies has been increasing in comparison pastures and this skills flight has not spared the to those directly purchased by NatPharm. The Ministry. There is a very high attrition rate of National AIDS Council (NAC), the Global Fund, pharmacy personal, making it difficult to USAID, DFID, ECHO, Irish Aid, Canadian efficiently manage the supply chain for medicines International Development Agency (CIDA), and other medical supplies. For instance, trained UNICEF and other UN agencies, have also been pharmaceutical staff were available in only 5% of providing medicines to the public sector. all health facilities according to the Vital Medicines and Health Service survey of 2009. At the beginning of 2009, resources for the Recurrent stock outs and lack of management procurement and distribution of 5,060 Primary capacity has made it difficult to determine the Health Care Package (PHCP) were secured from consumption rates, hence poor quantification of the Joint Donor Support programme for a period national requirements. A study carried out in 2006 of one year. With this support, drug availability at noted that those districts with pharmacy personnel the primary care level has greatly improved. There had a more consistent supply of pharmaceuticals is however a critical shortage of medicine at the than those without. This is believed to be due to referral facilities as the Primary Care Package of better management of the available supplies. drugs does not cover specialists' drugs for provincial and central hospitals. Unavailability of medicines remains a major challenge. The challenge has become so severe that Rational use of medicines has been promoted life-saving procedures are being postponed due to through the establishment of medicines the shortage of vital medicines. Furthermore, the therapeutic committees, training and deployment allocated resources were being affected by the of pharmacists and pharmaceutical technicians. hyperinflationary environment. A more recent and The Essential Drugs List of Zimbabwe (EDLIZ) worrying development is the pilfering of medicines remains the standard for prescribing medicines, and purchase of unregistered drugs from and has since been reviewed twice in the past 10 unapproved vendors. Major challenges are therefore years to keep up with new developments and being faced. knowledge. This process is spearheaded by the National Drug and Therapeutics Policy Advisory Key issues Committee (NDTPAC). Rational prescribing of • Inadequate funding and poor performance of medicines is further strengthened by the the Public Finance Management System. development, distribution and use of treatment • Failure to arrest the high attrition of protocols. A number of pharmaceutical, medicines pharmacists and pharmacy technicians. supervision and management programmes have • Failure to improve the security of supplies at been conducted as indicated above. NatPharm distribution and storage at Institutions. produces a monthly medicines status report. In • Weak monitoring and evaluation systems. turn, large institutions have also been producing • Weak supply chain management of medicines quarterly medicines status reports. and surgical sundries. • Failure to adequately recapitalize NatPharm. During the last ten years, greater autonomy was • Failure to increase capacity for local given to the Medicines Control Authority of production. Zimbabwe (MCAZ), as a way of improving drug • Failure to assure quality of donated medicines quality assurance systems, thereby guaranteeing before shipment. that medicines reaching the consumers are safe, Equity And Quality In Health: A People's Right PAGE 105 Goal 26: To improve overall availability of drugs, medical supplies and other consumables to 90% Objectives Activity/Strategies To increase medicines • Strengthen management and capacity of the Department of availability in all health Pharmacy. institutions to 100% for V, • Review and update policies (EDLIZ, Drug Donation). 80% for E and 75% for N • Provide adequate resources to purchase medicines and supplies as per standard for each level of care. • Continue Drug Monitoring and surveillance. • Continuous training in rational drug use and management of the supply chain of medicines and other related supplies. • Continue actively supporting NatPharm. • Promote and support local manufacture of pharmaceuticals and other medical supplies. • Lobby Ministry of Finance for increased budget allocation for medicines. • Encourage communities to set up security teams at district health centres. • Develop and expand the Medicines Information Systems and integration with NHIS. • Strengthen rational drug use at all levels. • Ensure availability of category C medicines to support PHC. • Improve and strengthen the disposal of expired medicines. To ensure 100% of all • Monitor adherence to pharmaceutical policies for all medicines. medicines entering the • Strengthen Medicines Control Authority of Zimbabwe. health sector are safe, efficacious and of good quality

3.4.2 — Medical Equipment and suppliers of medical equipment, it is now

3.4.2 Medical Equipment and suppliers of medical equipment, it is now necessary to revisit and update the standard list Trends and current status (with specifications) of equipment for each level of care. Medical equipment for diagnosis, treatment and monitoring of patients is essential and is required The last bulk purchase of medical equipment for in all hospitals. This includes equipment for public health facilities was in 1997; this saw a laboratories, research activities, and fixed plant number of institutions benefiting from diagnostic such as boilers and autoclaves. Currently available medical equipment. There has been no further bulk equipment is old, obsolete and non-functional. purchasing of medical equipment to replace the Lack of regular of maintenance and replacement obsolete equipment in health facilities due to lack of medical equipment is compromising client care of financial resources. In a bid to resuscitate the and leading to demotivation of staff and available equipment, an audit of the state of deficiencies in the basic training of health workers. equipment requiring spares was carried out in 2005 and this was followed by the purchase of the Policy has been to include procurement, identified spare parts. However, the audit noted installation and commissioning of medical that the ministry was using and repairing equipment in one package for all new health equipment that was no longer supported by any facilities. All the Family Health Project built manufacturer. The Ministry has thus not kept a hospitals and clinics came with equipment and data bank on the life of available medical other medical supplies. The Family Health Project equipment and is also not up to date with new built hospitals were equipped based on a standard medical technologies. list of equipment depending on the level of care. There has therefore been a Rural Health Centre Some institutions have however managed to and district hospital standard list of equipment purchase or receive donations from different derived from the Family Health Project rooming sources. A large consignment of emergency and equipping lists. With the many manufacturers obstetric care equipment was received from PAGE 106 The National Health Strategy For Zimbabwe 2009 - 2013 UNFPA in 2007. Laboratory items have been hospitals did not have 40% of essential received under the Global Fund and CDC. In equipment. The 2004 Maternal and Neonatal 2007, state of the art medical diagnostic Health Services study noted that institutions did ultrasound equipment was bought for each central not have basic equipment, including basic and provincial hospital. These supplemented other operating theatre equipment. existing high tech equipment in the form of Magnetic Resonance Imaging (MRI), Computed The 2008 and 2009 provincial visits by the Top Tomography, Digital Subtraction Imaging Management Team (TMT), the Minister of machines, although these have been in service for Health and Child Welfare and the Office of the some time. However, lack of foreign currency for Deputy Prime Minister noted the shortage of spare parts and equipment replacement has seen functional basic theatre equipment in all provincial some of these expensive technologies lying idle, or and district hospitals. It was noted that besides x- hospitals continuing to use obsolete equipment, ray machines, laundry machines, kitchen some of which might not be safe for patients. equipment and boilers, some essential pieces of laboratory equipment were non-functional. Equipment repairs have been carried out both internally and externally using the maintenance The Access to Health Care Services Study (2008), budget line item. The Ministry trained, equipped confirmed the status of equipment described above and deployed a number of equipment technicians and describes the equipment at most health to support provincial and central hospital purpose- institutions surveyed as “dismal”. Key informants built equipment workshops. However most, if not in the study “complained of lack of basics like all, of the 41 Equipment Technicians trained both working blood pressure machines, thermometers, in and outside the country have left the service. x-ray machines, autoclaves, incinerators, laundry The equipment technician training programme was machines, etc. Many of these had broken down discontinued some years ago. Whilst institutions and become unserviceable. However, they had not have a maintenance budget line item, this has not been repaired or replaced for years on end. It is been very useful in that the private companies next to impossible to provide health services of an contracted to repair equipment also required acceptable and effective standard under these foreign currency to purchase spare parts. Foreign conditions.” currency was not being availed regularly through the formal channels. The Ministry of Health and Child Welfare Equipment Department has also been inadequately Efforts have been made to share the high tech staffed for it to manage both the coordination of equipment in the private and public sector purchase and repair of medical equipment in including scanning machines. However, the hospitals. At national level, the administration and diagnostic equipment testing charges are beyond oversight of medical equipment management has the reach of the majority of the population. left a lot to be desired. As indicated above, the existing network of provincial and central hospital The contracting out of services has received mixed medical equipment workshops is mostly without reactions for various reasons. In some situations, technicians and spare parts to effect regular companies contracted out to provide services to maintenance of equipment. public institutions have done an excellent job whilst others have provided shoddy services. This A number of challenges are being faced in the area is also due to poor contract management practices. of technology and equipment. The most serious There are new efforts promoting private-public challenge is the cancellation of clinical procedures, partnership in the area of hospital diagnostic resulting in referral of patients outside Zimbabwe equipment for procedures that could easily be done locally, if only the required piece of equipment was available A number of studies and supervisory visits have or functional. In Maternal Health, the third been commissioned and conducted to check the obstetric delay was mainly due to lack of drugs status of medical equipment in public health and medical equipment. institutions. The findings of the National Medical Equipment inventory of 1999 were confirmed by More recently, energy and water supplies have the Maternal and Neonatal Health Services study become a major challenge. Institutions have in the of 2004 and TMT provincial visits in 2007. An past reported that some procedures, such as assessment of eight hospitals carried out in surgical operations, are done using a torch or 2003/2004 as part of an “Assessment of Quality candle light at night, a situation that was of Care” study revealed that seven of the eight confirmed by the Access to Health Care Services Equity And Quality In Health: A People's Right PAGE 107 study. Some generators need to be repaired and which will facilitate equipment management and new ones bought for those institutions without. purchase of appropriate medical equipment when There is also need to rehabilitate boreholes in a funds allow. number of the institutions, as erratic water supplies are a major concern at health facilities. Key issues • Lack of technical capacity in bio-medical Noting that most of the diagnostic and clinical equipment management. monitoring medical equipment is old and some • Lack of basic medical equipment for service obsolete, the Ministry developed a comprehensive delivery. list of equipment required by hospitals. This list • Poor procurement systems. now needs updating as more and more equipment • Lack of planned preventive maintenance, is reaching the end of its usefulness or new and including poor contract management. better technology is now available. Again, due to • Shortage of equipment technicians and no unavailability of financial resources, the Ministry training programme in place. has not been able to start procuring and replacing • Updating standard list of equipment for each the obsolete equipment. In the meantime, the level of care. Ministry has developed a health technology policy, • Lack of a health technology policy. Goal 27: To increase availability of functional equipment to ensure the delivery of effective curative and preventive services. Objectives Strategies To increase availability of • Updated standard list of equipment and technology for each level functional medical of care. equipment and technology • Each institution has an inventory for medical equipment. for diagnosis, treatment • Short and long term equipment replacement strategy developed. and patient monitoring • Phased purchasing of equipment and technology. appropriate for each level • Private - public partnership strategy in medical equipment of care technology developed. To implement a preventive • Equipment workshops resuscitated. maintenance programme • Phased rehabilitation and refurbishment of equipment. • Increase compliance with equipment maintenance services schedules. Build capacity both in the • Medical equipment technician training programme resuscitated. public and private sector PAGE 108 The National Health Strategy For Zimbabwe 2009 - 2013

