Health where it matters most:

An assessment of Primary Health Care in

Zimbabwe March 2009

© M Ndhlovu, TARSC

REPORT OF A COMMUNITY BASED ASSESSMENT

Training and Research Support

Centre (TARSC)
with
Community Working Group on
Health (CWGH)

May 2009

Produced in the
TARSC Community Based Research and Training programme
With support from Oxfam Canada
 Table of contents

Executive Summary.......................................................................................... 2

1 Introduction ................................................................................................. 6

2 The survey.................................................................................................... 8

3 Methods........................................................................................................ 9
3.1 Representativeness and sources of error ........................................... 16

4 Findings.................................................................................................... 16
4.1 Health education and promotion ............................................................ 17
4.2 Promotion of food safety and nutrition .............................................. 22
4.3 Safe water, sanitation and waste disposal ......................................... 24
4.4 Maternal and child health and immunisation ...................................... 28
4.6 Essential health services ........................................................................ 37
4.7 Community participation.......................................................................... 42
4.8 Perceived priorities.................................................................................. 44

5 Discussion and recommendations ........................................................... 47

References ..................................................................................................... 51

Cite this publication as: Training and Research Support Centre (TARSC) Community
Working Group on Health (CWGH) (2009) Health where it matters most: An
assessment of Primary Health Care in Zimbabwe March 2009 Report of a community
based assessment: TARSC Harare

1
Executive Summary
Primary health care is a strategy that seeks to respond equitably, appropriately, and
effectively to basic health needs and to address the underlying social, economic, and
political causes of poor health, to provide accessible essential health services and to
involve the participation of communities. Comprehensive PHC appears to be particularly
suited to addressing the current challenges and health needs in Zimbabwe. It addresses
the priority problems causing ill health, bringing resources for health to the individuals
and families that most need them, it addresses health at its most cost effective level and
taps a resource that communities have in abundance- people. Taking this forward calls
for clearer information on the current situation with respect to the major elements of
PHC, where the gaps are, and what potentials there are to revitalise PHC.

To support this, Training and Research Support Centre (TARSC), a non profit
organisation, through its Community based research training (CBRT) programme,
worked with the Community Working Group on Health (CWGH) in twenty districts to
carry out a situation assessment of PHC in Zimbabwe to inform advocacy and planning
for strengthened PHC. The programme built capacities for, implemented and reported
on a cross sectional survey of primary health care conditions in sentinel wards in 20
districts of Zimbabwe in March 2009. After permissions were obtained by CWGH, the
local teams used three major methods: a survey covering 540 randomly selected
households; interview with 71 key informants and 53 reports based on observational
data. The household sample had a higher urban share than the national average, which
may imply somewhat better health conditions than in the general population.

Households were, however, struggling with meeting the costs of health. A standard
basket of basic food, hygiene, public health and health care items has risen from US$71
in 2005 to US$272 in 2009. Health care costs became a larger share of household
spending on health in the period. Protecting from impoverishing effects of health care in
poor communities calls for the current policy of free health care for primary care level
services to be more rigorously enforced. It also calls for a health system able to prevent,
promote health and manage ill health, particularly for those with least personal income.
Less than half of households were satisfied with the performance of health systems
(service quality and outcomes) in this survey, lower in larger urban areas (perhaps
where people have higher expectations of service quality).

There were a number of problems in the environments for health: While safe water and
sanitation infrastructure was present there is need to monitor functioning and use of
these services as this was much poorer. In urban areas unreliable functioning, prolonged
cuts leading to use of unsafe alternatives, and in rural areas untreated poor quality water
sources undermine health, as do waste disposal in open pits and public sites. Improving
access to safe water, sanitation and waste disposal is a widely shared priority across
rural and urban areas. Reported urban diarrhoeal disease rates (recall) were generally
higher in urban than rural areas indicating the potential for epidemic outbreaks in more
crowded urban areas.

Addressing this means boosting the number of Environmental Health Technicians

(EHTs) and supporting them with resources (fuel, materials) to monitor, treat water and
organise improvements. Local government earmarked revenue for waste collection
should not be reallocated to other spending, and residents should be brought into

2
monitoring waste dumping. Residents and business can provide initial support with clean
up campaigns, as CWGH districts have done, but routine waste collection, water
treatment services and more reliable provisioning need to be improved as a public health
priority.

The current social and economic conditions mean that households face challenges in
meeting nutritional needs, and that particular vulnerable groups like women and children
need to be protected. Some elements of PHC were found to be widely present, and to
offer good entry points for revitalizing the system to achieve universal coverage of health
promotion, prevention and early detection and management of health problems,
particularly for these vulnerable groups. For example: Almost all (90%) households
reported having a child health card, 94% of facilities report implement growth monitoring,
81% of households access Antenatal care (lower in urban than rural areas) and 86%
were assisted by a skilled health worker in delivery, although falling as low as 35% in
some areas. Access to Voluntary counseling and testing (VCT) was high (88%),
although reported availability of ART treatment was lower (69% falling to 10% in some
sites). These are examples of high coverage services that are useful entry points for
expanding uptake of other services, including through integrated management models.