3.4.3 — Traditional Medicine on Traditional Medicine. Government has taken

3.4.3 Traditional Medicine on Traditional Medicine. Government has taken some steps to implement some of these Trend and current status resolutions. At the regional level, Zimbabwe is the In some developed and developing countries, convener of the Traditional Medicines Traditional Medicine (TM) has been integrated Coordinating Committee of the SADC. into the public health delivery system at various levels and is receiving official attention and Despite the early official recognition, Zimbabwe funding, with clear legislative and operational now lags behind, partly because of the limited frameworks that ensure that TM is accessible and functionality of the National Directorate of available to those who need the service. In Africa, Traditional Medicine to develop, promote and some Research Units in TM have been developed. coordinate the TM programme. In Zimbabwe, several institutions and individuals are carrying out research on TM ranging from Key issues laboratory studies to clinical evaluations but this is • The need to adapt, adopt and implement, individually driven, uncoordinated and lacks a where appropriate, WHO's traditional national agenda. medicine strategy as the basis for national traditional medicine programmes or workplans. Many Zimbabweans consult traditional health • Formulation and implementation of national practitioners (THP) at some point in their lives, policies and regulations. indicating that traditional health practice is an • Limited recognition of the role of traditional important component of Zimbabwe's health care medicine as an important component of delivery system at both the individual and primary health care. community level. Progress towards promoting • Non availability of drug safety monitoring traditional medicine (TM) with regards to systems for herbal medicines. formulation, rational use, safety, efficacy and • Paucity of research on traditional remedies. quality and improving access has been made. The • Lack of protection of intellectual property Traditional Medical Practitioners Act of 1981 is rights in Traditional medicine. the legal framework for the coordination and • Limited documentation of traditional medicine regulation of TM. The Traditional Medical and practice. Practitioners Council (TMPC) oversees all matters • Lack of National standards for safety, efficacy related to Traditional Medicine. and quality of herbal medicines. • Lack of role clarity between council, the The government subscribes to the various World professionals and the TM department. Health Assembly (WHA) resolutions including WHA Resolution 56.31and the SADC resolutions Equity And Quality In Health: A People's Right PAGE 109 Goal 28: To increase access to and rational use of safe, efficacious and quality traditional medicines Objectives Activity/Strategies To implement the • Develop and implement a traditional medicine strategy. Traditional Medicine Policy • Lobby government and communities on specific TM policy issues and code of ethics in including inclusion of TM into education curriculum. Zimbabwe To promote the proper use • Establish appropriate supportive mechanisms for research, of safe, efficacious and manufacture, processing, distribution, sale, import, export and use quality Traditional of traditional medicines. Medicines • Establish safety standards which assure patient’s right to safe medical treatment. • Promote the use of safe and effective traditional medical treatment through information, education and communication to health practitioners, the public and consumers. To educate and train • Increase the knowledge of Traditional Health Practitioners in Traditional Health primary health care. Practitioners (THPs) and • Increases awareness and knowledge of allopathic health Allopathic Health practitioners (AHP) in the role of traditional medicine in the health Practitioner (AHPs) system. • Develop and disseminate information, education and communication on the role of traditional medicine. To strengthen the • Develop an appropriate legal framework for protection of Protection of Intellectual traditional health practitioners, traditional health knowledge, Property Rights (IPR) of traditional medicines and practices. Traditional Medicine and • Increase awareness on Intellectual Property Rights (IPR) system and Indigenous Knowledge legal framework. • Participate in regional and international agreements regulating access to medicinal plant resources for pharmaceutical research. To contribute to • Participate in ITC on Biodiversity. production and • Collaborate with relevant institutions on education and training of conservation of medicinal THP and consumers on conservation. plants • Collaborate in developing guidelines on GAP, GMP, GPP, GLP and GCP. To strengthen the • Strengthen and capacitate the traditional medicine department. institutional framework for • Review existing legislation to create an enabling environment for traditional medicine implementation of traditional medicine activities. • Strengthen the capacity for research and development including local production of traditional medicines. • Strengthen the capacity of the ministry to coordinate the various aspects of traditional medicine such as, practice control, research and information, regulation of medicines, local production and distribution. • Lobby for increased allocation of resources for the promotion of traditional medicine. • Establish partnerships and networks with relevant regional and international organizations. PAGE 110 The National Health Strategy For Zimbabwe 2009 - 2013

3.5 — HEALTH FINANCING Accounts estimated government's contribution to

3.5 HEALTH FINANCING Accounts estimated government's contribution to total healthcare expenditure to be 39%, while the Trends and current status contribution by households was 29% against The main objectives of the Health Sector are to 10.8% by employers. ensure the prevention of disease among the population, as well as the provision of care and The Private Sector has continued to contribute to treatment services to the sick. Adequate financial the mobilisation of resources for the Health Sector resources and the existence of efficient and through one-off donations and adoption of wards effective financial management systems are at health institutions. Tax relief measures have been imperative if health sector objectives are to be implemented to provide incentives for corporate realized. and individuals to contribute to the funding of Health Sector inputs. However, less and less The National Health Strategy (1997 – 2007), set assistance has been coming from this source as the the agenda for launching the health sector into the private sector was equally affected by the economic new millennium. Recognizing that improvement in decline. the health status of the population will not depend on sectoral actions alone, it sought to pull together The declining performance of the economy has all national efforts which had potential to enhance meant less funding for the health sector. The health development into a promising new era. situation has been further exacerbated by the fact that direct development assistance, which used to Whilst the situation analysis carried out then augment expenditure on health services by availing showed a worrying decline in health status the much needed foreign currency, has declined indicators, the optimism associated with the dawn from US$71 million in 1997 to US$7 million in of the new era provided hope and conviction for 2002. While donor financing was 13% of the improvement. Similarly, the identified weaknesses total national health expenditure in 1999, by 2002 in the performance of the health system were it had gone down to only 1%, a trend which thought to be temporary, in the hope that the reflects the almost total absence of bilateral holding capacity of the economy, to support a assistance in terms of direct budget support. The robust health system, would improve. picture has however changed in the recent past. On the contrary: the challenges facing the health Over the last twelve months, Government has not sector continued and even got worse. During been able to raise enough revenue to support the second half of the implementation period of the health sector meet its mandate. Most private National Health Strategy (1997 – 2007), voluntary employer based medical schemes/health Zimbabwe experienced severe and escalating insurance were not functional during the recent economic challenges which peaked in the year economic environment. In essence, health services 2008. The economic downturn meant less revenue in Zimbabwe over the past 12 months have been generation, thereby decreasing funding for all running on material provisions from the donor Government activities. community. During the period of a functional economy, the To achieve the MDGs Zimbabwe should be Government of Zimbabwe has always given spending at least US$34 per capita per annum on priority to the social sector. Though the budget health. This is the minimum required to provide an allocation to the health sector has been below the essential package of health services. The 2009 levels required to for the delivery of quality health revised budgetary allocation works out to about services, health has maintained its ranking in the US$7 per capita per annum on health, leaving a top five ministries in allocation of Government deficit of about US$27 per capita per annum. By funding. the third quarter of 2009, the Ministry of Health and Child Welfare had received 10 percent of the Health care services have been financed from 2009 allocation several sources including government allocations, private voluntary organisations, medical aid While there has been a serious decline in the level /health insurance schemes, direct out of pocket of direct bilateral funding coming to Zimbabwe as payments and development assistance from both mentioned above, the country has continued to bilateral and multi lateral partners. Government receive support from UN Agencies such as the has remained the major source of health financing World Health Organisation (WHO), UNICEF, in the public sector with taxation being the major UNFPA, as well as the European Union (EU) and source of revenue. The 2001 National Health the Global Fund for HIV and AIDS, TB and Equity And Quality In Health: A People's Right PAGE 111 Malaria. Bilateral donors have also continued to extensively and exhaustively identify and quantify make substantial funding contributions channeled prevention and promotion activities that are through implementing partners and other pooled undertaken in the hospital setting. Until the latter funding mechanisms. is undertaken, the size of the problem will remain unknown, while movement of resources in the Concerted efforts will need to be made to offset absence of additional funding in real terms can the decline in revenue flows to the Health Sector only take place at the risk of affecting the viability by improving the efficiency of existing of some of these institutions. expenditures, as well as to ensure that there is An analysis will therefore need to be undertaken to greater allocative efficiency (see below). identify and quantify the proportion of funding that is used for preventive services such as Financial Management immunization, screening, health education and A number of instruments have been introduced in promotion, counselling etc, which are provided and recent years to strengthen financial management funded through institutional budgets. capacity in the Public Sector, including the Public Finance Management System (PFMS), which was Resource Allocation introduced in the Ministry of Health and Child In an effort to achieve a more equitable Welfare in 2004. This system is still experiencing distribution of budgetary allocations, several implementation challenges. The introduction and Resource Allocation Formulae have been implementation of the Results Based Management developed, piloted and availed for wider use. (RBM) concept in 2005 has also had an added There is some doubt however as to whether there impact in terms of enabling managers at all levels has been consistent and persistent use of the to link finances to service level activity. Attention different formula and, where this has happened, has also been given to the improvement of final allocations have still needed to be moderated. financial management skills for health managers. Special care will therefore need to be taken to ensure that in seeking to achieve the ideal, the National Surveys were conducted in 1999 and Ministry does not exacerbate existing inequities. 2001 as part of the National Health Accounts initiative. The process documented the flow of User Fees resources from Financing Agencies to providers of It has always been acknowledged that existing Health Care Services, and health expenditures from resources on their own would never be enough to all sources were documented and tracked to their meet the requirements of the health care system, ultimate use. Results of these studies have been especially in the light of an increasing disease used to inform policy, budgeting and the burden. Measures have therefore been taken to allocation processes in the public health sector. improve the efficiency of collection procedures, as well as to mobilize additional resources. The Allocative Efficiency Health Service Fund was established in 1996 to There is still considerable concern that despite the create an incentive for improved billing and government's commitment to Primary health care, collection. Retention of fees at the local level, as a disproportionate amount of public spending well as the flexibility that this provides in terms of continues to go to tertiary (curative services) and responding to emergencies and other exigencies, higher levels of care. It is believed that this has gone some way towards making the various benefits a minority of the population (urban and levels of care more responsive. better off) and provides less cost effective treatment in terms of health gain per dollar spent. At its inception, various partners contributed to This argument is based on the figures that appear the Health Service Fund. While the extent to in the “Blue Book” (national annual budget) where which this is happening has diminished in recent the medical care