These services have high coverage because they are provided close to communities by
primary care clinics, and over 90% of households report their clinics to be within 5km.
This presents a major opportunity for rapidly improving access to essential services, if
resources are provided for the functioning of these services. At this primary care level,
while numbers of categories of personnel, like EHTs, VHWs, Community nurses, need to
be improved, this survey did not find the level of geographical, urban-rural disparity in
personnel found in higher level services. Staffing was also raised less often than cost
and drug availability as constraints to service delivery, while for facility personnel
improving access to supplies, communications and improved staff incentives were seen
to be important.

We suggest that a package of essential services and resources be defined and costed at
primary care level (including community outreach) and that a priority be given to
ensuring that this basic level of provisioning is funded and universally delivered by all
providers of primary care clinic services (central, local government, mission and other
private) through budget, resource allocation and incentive mechanisms, monitored by
communities, local government and health workers. Further:
 Central government financing obligations to local government need to be clarified
and reliably honoured so that services are not compelled to unfairly charge poor
communities in contradiction to national policy.
 Fee barriers at primary care services need to be removed.
 Financial mechanisms need to be found for allocating, ringfencing and monitoring the
resources for clinics and community health (given that it is currently buried in district
budgets and managed at that level) that are acceptable and trusted by funders and
communities.
 Logistics problems such as communication need to be addressed. There are
opportunities for innovation: Cell-phones can for example be used for emergency or
medical communications, for passing information, tracking services and reporting
outbreaks, to update on drug stocks, orders, or through handheld personal digital
assistants (PDA), to communicate data in the health information system. There are

3
 opportunities in this for moving away from old paper based health information data
flows to less cumbersome electronic forms.

There are gaps and shortfalls in some areas that undermine PHC. These often relate to
resource gaps to primary care services, and people having to travel to further services
for care (with 53% of monitors reporting having to travel more than 10km to the most
frequently used hospital):
 There are gaps in the resources and support for prevention and promotion
activities by EHTs, VHWs and clinics that leave communities susceptible and
dependent on curative care. For example: Less than half of households (46%)
report having access to a Village Health Worker in their ward, coverage of
malaria spraying and TB contact tracing is relatively low; 20% of facilities were
reported to lack refrigeration for the cold chain undermining routine immunization.
 Very few facilities have a nutrition garden to provide therapeutic or community
intervention for nutritional needs. The report describes community initiatives
drawing local support for seed and fertilizer to set up nutrition gardens that could
be replicated in all health centres and schools.
 Nearly one in three maternal deliveries were done outside the district of
residence, as people search areas where they have better quality or more
affordable care. Only 22% of facility interviews reported having a waiting mother
shelter, so that costs of staying in the facility while they wait for the delivery, or
the absence of a place for them to stay can discourage uptake of assisted
deliveries. Clinics need resources to provide adequate quality maternity services
for normal deliveries without charge, backed by improved referral and waiting
mother facilities at hospitals.
 Drug supply stockouts and shortages were reported in a range of areas.
Improved drug supplies are a priority for health workers and communities and if
provided at primary care level would avoid people seeking care from higher level
services at significantly greater distances, with higher costs to households and
services.

Some areas call for policy or management review:

 Currently people with HIV, diabetes and other chronic conditions travel to
hospital or private facilities to obtain treatment, adding the burden of cost and
transport to the existing demands for managing their conditions and raising
barriers to uptake and adherence. It would be important to discuss opportunities
and means for decentralizing chronic disease care so that resources to manage
chronic metabolic problems like diabetes, hypertension, HIV are brought closer to
communities strengthening possibilities for building expert patient roles in patient
centred care.
 Key dimensions of PHC are much less available in urban areas and a coherent
approach to PHC for urban areas appears to be missing, despite the increase in
preventable and communicable disease and the rise in urban poverty. There are
signs of this gap: Urban communities are more mixed and less cohesive, urban
health knowledge is often as low or lower than rural on key aspects of health,
and practices such as waste disposal or food storage need to be effectively
addressed at individual and community level. We need to develop and implement
an effective and appropriate approach to PHC in urban areas, through dialogue
with urban health services, residents, local authorities and other stakeholders.

4
While district health systems anchor PHC, and effective primary care level services are
vital to deliver and support PHC approaches, the core and centre to the approach is the
people. This survey highlights that the way people manage their environments, their
health choices and responses to illness is the entry point for the rest of the functioning of
the health system. Nearly one in three households self treat child and adult illness so
that households are also a first point of care. This highlights the importance of
strengthening households and individuals in promoting health and managing illness and
we need to more effectively integrate this into the functioning of health systems.