services sub-vote, which funds years, the Ministry of Finance has continued to institutional based activities, gets much more than make allocations to the Fund in the form of what the preventive services Sub-vote III, which caters one could call an “equalisation grant”, for use in more for community and preventive health services. those districts whose capacity to generate revenue may not be as high as other districts. However, the While the need to redirect resources from hospital current economic environment has continued to based curative services to disease prevention and render this allocation valueless. At its inception it health promotion activities is generally was agreed that at least 40% of the revenues acknowledged, efforts to achieve this have met with generated by the Health Service Fund would be limited success, largely due to diminishing financial used for promotion and prevention activities in the resources in real terms as well as the failure to district. PAGE 112 The National Health Strategy For Zimbabwe 2009 - 2013 One of the reasons often cited for the existence of Care Services Study (2008) and the Assessment of a huge financing gap is the provision of what, to all Primary Health Care Study in Zimbabwe (2009) intents and purposes, is an unlimited package of recommend abolition of user fees at the primary free services, while the financing base has level. continued to shrink to levels where it is impossible to sustain this seemingly noble objective. It is The Access to Health Care Services Study (2008) therefore felt that the time may have come for corroborates the findings of operational research government to review the effectiveness of this studies undertaken in the Ministry, which policy. The Assessment of Primary Health Care concluded that some communities are indeed Study in Zimbabwe (2009) is proposing that a willing to pay for services provided the revenues package of essential services and resources be generated are used to improve the quality of defined and costed at primary level and that services offered at their institutions. This is clearly priority be given to ensuring that this basic level of an area in which further work will need to be provision is funded and universally delivered by all undertaken to inform the policy review processes. providers of primary care clinics (central, local government, mission and other private). While in theory it has always been acknowledged that those who can afford to pay should pay for The Access to Health Care Services Study (2008) health care services, implementation of this policy provides some insight into the user fee subject. has been difficult. The low tariffs that are applied The study found that the majority of communities in revenue collection in the Ministry of Health in the study (59%) paid to access health care and Child Welfare institutions, as well as services especially in the urban areas, commercial difficulties in implementing an efficient farming areas and mines. In rural areas, people are “exemption system” have also created a paying user fees at the district hospital level and disincentive. The National Social Security also in most rural health centres/clinics. The Authority (NSSA) has completed the development study also found that most people (66%) could of a Social Health Insurance Scheme, which is now afford to pay the fees charged, while the other ready for implementation. Once operationalised, 36% could not. However, only 38% of the the scheme will combine fee for service and respondents felt that they should pay user fees, community initiatives (e.g. payment in kind), as whilst 62% did not believe that they should pay to well as regular and timeous review of tariffs, and access health services. Key informants in the study should go some way towards contributing to the perceived the consultation and user fees as being mobilisation of additional resources for the health affordable and strongly believe that patients should sector. These initiatives will need to be pay to access health care services to enable the accompanied by improvements in the quality of institutions to replenish stocks and maintain health the service, as well as the actual care offered at facilities and equipment. They also argued that institution level. Research has shown that patients since the government could no longer afford to are generally not averse to paying for health care, as adequately finance health services, users should long as the quality of such service is commensurate pay; otherwise the whole system would collapse with the fees being charged. leaving the users worse off. Key issues This argument is now being used by health • Equitable distribution of resources. authorities who are now charging for services that • Strengthening Financial Management Systems. would normally be free (Government policy • Costing the core package of health services. provides for free health services for the under five • Inadequate financial resources for the health years, pregnant women, the above 65 years of age sector. and a few selected special conditions). The impact • Inefficient use of existing resources. of re-introducing user fees in some of these areas • Existence of financial barriers to access to has affected the utilization of health services. In health and Safety nets. the Maternal and Perinatal Mortality Study (2007) user fees were the commonly mentioned reason for lack of access. The study noted that user fees had adverse effects on maternal health in Zimbabwe as it is responsible for decreased use of health services by women at risk. The study recommends an urgent review of the user fee policy in order to remove it as a barrier to access for pregnant women. Both the Access to Health Equity And Quality In Health: A People's Right PAGE 113 Goal 29: To increase the levels of sustainable and predictable financial resource base to ensure provision of high quality services to the population Objectives Strategies To strengthen the Financial • Improve the implementation of the Public Finance Management Management system at all System (PFMS) at all levels of care. levels • Strengthen financial management and accounting skills for health workers at all levels of care. • Monitor and evaluate resource utilization. To improve use of existing • Institutionalize implementation of the Results Based Management resources (RBM) Concept. • Undertake regular National Health Accounts (NHA) audits and disseminate results widely. • Conduct Research to identify and quantify all preventive and promotion activities that take place within hospitals institutions. • Ensure adherence to referral chain through the use of a mandatory by-pass fee. • Review, redefine and cost packages of core health services for each level of care and prioritize allocation of resources accordingly. • Define and publish a health service package that will be provided for free including the clearly defining the beneficiaries. • Revisit policy on outsourcing non-core services e.g. security, cleaning and ground maintenance at provincial level. • Reduce leakages of hospital supplies. • Monitor the operation of funding agencies to ensure that the interests of providers and subscribers are protected. • Commission a study to map out partner areas of work. • Ensure that infrastructure Development and technology Acquisition is consistent with the country’s economic capacity. • Strengthen institutional capacity to coordinate Donor Inputs. To mobilize resources for • Develop a national health care financing policy and strategy. the health sector including • Explore and establish community health financing mechanism. to a sustainable financial • Redefine cost and guarantee every Zimbabwean an essential resource base of at least package of health services. US$34 per capita • Review user fees with the view to abolish them at relevant levels. • Review and update policy of central government funding for local government and other public health providers. • Lobby for the early introduction of an effective Social Health Insurance scheme. • Improve the effectiveness of existing social safety nets. • Conduct further research into practical exemption criteria. • Lobby for increased external technical and financial assistance to plug the financing gap. • Lobby for the attainment of the Abuja Declaration target of 15%of the National Budget. • Lobby for an increase in health expenditure to at least US $34 per capita to ensure the provision of high quality services to the population. • Explore the possibility of increasing private sector contribution to the provision of health sector funding including the use of legislation and tax relief measures. • Ensure that there is universal billing at all hospitals. PAGE 114 The National Health Strategy For Zimbabwe 2009 - 2013

3.6 — LEADERSHIP AND GOVERNANCE The Ministry of Health and Child Welfare

3.6 LEADERSHIP AND GOVERNANCE The Ministry of Health and Child Welfare operates within the functions mandated to the

3.6.1 — Governance and Management of the office of the Minister of Health and Child

3.6.1 Governance and Management of the office of the Minister of Health and Child Health Sector Welfare (Restricted: Hand-book on the Functions of the Minister of Health and Child Welfare, Trends and current status March 1993) as well as the provisions of the Governance in our situation is concerned with Public Health Act (Chapter 15:09) and the Health issue of organizational structures, management Service Act amongst others. structures, policy and regulatory frameworks, coordination and partnerships with stakeholders, National Health Policy Implementation information for decision making and fair resource Framework allocation. The health sector activities have been guided by two policy documents, Planning for Equity in The Zimbabwe health sector is comprised of Health of the early 1980s and the National public and private components, including Health Strategy, “Working for Quality and Equity traditional medicine practices. in Health” (1997-2007). The public sector provides health services through The National (Central) Level facilities under the Ministry of Health and Child The Zimbabwe health care system consists of four Welfare, Ministry of Local Government, Ministry graded levels of health care, each engaging in an of Education, Ministry of Defence, Ministry of appropriate mix of promotive, preventive and Home Affairs and the Prison Service. curative activities, with the higher levels providing support, supervision and referral facilities for the The categories of local authorities include Rural levels below. Each of these levels has a link with District Councils (RDCs) and Urban Local corresponding structures in the socio-political Authorities. The Private Medical sector includes system, to ensure political and community inputs the Private for Profit Medical Sector (Private and intersectoral collaboration with health related Industrial Clinics, Private Hospitals, Maternity agencies. Homes and General Practitioners), Traditional Health Practitioners and Complementary Health Health is part of development and as such it is a Practitioners. dynamic process. Accordingly, the functions and structure of the Ministry of Health and Child The Not-for Profit Private Sector providers Welfare continuously change to meet the ever- include church related and other NGOs. The changing demands and challenges. The Ministry of Zimbabwe Association of Church Related Health and Child Welfare has been restructured Hospitals (ZACH) represents church related twice in the last ten years with the aim of not only hospitals. accommodating new programmes but as part of continued improvement in efficiency. The Code of Professional practice for all health practitioners in Zimbabwe is regulated by the The Ministry of Health and Child Welfare's Health Professions Act Chapter 27:19 (2000) headquarters role is regulatory, policy setting and whilst that of traditional healers is regulated provision of a legally enabling environment for the through the Traditional Practitioners Act (1981), operations of the various health service providers providing a framework for practice and regulation and funders. of its members. A number of institutional arrangements in the The Health Service Act provides for the form of Minister's policy making meetings, establishment and the operations of both public Permanent Secretary weekly meetings, the Planning and private hospitals and Medical Aid Societies. Pool and the Top Management Meetings are in Minimum standards of practice for both hospitals place to guide the operations of the Ministry of and medical aid societies are also provided for in Health and Child Welfare. A further development the Act. The Health Service Act provides for the in the health sector has been the establishment of establishment of the Health Service Board, the Health Service Board which is mandated to Community Health Councils and Hospital deal mainly with issues pertaining to the Management Boards at Central and Provincial conditions of service for members of the public Hospitals. health sector. Equity And Quality In Health: A People's Right PAGE 115 Provincial level The biggest challenge is overcoming the perception The Provincial Medical Directorate (PMD) is a that ascribes failures in the health system to functional extension of the national level. The internal defects of policy, whilst disregarding the Provincial Medical Directors have the external environment with which the health system responsibility to co-ordinate the planning and has contended within the last ten years. In management of the health delivery system in the Zimbabwe, real decreases in public health provinces. The PMD also ensures that government expenditure have resulted in deteriorated health policy is adhered to and that national policies and facilities, drug shortages and a drastic decline in goals are being implemented. Community and the quality of public health services from which it other sectors' health inputs are captured through is yet to recover. There is greater awareness now the Provincial Development Committees. than ten years ago of the need to improve the responsiveness of the health system. Therefore, to District level ascribe failures in the health system to a weakness The District Health System is the operational level of regard for demand when in fact the political of the health delivery system. Its goal is to provide economy has starved it of resource supply, is to a comprehensive range of promotive, preventive, blame the victim. curative, rehabilitative and palliative health services, to all the sectors of the community, in line with Over the past decade, structures and managerial national and provincial policies and guidelines. processes driving service development have moved Community and other sectors' health inputs are far ahead of the national political and captured through the District Development administrative processes and structures. From a Committees. health sector point of view, this progress has been Primary level most welcome, in that most decisions which local The Primary Health Level provides the first point managers should make have been decentralized to of contact between the community, village health the service delivery level. However, bottlenecks still workers and the formal health delivery system. The exist, particularly in those areas where local health level comprises of a network of clinics and rural managers need their counterparts in other sectors health centres, which provide comprehensive to make decisions which affect service development promotive, preventive, curative and rehabilitative and provision. This continues to be a source of services. frustration as more often than not, it delays progress. This progress has however had its own The 1997-2007 strategy identified opportunities internal challenges. The local managers, responsible for strengthening the functioning of the health for making the decisions at each level, are no system through the implementation of a cocktail longer there due to the high attrition rate of the of health sector reforms including issues such as experienced professionals across all disciplines. In decentralization, Public and Private Sector December 2007, over 80% of management posts Collaboration, strengthening management and in the Ministry of Health and Child Welfare were organisational development etc. Although most vacant (pg 97). planned activities were carried out in these areas, no further attempt was made to institutionalise A management culture that did not focus strongly them. enough on clear objectives, performance and accountability was identified as one of the Zimbabwe, as other developing countries, has a indicators of poor managerial performance in the national health system which is based on three health system in the 1997-2007 National Health essential pillars. Strategy. Ten years down the line, cries of the need 1. Priority in health care is based on the for better communication and support continue to development of comprehensive and integrated resonate throughout the health system. This is a preventive and curative primary level services, clear testimony that the national objectives being starting with the provision of services to those pursued by, and the performance expected from, in greatest need; primary health care services the operational level are not being clearly which are supported by increasingly specialized communicated. New approaches need to be higher levels of care, in a coherent national developed in the future, perhaps with the full health system. (Primary Health Care Strategy) participation of the workforce. The introduction 2. Communities participating actively in the of the Results Based Management Systems by planning and organization of primary care Government is one such avenue of addressing this services. deficiency. 3. Actions being taken in economic and social sectors that address the non-health determinants of health development. PAGE 116 The National Health Strategy For Zimbabwe 2009 - 2013 The Results Based Management System requires conditions. With the above situation, morale, that objectives be worked out after carefully motivation and performance of health workers are identifying client's needs and/or problems, and the low and attitudes to patients poor. extent and/or seriousness of the problems/needs. Client needs are best addressed by involving them The 1997 – 2007 Strategy did not say much in the planning and management of health about internal audit. Ministry of Health and Child services. The existing institutions, such as the Welfare has over the past five years shown more Health Centre Committees, Community Health interest on this subject. Internal Audit function Councils, and the Public Health Advisory Board, plays a key role in assessing and reporting on an can go a long way in meeting this requirement; organization's governance, risk and compliance. they are however not fully functional. The Ministry of Health and Child Welfare (MOHCW) has since 2002 given Internal Audit a The issue of centralized planning and decision high priority by creating a deliberate policy of making resulting in the inefficient deployment and supporting its activities geared towards the use of resources has been dealt with through the objectives of risk management. The Ministry is on-going empowerment and decentralization currently introducing risk management in all process. The challenge that still exists is whether departments. local managers have the technical and managerial capacity for running decentralized health systems. Key issues The flight of experienced managers soon after the • Developing a management culture that focuses process of implementing the 1997 – 2007 health strongly on objectives and accountability. strategy began, coupled with increased attrition, • Decentralization of decision making authority has not helped the situation. In addition, the to service delivery levels. management development programmes running • Development of accepted performance then were suspended in 2001 due to funding indicators and criteria for performance audit, constraints. to achieve improved levels of accountability by managers for their performance. The 1997 -2007 Strategy note the absence of • Management and organizational development, customer focus as a challenge. Whilst tools such as including training. the patients charter were developed and training on • Supporting the operational levels to develop their use delivered, not much progress has been and maintain systems, methods and procedures, observed. However, what is often ignored is that which allow health services to respond to local health workers are people first, and as such, the needs. environment they work in influences their • Recognizing that systems, methods and relationship with patients. Their work procedures, work best with competent staff, environment does not induce good relations, hence the need to integrate training and particularly the sporadic stock outs of essential development into wider human resource and inputs and poor maintenance of infrastructure. It organizational objectives. is next to impossible to provide health services of • Strengthening the audit functions of the an acceptable and effective standard under these Ministry. Equity And Quality In Health: A People's Right PAGE 117 Goal 30: To improve governance and management of the health sector. Objectives Activity/Strategies To strengthen management • Strengthen Ministry’s capacity to formulate, develop and and leadership at all levels implement policies. of the health sector • Continuously review and update the skills of managers at all levels. • Resuscitate the management development and leadership training programmes. • Strengthen and improve audit skills. • Develop and introduce the concept of health risk assessment and management into the health sector. • Develop mechanisms for enforcing and improving compliance with existing legislation. • Build partnership between political leaders and providers. • Mobilize political and religious leaders for health. To strengthen the • Adapt and implement the provisions of the Ouagadougou decentralization of health declaration. service management to • Consolidate and strengthen the decentralization process in the local levels health sector. • Facilitate community participation in health matters through hospital and community management boards. • Strengthen self-managing units at district, provincial and central levels. • Build capacity to manage the decentralized health system. • Strengthen community participation and involvement in health service planning and management. To strengthen the role of • Review and where necessary amend the role of existing regulatory regulatory bodies and bodies. agencies • Create an enabling environment for regulatory authorities. To provide clear strategic • Improve and strengthen planning, implementation and monitoring direction for health function at all levels of care. development • Institutionalize the principle of “three ones” (one plan, one coordinating board and one monitoring mechanism). To clearly define the • Review and update health legislation to ensure that legislative gaps appropriate regulatory are filled on areas that need improvement. framework to ensure the • Strengthen capacity in health legislation and regulation. various stakeholders fulfill • Develop strong health advocacy skills within the MoHCW. their responsibilities in health To coordinate activities • Review and redefine the roles, functions, lines of accountability and among the different units decision making at each level of the health system. within the Ministry of • Redefine the work of the different units and departments. Health and Child Welfare • Strengthen the role of the planning pool. • Review and strengthen internal and external communication with stakeholders. To establish functional • Undertake and publish annual audits in the health sector. mechanism to ensure • Develop mechanisms and processes that allow citizens to transparency and participate and influence health policies and decisions and also accountability in the health monitor health providers. sector • Establish mechanisms to improve public accountability. PAGE 118 The National Health Strategy For Zimbabwe 2009 - 2013