Information is fundamental. The assessment found that people have a reasonable

knowledge of common health conditions, but lack the specific knowledge needed to act
in an informed way to promote and protect their health, (such as to make and use SSS
to manage dehydration). Communities need consistent, regular, specific information
flows and ad hoc one off information to communities needs to be integrated into a more
comprehensive health literacy programme, as is currently being implemented in the
CWGH districts. Support for the functioning of Village Health Workers and other
community based health workers; person to person health information and mass media
also provide a means to improved health information flows. The high level of radio
ownership is currently an under-utilised resource for health, given gaps in transmission
coverage and perceived poor quality programming. Addressing this and also promoting
health information flow through community newspapers, community radio and schools
would significantly enhance people’s role in health if appropriately designed and
disseminated. Technologies such as cell-phones are found to be widely available and
SMS messages through cell-phones can send specific targeted messages on health
actions.

However PHC approaches seek to build a higher level of ownership and participation
than information exchange. There are a number of approaches that have empowered
communities to advance health that can be shared across districts. A more consistent
formally recognized mechanism for dialogue between communities and authorities and
providers is needed, such as the health centre committees (HCCs) that are found in 40%
of sites in this survey. While present, these were found to lack coherent integration with
planning systems, and to be functional in only a third of sites. The investments needed
to activate these mechanisms is not high, with returns for social dialogue and planning,
health worker and community morale and empowerment. HCCs were found in the
survey to be associated with higher levels of satisfaction with services, possibly due to
the communication, improved understanding and morale support they enable between
communities and health workers. They offer an opportunity to take forward the shared
local priorities across health workers and communities as found in this survey and also
to discuss how to accommodate differing priorities between them.
This assessment signals the potential for rebuilding Zimbabwe’s health system from
the bottom up. While we recognize its limitations, we present the issues and options
that it raises from local level for wider discussion and input. Putting in place a national
PHC strategy, backed by clear service entitlements, with resources effectively applied
to community and primary care levels of the health system, could be an entry point to
wider PHC oriented changes. As the report argues, experience from Zimbabwe and from
a wide range of international settings suggests that this is money well spent, with high
health and social gains. And for communities and local health workers, it’s a matter of
common sense to address health where it matters most – as close to the people as
possible.

5
1 Introduction
Health in Zimbabwe is under significant challenge. It has been undermined by AIDS,
poverty and economic decline, social inequalities and political discord. As a result,
despite stated policy commitments to health, communities have experienced outbreaks
of epidemics and falling service quality. In 2009, the opportunity and demand is there
to turn this situation around. At independence, when Zimbabwe had a similarly high
level of national expectation for people’s conditions to improve, the country founded its
interventions in the health sector on policies of equity in health and Primary Health
care (PHC). This meant that not only would attention be given to treating illness, but
also to promoting health, and to ensuring that people do not get ill. With this strategy,
over a relatively short time period of a few years, significant gains were made at that
time in improving health and access to health care nationally, despite the war and
under-development of the 1970s.

Health systems include all those actions whose primary purpose is to promote, restore
or maintain health. This is often reduced to health care services, but health systems
are much more than this. They promote health in communities, protect people from
sickness, generate trust and reduce the barriers that people face in using services.
Primary Health Care is a strategy for organising health systems so they effectively
promote health. It encompasses essential health care made universally available to
individuals and families by a means acceptable to them and at a cost that the society
can afford. It includes actions across different sectors to promote health.

Primary health care is a strategy that seeks to respond equitably, appropriately, and
effectively to basic health needs and to address the underlying social, economic, and
political causes of poor health. It includes at least the following, giving priority to those
most in need:
 education concerning prevailing health problems and the methods of preventing
and controlling them;
 promotion of food supply and proper nutrition;
 an adequate supply of safe water and basic sanitation;
 maternal and child health care, including family planning;
 immunization against the major infectious diseases;
 prevention and control of locally endemic diseases;
 appropriate treatment of common diseases and injuries; and
 provision of essential drugs;
Primary health care (PHC) promotes community participation in health sector planning,
organization, actions and decision making. Health workers are trained to work as a
team and are available and able to respond to the health needs of the community.
PHC is sustained by integrated, functional and supportive referral systems.

Its not only in Zimbabwe where a PHC approach has achieved measurable gains in
health and health systems. Notwithstanding challenges and obstacles, scaling up
comprehensive PHC was found in settings as diverse as Bolivia, Sudan, Ethiopia, and
remote areas of Australia to lead to improvements in health and access to health care,

6
including for poor communities1. These improvements have been found even in
conditions of very low incomes, instability and high HIV prevalence.

Comprehensive PHC, as outlined in the box above, appears to be particularly suited to

addressing the current challenges and health needs in Zimbabwe. It addresses the
priority problems causing ill health, it brings resources for health to the individuals and
families in the community that most need them, it addresses health at its most cost
effective level and it taps a resource that communities have in abundance- people. Not
surprisingly, therefore, the Community Working Group on Health (CWGH) in 2008
resolved to advocate for strengthened PHC in Zimbabwe. Taking this forward calls for
clearer information on the current situation with respect to the major elements of PHC,
where the gaps are, and what potentials there are to revitalise PHC.