3.6.2 — Policy Development And Legislation without serious analysis of the potential adverse

3.6.2 Policy Development And Legislation without serious analysis of the potential adverse Related To Health problems they might cause. Trends and current status The importance of improving the health and The policy framework of any sector is intended to quality of life of the population is a national set the development agenda, by translating the political agenda, which cannot be understood priorities of the body politic into comprehensive purely from a sectoral point of view. The policy objectives and actions to carry the objectives allocation of resources for health and its through. The implementation of the actions so supportive components is probably not an exercise identified is influenced by the dynamics of the in numbers, undertaken during the annual external environment, at times given to unexpected budgetary process. At best, it is possibly a shocks and change. This, in itself, creates problems, concerted political effort, which blends together a even conflict, in selecting and maintaining cocktail of public investments influencing priorities. improvement in the quality of life of the population; health service provision being one of Experience in the last ten years has shown beyond these elements, amongst many. doubt that setting priorities does not lend itself to a quick technical fix. It is in fact a complex process, The negative indicators describing the health of essentially political and ethical in character, the population, and the perennial shortages of involving the interplay of a number of inputs in the sector, are a result of this oversight. considerations among which are notably those of No corrective strategies or measures were equity and efficiency. These are not always developed or anticipated. A current example, in compatible. many countries in the region and afar, in ignoring these external factors is the promotion of the The current situation, where gross inequalities in production of bio-fuels. This is not an unwelcome health persist, has ensured that equity has remained development, but it has potential to decrease food a dominant factor in health investment. However, production and increase food prices, if not experience has also shown the complexity of a properly designed with people in mind. Access to process that seeks to balance various conflicting affordable healthy foods is pivotal in maintaining claims for priority status. This suggests the need health in general, and the nutritional status of the for a fresh approach that abandons the quest for a population in particular. simple set of rules and figures, but instead emphasises the importance of the decision making The 1997 – 2007 strategy further emphasized the process itself. In this regard, priority setting need for decisions to be made as close as possible decisions, whatever they may be in a particular to the people. As far back as 1983, the then Prime context, must be transparent and based on fair, Minister's directive on the process of local reasoned and defensible grounds, which must be governance and development recognized this need. accessible to the public. However, evidence shows that without a legal framework compelling state institutions, agencies The 1997 – 2007 National Health Strategy and their partners to adopt an inclusive approach emphasized the need for a coherent national policy to programme design and management, local needs development and planning framework, as a pre- are often likely to continue to be side lined in requisite for improving health and quality of life. preference for sectoral technical interests. In this Unfortunately, this requirement was understood respect, indicators of performance and from a health sector point of view, to the exclusion improvement are reduced to an annual ritual of of broader political imperatives, which naturally numbers, often without any relevance to the local affect the performance of the health sector and its human condition. capacity to contribute to overall human development. Zimbabwe has recorded some successes in identifying an appropriate legal and regulatory In other words, this policy framework was framework with potential to promote understood as the sole responsibility of the Health collaboration and conformity. The balance is Sector. It is not surprising therefore, that the however tilted in favour of the regulator. The influence and impact of economic and social challenge is to transform these institutions into policies on the livelihoods of the people and the empowerment tools for the beneficiaries i.e. performance of the Health Sector were communities. underplayed. The external determinants of improved health were mentioned in passing, Equity And Quality In Health: A People's Right PAGE 119 The 1997-2007 National Health Strategy, further These changes created tensions and contradictions recognised that the Ministry of Health and Child in the delivery of health services. For a start, some Welfare, as a state institution, had a responsibility of the reforms have brought confusion in the to provide expertise in the design of national organizational processes of the health system. For development policies which are known to sustain instance, the practice of integrating vertical the continuous improvement of the health status programmes into the on-going health system has and quality of life of the population. This was in been shown to be at odds with the requirements of recognition of the fact that the relationship international responses to major diseases. Funding between the population's health status and the mechanisms such as the Global Fund (TB, AIDS, actual delivery of health care will probably remain and Malaria) GAVI etc, are a case in point. The a complex one and contestable at times. Social and development of multiple parallel systems of economic factors are at least as important, and funding, provision and accountability, has brought probably far more so, in the equation. with it new pressures on the health system. The various proposals for selective incentive regimes for The question which needs to be dealt with is what staff has added to these pressures and tensions. the health service's contribution to improving the population's quality of life could and should be. It is important for the country, at the policy and Many pieces of legislation exist under the planning levels, to avoid the “take all” culture in administration of various sector ministries, terms of resources potentially offered, as this is intended to secure the wellbeing of the population tantamount to promoting short term solutions to and also to offer opportunities for individuals and long term problems. The consequences might work others in society, to take responsibility for their against public policy and interest and may even actions in this regard. lead to loss of control. Recent local, regional and international Health is a core aspect of human well being. The epidemiological events clearly indicate that capacity to achieve a long life in good health is one securing the health and safety of the population is of the key determinants of quality of life. Ill a matter of national security. The recent health and lost years of potential life create a huge promulgation of the International Health dividing line between the poor and the rich. The Regulations is testimony to this recognition policy implications arising out of the current internationally. As stated elsewhere in this situation probably requires focusing on; document, achieving this goal requires a framework, led by government, within which other • Institutionalising an effective mechanism for stakeholders will participate. A situation where financing primary health care. The policy issue private individuals and others in society devise is about the institutional structure which will their own plans, often ignoring the public interest, create and sustain accessible primary care should be discouraged. Poor coordination services. The challenge is that of re-building amongst state organs breeds this kind of decent public primary care services. behaviour. • Maintaining public hospitals is important Whilst it is inevitable and indeed proper, that the because they are the lifeline for the poor when health service should be dynamic and move with faced with severe illness. The quality of services the changing times, the past decade witnessed an which they deliver is key to the behaviour of increasing pre-occupation with initiatives to re- the health system as a whole. The major engineer the health system in the form of health challenge is in creating political and sector reform. Reform dominated the platform for institutional incentives for the progressive health development debate. The key ingredients allocation of resources. were, amongst others, decentralization, public/private collaboration, hospital autonomy Despite the development and publication of clear (self managing units), new financing mechanisms, policies, it is clear that the health service still pays priority setting and resource allocation, patient far too much attention to supply problems, as satisfaction and incentives for health workers. opposed to demand challenges. This situation is Though little understood then, there were also thought to partly arise from the lack of a critical emerging external pressures, such as the general mass in all the disciplines necessary for advancing public sector reforms and globalization, amongst health policy research and analysis. In addition, others, which brought with them unforeseen there is excessive duplication of efforts, especially impacts on the process of reform. in relation to fashionable research areas. The few skilled researchers that are still in the country are PAGE 120 The National Health Strategy For Zimbabwe 2009 - 2013 overloaded and frustrated, as they feel that the which have taken place so far and those proposed, policy and service environment is not conducive to have potential to improve the responsiveness of the implementing their research findings. health service. In addition, the stewardship role of the Ministry of Health and Child Welfare will be The National Health Strategy (1997-2007) clarified and better understood, in a context strongly supported the need for an inter-sectoral stakeholders have confidence in. collaboration structure at the national level, which would form a platform for state agencies, whose At the end of the day, providing health services is work directly influences improvements in health essentially a political process. Deciding who has status and quality of life. The rationale was that access to which services, is indeed to make a interventions which had potential to improve political decision. This must be clearly understood. health status and reduce health risks, required a Further, it must also be understood that good structured approach, which recognised the public health policy should be tested at the level of multiplicity of societal needs in terms of; service delivery, particularly to the weakest in society. • All understanding the interventions i.e. their objectives and impacts. Key Issues • Collaboration from others, also recognising the • Gross in-equalities still exist in the health value placed on their needs. sector. • Design of interventions, towards increasing net • Health considered a sectoral issue instead of benefit to society. making it a national issue. • Implementation plans and monitoring • Community participation in decision process mechanisms, consistent with the above. still very low. • Resources (Now and future), their deployment • Weak analytical skills before adoption of and tracking. external driven agendas. • Re-enforcing the Primary Health Care Some progress has been made, in that ad-hoc Approach. consultations do take place. The difficult times the • Better use of research findings in policy country is going through demand a robust and formulation. coherent policy and planning framework to guide • Strengthening inter-sectoral collaboration. the deployment of scarce resources. The changes Equity And Quality In Health: A People's Right PAGE 121 Goal 31:To strengthen capacity to formulate, develop and implement health policies and regulations Objectives Strategies To create an inclusive • Strengthen the role of the Public Health Advisory Board in health policy development proposing, reviewing and agreeing appropriate health policies and framework monitoring their implementation. • Strengthen institutional capacity of the ministry for health policy analysis and development. • Review and strengthen the work/role of existing planning structures. • Formulate appropriate regulatory framework that will ensure various stakeholders that have activities that impact on health fulfill their responsibilities in health. • Establish a mechanism to involve all stakeholders in the development of health policies, rules and regulations. • Develop strong health advocacy skills within the MOHCW. To link health service • Contribute and participate in the development of social protection provision to national social mechanisms. development objectives • Develop tools for measuring impact of social protection initiatives. • Simplify access to health and other social services for vulnerable groups. To define role of local • Amend Public Health Act to place a duty for service development/ authorities in health services provision on local authorities. development and provision • Develop appropriate funding arrangements (including service contracts). To coordinate activities • Review the terms of reference for the various coordination/ among the different units monitoring structures (planning pool, minister’s meeting, secretary’s within Ministry of Health meeting, TMT meetings etc.). and Child welfare To identify and clarify • Review the effectiveness and impact of policies on health of the policies which affect and population. promote the protection of • Assess the effectiveness of the public health act and other related the population’s health legislation on health. • Develop a comprehensive and participatory policy development framework (role clarification of the state and other players inside and outside the health sector important factor). To strengthen the health • Make other sectors aware of the implications of their policies on policy development health and quality of life. framework through • Strengthen a common planning framework with other stakeholders coordination, dialogue and whose activities have a bearing on the health of the nation. collaboration with sectors • Strengthen inter-sectoral cooperation and coordination at all that have an impact on administrative levels. health and quality of life To review existing health • Review and amend policies on free health and exemption. policies, legislation, and • Review and amend policies on health services provision. regulations so that they are • Review the public health Act. consistent with changing • Commission a study on the legal framework binding stakeholders. circumstances • Advocate for the protection of health rights in the constitution. • Map and monitor health policy research efforts to identify gaps and imbalances (liaising with stakeholders in identifying health policy research issues). To monitor and evaluate • Evaluate the impact of policy changes as they are implemented. the impact of policies on • Undertake corrective measures to meet set objectives. access, equity, efficiency • Publish and disseminate policy documents. and community satisfaction PAGE 122 The National Health Strategy For Zimbabwe 2009 - 2013 PART 4: Inclusive Implementation Equity And Quality In Health: A People's Right PAGE 123

4.1 — ENHANCING COMMUNITY communities to support health and health related

4.1 ENHANCING COMMUNITY communities to support health and health related PARTICIPATION AND INVOLVEMENT IN activities. They felt that the current regulations did IMPROVING HEALTH AND QUALITY OF not allow them to solicit help from communities. LIFE The study also confirmed that dialogue between health workers at the periphery and communities is Trends and current status minimal. The ability and capacity of communities to participate in health development activities An avenue to get communities to contribute to the depends on the decision making space they enjoy health sector exists through local level management and the degree to which they control the resources structures. Village Development Committees for them to carry through those decisions. In (VIDCOs) and Ward Development Committees practice, their ability to make these decisions will WADCO), are expected to take part in decision also depend on the quality and availability of the making and management of health facilities at the necessary information they require. community and district levels. However, a number of districts report that in many instances, these Since 1983, when the then Prime Minister's committees are not meeting regularly and in directive established local governance structures, certain instances they have been disbanded. In communities have at least in theory enjoyed contrast, Health Centre Committees meet political control over issues which affect their lives regularly. Even so, the high levels of staff turnover at the local level. It is in view of this that the tend to weaken health facility managerial structures health service has placed community participation as new inexperienced staff often replace those that squarely on the health development agenda. leave for greener pastures. However, experience has shown that the knowledge At the service level, success has been recorded gap between communities and service providers through the re-integration of the village health remains wide, to the extent that community worker into the health system thereby recreating contributions have not always been taken on board. the vital link between an organized village In other words, the creation of participatory community and the local health service. This structures, on its own, is not enough. For example, together with the Environmental Health Technician the district is the basic planning unit in matters of and the recent introduction of the primary care local development and administration, under the nurse will strengthen the primary level team. direction of the District Development Committees. However, success has been limited, However, an under-utilization of primary care largely because the District Development services in general has been observed in the recent Committees do not control local development past. This is thought to be related to supply side resources. These remain firmly in the hands of inadequacies, in terms of shortages of drugs, local officials, controlled by their line ministries, equipment and trained staff, particularly midwives there by stifling synergy between the direction of and environmental health technicians. In addition, planning and financing, and ultimately the community's ability to make choices depends implementation. Sadly, this situation has often on their level of literacy. Investing in the education resulted in community needs and interests being of the population, particularly women, is an sidelined. important component in the exercise of community health rights. The basic elements which The Study on Access to Health Care Services form actions communities can take to secure their noted that Communities are willing to support own health should be part of the education their local health institutions in cash or in kind. agenda. It is only when the key players in health However, they remain uncertain as to how they development have a common understanding of should volunteer their assistance and contribution, what needs to be done and its meaning, that saying they need guidance. In light of this, there is progressive participation and collaboration can need to develop together with the community a take place. Health promotion and education in Community Level Health Package which clearly school curricula, in such areas as nutrition and defines how communities can contribute to their lifestyles and the role these play in the causes of own health and also to health development diseases, is, for example, a good start. including community health financing. It is important to recognize that getting The study further noted that health workers at the communities on board is not an incidental matter periphery claimed they that they have no – it takes time and effort. The establishment of parameters to guide them in mobilizing Community Health Councils, and the introduction PAGE 124 The National Health Strategy For Zimbabwe 2009 - 2013 of the Patients' Charter, was meant to provide consultation. This suggest ensuring that the formal mechanisms for the voice of communities public's voice is heard and brought to bear on to be heard. The Patients Charter set out clearly a policy decisions taking place in and outside the person's rights to care within the health service, health sector, including oversight over the and the standards of service which the performance of the health sector as a whole. The Government intended to see achieved. Parliamentary Portfolio Committee on Health has been very active in facilitating wide public The Charter had a very mixed reception, coming as participation and consultation. On the other hand it did at a time when the performance of the the Public Health Advisory Board has not been health system was declining. No study has been functional. carried out to ascertain the impact of the Charter. Though not explicit in the principal law, the values The assumption is that if the Charter has had any enunciated by the public health system imply that impact, patients should be receiving what they are health care is a human right, and therefore entitled to. There should also be visible cooperation in meaningful ways between providers improvements in service standards. The public and those they serve is of paramount importance. should also be more aware of their rights, and All individuals and groups providing access to know what to expect from the health service. services have a continuing duty and responsibility Information from communities however, shows to promote and improve the quality of services otherwise. The fact that no system of monitoring which people need. In this regard, community or enforcing national compliance was established participation should be considered as an and followed up, did not help development in this appropriate means of dealing with health area. problems, which should be defined in collaboration with the communities and the In the case of Community Health Councils, the workforce which serves them. Organizing majority of institutions and districts have not been communities for this purpose should be considered able to establish one. It is thought that at present, as a goal in its own right. only five districts and institutions have functional Councils. This 2009-13 National Health Strategy should therefore prioritize people's concerns on services as In addition, the majority of districts, institutions identified by the Study on Access to Health Care and indeed the general public are not aware of the Services, District Health Services assessment fact that Hospital Advisory Committees were 2005/6 and other relevant studies, as the health abolished and replaced with Community Health system exists to address people's concerns. The Councils. The Councils were meant to widen the Study on Access to Health Care Services, noted scope of participation beyond the hospital walls. the need for adequate staff, medicines, shortages of ambulances, electricity, water supplies, There is considerable evidence that ambiguity, telecommunications and quality of food, as limited authority, lack of information and poor concerns most people wanted addressed. These quality of representativeness, have contributed to people needs should therefore be the core business poor results in community participation and of this health strategy. involvement in health issues. The major outcry It is expected that Community participation will from communities and health workers is for policy further be strengthened through the introduced making and mechanisms for its implementation to Results Based Management system that requires be accountable to them. This demand goes beyond that the needs and problems of clients be clearly the usual perception of community participation, identified and addressed with their involvement. as a simple act of assembling stakeholders in a workshop in order to gather their views. Building Key issues participation in the development of health • Limited information to community on health services, is, by its very nature, a social and political status, determinants of health and risk factors. process, which will ultimately demand the • Non involvement of communities in health achievement of visible results. planning and management. • Non functional Public Health Advisory Board. Policy accountability at the national level most • Legal status of Health Centre Committees. likely depends on the extent to which structures • Non involvement of local level structures in such as the Public Health Advisory Board, the monitoring and reporting to the public on the Health Services Board and the Parliamentary implementation of health policies. Portfolio Committee on Health, are able to • Lack of authority by communities to manage facilitate wider public participation and locally available resources. Equity And Quality In Health: A People's Right PAGE 125 Goal 32: To enhance community participation and involvement in improving health and quality of life and in health development Objectives Strategies To make available to all • Improve public health reporting. Zimbabweans, information • Publish and disseminate an annual national health profile that is on the health status of the understandable to the general public. nation including • Develop and publish a simple document defining the determinants determinants and risk and risk factors for health and how individuals, families and factors for health communities can enhance their own health. • Develop and publish a simple document on health promoting and early health care seeking behaviours. • Work closely with the media to facilitate dissemination of information. To create an enabling • Define and agree with individuals, families, communities, schools environment and and church organizations their responsibilities in service provision. encourage individuals to • Make greater use of existing grassroots structures in health planning. take responsibility for their • Work very closely with community social groups after defining own health and secure the clearly the scope of their work. health of the others To establish methods for • Strengthen joint health and civic planning structures at all seeking broadly based administration levels. national consensus on • Strengthen the role of the Public Health Advisory Board. priorities to be addressed • Encourage opinion leaders such as church and traditional leaders to participate in national health programmes. To make individuals, • Progressively develop the Patients Charter. families and communities • Create system for enforcing the Patients Charter. aware of their rights and • Create an effective mechanism for dealing with grievances and responsibilities complaints. To re-vitalize and • Sensitize policy makers, planners and communities on the strengthen the role of the importance of VHWs. village health worker and • Redefine the work of the VHW and other community health other community health workers. workers To provide an enabling • Develop a policy and strategy to strengthen community participation Implementation framework and involvement. for community • Resuscitate and strengthen community health councils and participation community health centre committees. • Elaborate a policy framework for community participation. • Review and disseminate guidelines for the establishment and functioning of the community health structures. • Develop a clear institutional framework for intersectoral support to community interventions. • Develop participatory tools for community involvement in health planning and development. To empower communities • Identify and map out the key community stakeholders. and ensure their • Create an environment for empowering communities in the involvement in the governance of health services through appropriate capacity building. governances of health • Redefine the key roles and functions of the community services stakeholders and community structures. • Provide appropriate funding for community activities. PAGE 126 The National Health Strategy For Zimbabwe 2009 - 2013