To support this, Training and Research Support Centre (TARSC), a non profit
organisation, through its Community based research training (CBRT) programme,
worked with the Community Working Group on Health (CWGH) in twenty districts to
carry out a situation assessment of PHC in Zimbabwe to inform advocacy and
planning for strengthened PHC. Beyond a quantitative assessment of different
dimensions of PHC, TARSC in this process also aimed to build capacities in CWGH
personnel within wards in districts to assess and report on the primary health care
conditions in their districts, using scientific research methods. Through building skills in
collection and analysis of data, we aimed to build evidence and reporting on the
current PHC situation at local and national levels, and to support the capacities in
CWGH districts to take ownership of and engage on the findings.

The work was designed and implemented by TARSC (R Loewenson, A Kadungure, C

Maxwebo, Z Mlambo, M Makandwa) with CWGH (I Rusike, T Chigariro, A Makone, K
Ndlovu, S Macheka, M Sumbani, H Madakadze, E Nkomo, C Nyama, N Moyo, T
Mpofu, A Rusike, A Mangwana, F Chirwa, I Sakabuya, N Mishena, J Banda, S
Mashinya, C Sibanda, J Phiri, M Nkomo, N Moyo, B Ndebele, N Xaba, M Ncube, C
Mpofu, R Zikhali, G Ndlovu, D Masuku, H Mhlanga, A Damuson, A Masuku, D
Chirimuuta, C Mushawatu, S Marisi, S Khumalo, T Mudyiwa, Z Marizeni, WB Mswazi,
T Chadyiwanembwa, G Ndima, W Chiparamakura, A Nyachowe, Rev T Mucheri, TC
Mutonhere, P Mandevhana, W Mandimika, R Jembere, S Marima, S Beremauro, N
Musekiwa, S Coffee, N Mgutshini, E Takaidza, JT Vambe, R Chikara and B Chirau).
CWGH districts sought authority in each district to do the work. The data was analysed
at TARSC (A Kadungure, R Loewenson, C Maxwebo), and the results reviewed with
the CWGH at a results meeting and skills workshop involving representatives of each
team from the twenty districts and the national CWGH office.

This national report has been prepared by TARSC (R Loewenson) with review input
from the team2. District level briefs are also being prepared.

1
For example this is reported in WHO Commission on the Social Determinants of Health
(2008) Closing the gap in generation Final report of the WHO CSDH, WHO Geneva; in Perry,
H., Shanklin, D., Schroeder D. (2003). Impact of a Community Based Comprehensive Primary
Health Care Programme on infant and child mortality in Bolivia. J Health Pop Nut, 21(4), 383-
395; in Wakerman et al (2008) PHC delivery models in rural and remote Australia – a
systematic review BMC Health Services Research 8:276
2
Comments and feedback on the report are welcomed. Please send to [email protected];
[email protected]

7
2 The survey
The overall programme aimed to obtain an assessment of primary health care
conditions; and further to equip CWGH personnel to assess PHC conditions in their
wards, and finally to use the evidence to support local and national dialogue on
priorities for strengthening primary health care.

Specifically, the programme built capacities for, implemented and reported on a cross
sectional survey of primary health care conditions in sentinel wards in 20 districts of
Zimbabwe.

This report outlines the methods, findings and conclusions from the programme at
national level. The training is separately reported. Districts are preparing their own
reports on the evidence from their wards. Both district and national level engagement
is planned on the findings.

The survey assessed the following dimensions of PHC:

Through reported data by CWGH monitors and key informants
 levels of disease, nutrition and health service use
 water, sanitation at public facilities, community level waste disposal,
community level food hygiene and energy sources
 Primary care – public sector infrastructure, water, waiting mother facility,
staffing, incentives, drugs- VEN rates, diagnostic facilities, services offered,
and uptake; Other primary care providers and uptake; Distance to services
 ART supply and coverage
 Primary care quality of care standards for all providers
 Resources and systems for management of TB (case tracing, treatment and
DOTS), malaria (spraying and treatment), cholera (water treatment, case
treatment)
 Antenatal care (ANC), Prevention of mother to child transmission (PTMCT )
and skilled worker delivery access and uptake
 Growth monitoring and immunization access and uptake; Nutrition garden
 Contraceptive prevalence – condom and other
 VHW numbers, coverage, resourcing and challenges
 Mechanisms for governance and participation fort all providers
 Priorities for health
 Costs of a basket of goods essential for health

Through household survey:

 4 week recall of diarrhoea, malaria, fever, respiratory infection, skin infection
 Last treatment, why, distance to service, cost for what, barriers and
satisfaction
 Knowledge of cholera, malaria, plague; sugar salt solution (SSS)
 ART access, source, cost and barriers
 water, sanitation, waste disposal and food hygiene, energy sources for cooking
 Growth monitoring and immunization coverage, access and uptake
 ANC, PTMCT; assisted delivery access, and uptake; Contraceptive prevalence
 School age Girls and boys in and out of school
 VHW visits, reason and perceptions
 Priorities for health