4.2 — PARTNERSHIPS FOR HEALTH negotiated contracts”. Whilst service contracts

4.2 PARTNERSHIPS FOR HEALTH negotiated contracts”. Whilst service contracts were developed, these were not implemented, Trends and current status except in Matebeleland North, Mashonaland West Improvements in the health status and quality of and East provinces. life of the population do not depend solely on interventions within the health sector. It takes the As the case with missions, local authorities provide efforts, contributions and participation of a and finance health services to people in their areas myriad of stakeholders involved in both financing of jurisdiction. Their statutory duties are stated in and direct provision of health services. It the Public Health Act as follows; “Every local nevertheless remains the responsibility of the state, authority, shall take all lawful and necessary through the Ministry of Health and Child Welfare, procedures, for the prevention of the occurrence or to provide leadership and more importantly, for dealing with the outbreak or prevalence of any stewardship, in harnessing and nurturing these infectious or communicable or contagious efforts and contributions. diseases”. In practice, this means the provision of mainly environmental health services relating to Experience has shown that maintaining sustainable water supply (until recently), sanitation, prevention partnership frameworks should be an ongoing of pollution, control of communicable diseases negotiation process, promoted within an ambit of and food hygiene. However, both the Public co-operation in which other strategic options have Health Act and the Urban Councils Act, do not to be considered. Promoting equity, quality and place a duty on local authorities to provide access to health care should be the focus. Without personal health services such as, for example, this focus, buttressed by the state, partners will curative and mother and child health services. tend to gravitate towards the satisfaction of their own needs, including the pursuit of private gain As with missions, local authority health services are above public interest. partly funded from grants from the state, disbursed through the Ministry of Health and Partnerships with Public Health Providers Child Welfare but increasingly, from local revenues. With regard to grants from the state, the report of The 1997-2007, National Health Strategy, the Review Commission into the Health Sector, emphasized the need for the wider social stated “However, the proportion provided by the participation of all sectors, communities and government has declined to the extent that it individuals themselves, in health care provision, represents for Bulawayo and Harare, only 4% of financing, service standards setting, regulation, the costs incurred by the local authorities on monitoring and evaluation of performance. Over personal health services. In addition, there is no the past years, there is evidence (some of it formula used for the allocations, which are anecdotal), that despite this call, the responsibility completely unpredictable. This makes planning for for improving the health status of the population services difficult for local authorities. User fees remains perceived as a sectoral issue. In addition, “are prescribed by government and local the sustainability of partnership frameworks authorities have no say in the matter”. Grants for depends on the capacity of the principal (the Bulawayo and Harare are now estimated to have state) to meet agreed obligations. For example, the fallen to 0.01% of their total health expenditures. deficiency in the relationship between the Ministry of Health and Child Welfare and local authorities, Missions and local authorities have been important as well as with missions, is largely due to the traditional partners in service provision and absence of a definite commitment from the state financing. They have however continued to provide on the level of grants or support to be provided to and finance services on the basis of an informal these stakeholders. “agreement” with the Ministry of Health and Child Welfare. Although they may receive This weakness is worsened by poor technical substantial resources from the state through the capacity, on the part of the Ministry of Health Ministry of Health and Child Welfare in the form and Child Welfare, to monitor and link the usage of grants, audits on the use of these grants have of grants or support to desired health outcomes. not been conducted systematically. In addition, In the case of mission hospitals, the report of the information on the use of resources and the Review Commission into the Health Sector stated provision of services has not been regularly “as of now, there are no service contracts between provided to the Ministry of Health and Child the government and mission hospitals. The Welfare. working relationship between the government and mission hospitals needs to be clarified through Equity And Quality In Health: A People's Right PAGE 127 Private and Public Partnerships instance, discharge patients earlier, introduce perverse rationing, or worse, deny them care The private sector in Zimbabwe has potential to altogether. Private funders and providers have not contribute meaningfully to the process of fully supported calls for increased regulation, achieving national health objectives. Though fearing that government will begin to recommend cooperation between the private and public sectors appropriate treatment and therapy for various has existed for a long time, this has been ad-hoc conditions. Issues of clinical freedom have also and informal. This potential needs to be tapped been raised. and coordinated. Opportunities exist in increasing the capacity of local manufacturers to produce Some of Zimbabwe's traditional international essential supplies for the health sector (e.g. drugs, partners suspended cooperation and direct equipment and sundries). development support in 2002. A number of them, however, continue to channel development However, initiatives in this direction require a resources through Private Voluntary Organisations, national approach, as they cannot be solely sectoral International Non Governmental Organisations because of the wider implications involved in and the United Nations family. Since some of designing and managing public and private sector these resources do not flow through government partnership frameworks. The stewardship role of channels, there have been obvious difficulties in the state and the Ministry derives credibility and tracking them and monitoring their use. Support visibility from and to the extent to which the is mostly for HIV and AIDS and programmes contributions of stakeholders are recognized and related to nutrition, children and mothers. acknowledged. Difficulties have been experienced in accessing resources from global initiatives such as the Global In participating in both the provision and Fund in the past. financing of health services, the private sector should really be complementing the work of the However, the bi-annual Ministry and partners public sector. The private sector frees space to meetings have continued to be held, with willing allow the public sector to concentrate on the needs partners participating. Bilateral agreements or of majority of the population, particularly the memorandum of understanding have also been vulnerable groups. Their work is regulated partly signed with partners and countries supporting through the Medical Services Act, which was working with the Ministry. There is however need intended to create a level playing field for patients, to revisit the existing MOUs and coordinating providers and funders. The challenges resulting structures in order to make them more useful. from the performance of the economy have strained this relationship, putting the health of Beneficial cooperation has grown over the past patients at risk. years, with a number of countries. The principle remains that partners are welcome to support the The growth of the black middle class over the national health development plan. The structures years immediately after independence brought with for the transparent management of development it extended growth in private medical insurance. support, in use up until 2002, are still appropriate These events also triggered the rise in the number for use today. of private medical practitioners, since their economic survival depends on the existence of an Partnerships with other ministries and sectors assured revenue base. This rapid growth under the present economic situation has given rise to new Intersectoral collaboration should be based and tensions, which, at times, have led to unfair focused on the common goal i.e. doing those practices. The patient bears the burden of these things which improve the quality of life of the practices and this has begun to generate pressure population, together. on the government for increased regulation to protect patients, funders and providers, from This is by no means an easy task but one which financial and medical hardship. cannot be ignored because the primary purpose of intersectional collaboration is to ensure that Medical Aid Societies have limited funds for national resources are allocated in ways that hospital care. They therefore have an interest in maximise benefit to society. At the district and employing techniques that will reduce inpatient provincial levels, opportunities exist for taking this use. It is not unusual, for example, for Medical approach forward. The structures are there in the Aid Societies to refuse re-imbursing providers for form of Provincial Councils, Provincial certain types of care. On the part of providers, Development Committees and District fearing non reimbursement, they might, for PAGE 128 The National Health Strategy For Zimbabwe 2009 - 2013 Development Committees. Perhaps, the issue to Organisations representing various health deal with is how to organise the flow of sectoral professions have continued to work in partnership funds, in order to achieve the common goal. with the Ministry of Health, in providing the regulatory framework for all health care providers Elsewhere in the document (pg 33) it has been and purchasers. Professional bodies in partnership indicated that poverty is a known negative with the MOHCW have been responsible for determinant of health. Tackling poverty remains a setting and monitoring standards and regulations top priority. Reduction in poverty will positively governing the conduct of various health influence the health and quality of life of professionals. communities. The institutions of higher learning have not been The development of gender-sensitive health given their rightful positions in the health system. policies is of high priority, and a whole range of The various activities they perform in improving reproductive health strategies have been health and quality of life seems to have been implemented as a package aimed at improving the unnoticed. Ministry of Health and Child Welfare lives of women. needs to work more closely with College of Health Science in patient care, training, laboratory services Educational opportunities, especially for women, research etc. have been shown to have a major impact on the improvement of health standards of countries the Partnership with the community deserves a special world over. The health sector will continuously attention and has therefore been dealt with identify new opportunities for strengthening health separately in the previous section. literacy together with Ministry of Education. Key issues The health sector has continued to play its role in • Wider social participation of all sectors, the promotion of safe water supply and sanitation communities and individuals on health issues. facilities and has worked closely with the Ministry • Service contracts with health service providers. of water in ensuring the safety of drinking water. • Review the Public Health Act, Rural District The health sector has also continued to work with Councils Act, Urban Councils Act. relevant authorities in promoting food security. • Agreements or Memorandum of understanding Collaboration with the Nutrition council has been with health partners. maintained. Other intersectoral committees include • Enhancing multi-sectoral collaboration in the Country Coordinating Mechanism, Roll Back health in issues. Malaria, the Epidemic Prevention and Control etc. • Central Government financing obligations to There is however a lot that needs to be done to local government. promote intersectoral collaboration with other government agencies. Equity And Quality In Health: A People's Right PAGE 129 Goal 33: To enhance collaboration with both local and international development partners Objectives Strategies To strengthen partnerships • Review and strengthen guidelines for working with public health with public health providers. providers • Increase funding/grants to public health providers. To increase and strengthen • Develop a policy on public/private mix and regulation of the private sector involvement private sector. in the health sector • Develop as system for coordination the operations of public and private sectors. To increase and strengthen • Elaborate a policy framework for intersectoral collaboration and intersectoral collaboration coordination. and coordination in health • Revisit and advocate for the resuscitation of the intersectoral development Cabinet committee on social services. • Develop a mechanism of making other ministries and sectors aware of their responsibilities in health. • Develop intersectoral action plans that address major determinants of health. • Develop a clear institutional framework for intersectoral support to community interventions. To strengthen partnerships • Adapt to local conditions and implementing decisions taken by with local and international multilateral organizations of which Zimbabwe is a member state. health partners • Strengthen regional and international cooperation on health issues. • Strengthen donor coordination. To strengthen partnerships • Determine the size and scope of different providers (Mapping). with health related • Define the roles and responsibilities of stakeholders. stakeholders • Establish a mechanism to involve all stakeholders in issues concerning health and quality life. • Review and improve Memorandum of Understanding with the different stakeholders. PAGE 130 The National Health Strategy For Zimbabwe 2009 - 2013 References REFERENCES Annual ART Report 2008 Assessment of Maternal and neonatal health services in Zimbabwe – MOHCW , UNICEF, UNFPA, WHO 2004 Brudtland 2001. The breakdown of family structures and social values have been reported as the contributory factor to depression, leading to abuse of alcohol and use of illicit drugs Census 2002 National Report Commission of review into the health sector report 1999 Country programme action plan 2007-2011 Districts Management Study 2005 Health where it matters most: An assessment of primary health care in Zimbabwe 2009 Inter-Censal Demographic Health Survey 2008 Labour Force Survey Midzi et al, 2008 polyparasitism among primary school children living in rural and commercial farming areas in Zimbabwe Ministry of Health and child welfare Child Health situation analysis Multiple Indicator Monitoring Survey (MIMS) 2009 National health strategy for Zimbabwe 1997-2007 2003 Poverty Assessment Study Survey (PASS) 2003 Restricted: Hand-book on the Functions of the Minister of Health and Child Welfare, March 1993 Short term emergency recovery programme (STERP) Stakeholder review meeting on the community assessment for strengthening primary health care National meeting report 2009 Study on access to health care services in Zimbabwe Study on Waste Management 2007 MOHCW Vital Medicines and Health Service Survey (2009) Zimbabwe 2003 poverty assessment study survey report Zimbabwe demographic and health survey 2005-06 Zimbabwe health for all action plan 1985 Zimbabwe Maternal and neonatal health roadmap 2007-2015 Zimbabwe Maternal and Perinatal Mortality Study 2007 Zimbabwe STEPwise survey 2005 Zimbabwe vulnerability assessment committee rural food security assessment 2009 Equity And Quality In Health: A People's Right PAGE 131

National Health Strategy for Zimbabwe, 2009 – 2013

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