8
3 Methods
A cross sectional survey in March 2009 that used three major methods
 A household survey using a standardised questionnaire
 A report form from monitors based on observational data
 Interview with key informants in the health sector at primary care level

The districts: The survey was carried out in 20 districts through data collected at
ward level in the districts. The districts were;
Northern Region: Arcturus, Bindura, Chikwaka, Chinhoyi, Chipinge, Chimanimani,
Chitungwiza, Kariba, Masvingo and Mutare
Southern Region: Bulawayo, Chiredzi, Chiwundura, Gweru, Hwange, Insiza/
Filabusi, Kwekwe, Plumtree, Tsholotsho and Victoria Falls

Figure 1 shows the districts with sites and Table 1 shows the profile of these districts.

Figure 1: Map of Zimbabwe showing districts surveyed

Districts with
participating sites -
PHC Assessment

9
Health information from household surveys is largely not analysed to district level and
is only available at provincial level. It would appear that districts with greater urban
populations have better health statistics, and health statistics in the 2006 Zimbabwe
Demographic and health survey seem to be poorer in Manicaland. Some areas, like
the low immunisation coverage, have since been addressed through campaigns
(Loewenson and Masotcha 2008)). Access to doctors is generally limited in these
districts, and while needed for referral facilities in districts, the majority of PHC services
can be delivered through nursing and other health personnel. Many countries have
significantly expanded PHC through trained health extension workers/ community
health workers and primary health care workers.

The sentinel sites in the survey were wards, which are also the catchment area of the
primary care level of health services, the clinic. Up to 3 ward sites were combined to
make up the evidence for a district. The wards were purposively sampled as those
places where CWGH personnel are based. In five districts there were less than three
wards covered and in four districts, one or more of the three reports were from the
same ward.

The CWGH districts identified three people per CWGH district, based on their skills
levels and roles in community health outreach. Two 3-day training workshops were
held to build research skills and train in the methods. A total of 56 monitors were
trained and 53 returned forms for the research (a 95% response rate).

The households: For the household survey, a multi stage sampling design was
used. Each district was divided into clusters, clusters randomly selected and then
households randomly selected with the cluster from a complete household listing of the
cluster. Given logistic and budget constraints each of the 3 ward sites per district
covered 10 households, or 30 households per district. A total of 270 households were
surveyed in Northern Region and 270 households in Southern Region, with 540 in
total.

The respondents were largely from low income families: paid employees or own
account workers, with about one in ten looking for work or unemployed (See Table 2).
Those in large scale mining or plantation enterprises had significantly higher levels of
paid employees.

The households in the survey generally relied on own farming, vending, formal retail and
civil service employment for income (Table 3), with greater reliance on manufacture,
vending and remittances in urban areas. The remittances were reported to largely come
from family members who have migrated out the country and to be irregular. Seven
districts were primarily rural with high levels of own farming: Bindura, Chipinge, Chikwaka,
Chiwundura, Insiza, Plumtree, Tsholotsho (Table 3). The rest, apart from those with large
scale farming (Chimanimani) and mining (Arcturus and Hwange), were urban.

The sample thus had a greater share of urban households than in the general population.
As noted later in the report, the higher share of brick housing in this survey than in the
general population (Figure 3), and the higher urban share may imply that this sample has
better health conditions than in the general population, and that the real picture of health is
somewhat worse than the one we present.

10
Table 1: Profile of the districts included in the survey

District Province Population HIV IMR Prevalence All Basic Doctor Nurse/
Prevalence (Provincial of fever vaccinations midwife
2008 (Provincial level) (Under 5) (%
(District) level) 2005-06 coverage) % of births attended to
2005-06 by cadre
Arcturus (Goromonzi) Mashonaland East 161,059 18.0 47 8.5 79.6 4.2 92.5
Chikwaka
(Goromonzi)
Chitungwiza Harare 337,667 (i) 19.3 46 9.8 51.3 20.0 76.0
Chimanimani Manicaland 120,469 19.7 71 8.9 41.2 8.3 80.0
Chipinge 296,501
Mutare 170,466
Chiredzi Masvingo 217,559 15.1 42 3.8 50.2 2.9 92.8
Masvingo 203,130
Gweru Rural Midlands 88,110 16.1 53 6.6 42.6 5.3 88.9
(Chiwundura)
Gweru Urban 147,156
Kwekwe 97,415
Bindura Mashonaland Central 108,594 18.5 45 9.2 56.6 5.1 89.8
Kariba Urban Mashonaland West 77,410 19.1 56 11.5 56.3 10.6 83.9
Chinhoyi 58,468
Bulawayo Bulawayo 707,130 16.8 34 3.5 71.8 38.6 56.7
Insiza (Filabusi) Matabeleland South 89,360 20.8 32 7.5 49.5 11.7 83.4
Bulilima (Plumtree) 98,425
Tsholotsho Matabeleland North 125,022 19.0 46 3.9 49.9 10.1 82.8
Hwange 64,131
Victoria Falls 32,912
Total Zimbabwe 18.1 60 7.5 52.6 10.0 84.2
Source: CSO 2008; CSO Macro international 2007 (i) official figure. The population of Chitungwiza is estimated in fact to be higher than this.

11
Table 2 Occupation of main household income earner of survey respondents

Own Unpaid/ Looking for Retired/

Paid Account Family work/ Home- sick/ too
District No Employee Employer Worker Worker Unemployed maker Student old Other
Nothern Region
Arcturus 30 93.3 - 3.3 - - 3.3 - - -
Bindura 30 10 0 6.7 50.0 16.7 6.7 - - - 10.0
Chikwaka 30 23.3 - 46.7 13.3 6.7 - - 10.0 -
Chinhoyi 20 20.0 - - 5.0 15.0 5.0 5.0 5.0 45.0
Chipinge 30 13.3 - 70.0 3.3 3.3 3.3 - 6.7 -
Chimanimani 30 73.3 - 10.0 - 6.7 - - 10.0 -
Chitungwiza 20 65.0 - 25.0 - 10.0 - - - -
Kariba 30 66.7 3.3 26.7 - 3.3 - - - -
Masvingo 20 60.0 - 5.0 - 20.0 5.0 5.0 5.0 -
Mutare 30 50.0 6.7 26.7 3.3 3.3 - - - 10.0
Sub Total 270 46.5 1.8 24.5 4.4 6.5 1.4 0.7 3.6 8.7

Southern Region
Bulawayo 20 55.0 15.0 - - 10.0 - 5.0 - 15.0
Chiredzi 20 20.0 10.0 65.0 5.0 - - - - -
Chiwundura 30 23.3 - 13.3 13.3 26.7 16.7 - 6.7 -
Gweru 30 70.0 3.3 13.3 - 3.3 - - 3.3 6.7
Hwange 20 90.0 - - 5.0 - 5.0 - - -
Insiza/ Filabusi 30 6.7 - 16.7 26.7 16.7 26.7 - 6.7 -
Kwekwe 30 30.0 - 50.0 - 6.7 10.0 3.3 - -
Plumtree 30 33.3 - 3.3 6.7 30.0 - - 20.0 6.7
Tsholotsho 30 30.0 - 6.7 10.0 6.7 43.3 - - 3.3
Victoria Falls 30 40.0 3.3 46.7 - 3.3 - - - 3.3
Subtotal 270 37.2 2.5 21.1 6.9 11.0 11.0 0.7 4.0 3.3
Grand Total 540 41.8 2.2 22.8 5.7 8.7 6.2 0.7 3.8 6.0

Households had relatively low ownership of assets, although ownership of radios, cell
phones, fridges and wheel-barrows was higher (Figure 2). This indicates both barriers and
potentials for health:
 Radios can support information flow, BUT many areas do not receive local radio
stations, people rely on media from neighbouring countries, the local programming
is not always popular and people may not have the electricity or batteries to run
radios. So it is an under-utilised resource.
 Cell-phones are relatively widespread and are a vital resource for emergency or
medical communications, for passing information, tracking services and reporting
outbreaks, even in remote areas. There would be great potential in using
cellphones to update on drug stocks, orders, or through handheld personal digital
assistants (PDA), to communicate data in the health information system. One
CWGH cadre pointed to that their alarm function can usefully be used to remind

12
 people about taking medicines!. Nevertheless there are constraints in the cost of
top ups and transmission coverage that need to be addressed.

On the negative side, poor household ownership of assets for transport are a definite
constraint to accessing resources and services, and public transport infrastructures are
an important factor in most areas. The collapse of postal services has also disrupted
communications and information exchange, adding to weaknesses in public
infrastructures and services. The finding later that many households use services
distant from where they live makes transport and communications vital for service
access and uptake.

Table 3 Source of household income of survey respondents (%total)

Informal Formal Formal

Own Farm man- Manu- Commercial Remi- Civil Other
District No Farming Worker ufacture facture Mining Vending / retail ttances servant (i)
Nothern Region
Arcturus 30 - 7 3 - 63 7 .7 - .7 7
Bindura 30 60 - - 3 - 3 13 - 20 -
Chikwaka 30 40 - 10 - - 17 - 13 13 -
Chinhoyi 20 5 5 5 - - 10 5 5 50 15
Chipinge 30 70 7 3 - 3 3 3 3 3 3
Chimanimani 30 - 30 3 10 - 33 - - 17 7
Chitungwiza 20 5 - - 5 - 30 15 10 30 -
Kariba 30 - - 3 20 - 3 30 3 30 10
Masvingo 20 10 - 5 - - 30 10 10 15 20
Mutare 30 - - 7 - - 10 20 - 20 20
Sub Total 270 20 5 4 4 7 13 10 4 18 10

Southern Region
Bulawayo 20 - - 10 5 - 15 10 - 30 30
Chiredzi 20 - - - - - 70 5 - 20 5
Chiwundura 30 53 - - - - 33 - 13 - -
Gweru 30 3 - 3 10 - 13 13 10 33 13
Hwange 20 - - 10 5 40 5 - 15 5 20
Insiza/ Filabusi 30 50 3 - - 13 20 - 3 7 -
Kwekwe 30 - - 3 - 10 37 7 17 17 10
Plumtree 30 30 3 10 - - 3 3 10 7 30
Tsholotsho 30 73 - 3 - - 13 - 3 - -
Victoria Falls 30 - - 17 - - 37 13 7 20 3
Subtotal 270 23 1 5 2 5 24 5 8 13 10
Grand Total 540 22 3 5 3 6 19 8 6 16 10
(i) the “other” categories include money changing, cross border trading and other
informal activities

13
Figure 2 Assets of respondents to the household questionnaire

Wheel-barrow

Car
asset

Fridge

Phone

Radio

0 10 20 30 40 50 60 70
% total ow ning asset

The physical characteristics of the housing of respondents is shown in Figure 3 below.

This generally reflects the household’s economic conditions and also has an important
bearing on environmental exposure to disease.

Figure 3: Materials used for respondents housing

Plastic/ Iron/
Mixed Mud and
2% Thatch
16%

Wood
3%
Concrete
7%
Brick
72%

The 2005/6 Zimbabwe Demographic and Health Survey (ZDHS) found that 33% of
households live in mud and thatch dwellings, and 0.4% in shacks. It would appear that
brick dwellings were more common in this survey, suggesting a more urbanised,
economically secure population than the national average. Mud and thatch housing
was generally more common in rural areas and brick in urban, as was to be expected.
The majority of households surveyed in Northern Region lived in brick housing, with
only 2% overall living in shelter made from plastic, iron or other materials of informal
dwellings, found in Chipinge. In Chimanimani there was a high proportion of wood

14
housing and in Chipinge mud and thatch housing. In Southern Region while brick
housing was common, there was a higher share of mud and thatch housing,
suggesting perhaps a more rural, less secure population on that region. In Bulawayo,
Hwange and Kwekwe sampled areas also included use of concrete housing.

From the ZDHS and other survey data, it is likely that this survey portrays a slightly
more favourable health picture than in the general population.

The health services: Key informant interviews were obtained up to three clinics
accessible to the community in that ward. This reflected a mix of clinic types, largely
public (particularly local authority), but also numerous private sector services. The
private clinics were mine or agricultural estate clinics, and also private surgeries and
informal private providers (Table 4). There was some report that scarcity of supplies in
public clinics has led to some mushrooming of informal private practice, particularly in
urban areas.

Table 4 Distribution of clinic types for key informant interviews ( = clinic)

Type of clinic facility
Number of Local Private
interviews Government Authority Mission Sector
Nothern Region
Arcturus 3 
Bindura 3 
Chikwaka 3 
Chinhoyi 2 
Chipinge 5   
Chimanimani 4  
Chitungwiza 4   
Kariba 3 
Masvingo 3  
Mutare 6   
Southern Region
Bulawayo 4 
Chiredzi 2  
Chiwundura 4   
Gweru 6   
Hwange 3  
Insiza/ Filabusi 3  
Kwekwe 4  
Plumtree 3  
Tsholotsho 3 
Victoria Falls 3  

Northern Region Total 36 33% 33% 33%

Southern Region Total 35 29% 43% 6% 23%
Total all districts 71 31% 38% 3% 28%

15
3.1 Representativeness and sources of error
While the teams were mentored and supported in the process we are aware of
shortfalls that arise in implementation:
 In three districts (Bindura, Chinhoyi and Chitungwiza) households were
sampled on a systematic rather than random basis, with households chosen in
intervals or contiguously in an area. This reduces the variation between
households in these areas.
 In some districts some questionnaires had incomplete data collection with
responses to questions not recorded. Where on analysis errors or
inconsistencies were identified in data, mentoring review including at the follow
up analysis workshop was done to review this data and make corrections
where relevant.

We anticipated such errors given that researchers were generally new to this type of
work and came from community level. Field visits were very useful to reduce this but
as transport was limited we were in some districts compelled to support field work
through phone calls which helped in monitoring progress and addressing queries but
not in ensuring quality of data in the field. The review meeting provided an important
opportunity therefore for checking and discussing the data.

While noting these sources of error we consider the data to be a sufficiently robust
picture given the triangulation of different sources of evidence (monitors, households
and key informants).

As we note earlier based on the higher share of urban households and brick housing, it
is possible that the real picture nationally is somewhat worse than that we report in this
survey.

4 Findings
The findings are reported within the key areas of Primary health care, that is:
 Health education and health promotion;
 Promotion of nutrition and food safety;
 Safe water, sanitation and waste disposal;
 Maternal and child health;
 Prevention and treatment of common diseases;
 Essential health services, adequate health workers, provision of essential drugs;
 Community participation
 Priorities for health

16
4.1 Health education and promotion
The survey used some indicators to assess coverage with health information and
promotion. Given the scale and profile of the cholera epidemic in 2008/9, with all
provinces affected and concerted responses to manage illness, it was anticipated that
knowledge of how to manage diarrhoeal disease should be relatively high. One
aspects of this is knowing how to make and use oral rehydration solution (ORS), a
community means for managing acute diarrhoea. It is important that this be made
correctly for it to properly rehydrate (See Box 1 below), and putting too much salt or
sugar can worsen the situation.

Box 1: Preparation of salt and sugar solution (SSS)

What you will need in order to prepare the salt and sugar solution
 use a clean 750ml bottle
 pour in 750ml of safe water, i.e.
bottled water or water from a tap,
borehole or closed well
 add half a level teaspoon of salt
 add six level tablespoons of sugar
 Mix and taste the prepared SSS
 Give the solution frequently, and after each bout of diarrhoea or vomiting, until the
patient is seen by a health worker.

Almost all households in districts (above 93%) had heard about Oral Rehydration
Solution (ORS) and SSS, except Victoria Falls where knowledge levels were at 80%.
ORS is usually the term used for the pre-prepared packets for electrolytes and SSS for
the home prepared solution. We asked about SSS as this is more under household
control.

A lower but still high share knew the correct amount of water to use for SSS, but far
fewer the correct amount of salt and sugar, ranging from 20% to 85% (See Table 5).
Similar levels of gaps in knowledge were found in relation to how often to administer
SSS. Knowledge was poorest in Masvingo and Plumtree and highest in Arcturus,
Chiredzi and Gweru. Even where knowledge was relatively high, while access to salt
was high, access to sugar to make SSS was significantly more limited. Where people
lack these resources they are reported to use plain water, mahewu or other fluids.

Hence even during a high profile cholera epidemic, households were found to lack the
correct knowledge or accessible resources to manage dehydration. Further, as shown
in Table 6 and Figure 6, knowledge of the signs and management of cholera was also
very variable, from levels below 50% in two districts, to above 90% in 4 districts.

Malaria is endemic in many of the districts and most people knew how to prevent
malaria. The findings suggest that communities are far less informed about less
common but serious epidemics (like plague), but have built a level of community
knowledge around more frequent conditions. Knowledge about plague in Hwange, for
example, was reported to relate health information on this in the 1990s.

17
These findings suggest that health literacy programmes need to give people a
reasonably wide knowledge and reinforce this with more frequent repeat of information
for common endemic diseases. For example as knowledge levels around cholera are
likely to fall over time it would be advisable to have regular and timely health promotion
information on cholera risks and management. The Village Health Workers and
Environmental Health Technicians have an important role to play in this.

Salt Solution (SSS)

% Know
% Have how
heard frequently
about % Know the correct amount to use
District No ORS/SSS for SSS of SSS % have for SSS
water salt sugar sugar salt
Northern Region
Arcturus 30 100.0 100.0 80.0 70.0 70.0 53.3 96.7
Bindura 30 100.0 100.0 50.0 53.3 53.3 46.7 100.0
Chikwaka 30 93.3 76.7 40.0 66.7 66.7 53.3 90.0
Chinhoyi 20 95.0 100.0 80.0 55.0 55.0 70.0 90.0
Chipinge 30 93.3 70.0 53.3 53.3 53.3 53.3 86.7
Chimanimani 30 96.7 76.7 56.7 36.7 36.7 63.3 80.0
Chitungwiza 20 100.0 85.0 60.0 55.0 55.0 75.0 80.0
Kariba 30 96.7 100.0 50.0 80.0 80.0 56.7 83.3
Masvingo 20 100.0 85.0 30.0 20.0 20.0 75.0 90.0
Mutare 30 96.7 83.3 56.7 70.0 70.0 60.0 86.7
Sub Total 270 95.1 85.6 54.4 56.4 56.4 57.9 86.8

Southern Region
Bulawayo 20 100.0 85.0 50.0 50.0 20.0 75.0 95.0
Chiredzi 20 100.0 100.0 65.0 90.0 65.0 95.0 100.0
Chiwundura 30 93.3 76.7 50.0 70.0 40.0 50.0 90.0
Gweru 30 96.7 73.3 56.7 63.3 66.7 96.7 100.0
Hwange 20 100.0 95.0 30.0 85.0 75.0 70.0 95.0
Insiza/ Filabusi 30 100.0 86.7 63.3 60.0 66.7 36.7 90.0
Kwekwe 30 100.0 83.3 36.7 63.3 46.7 76.7 93.3
Plumtree 30 100.0 73.3 46.7 53.3 26.7 53.3 76.7
Tsholotsho 30 96.7 93.3 80.0 83.3 80.0 40.0 83.3
Victoria Falls 30 80.0 80.0 40.0 66.7 30.0 76.7 86.7
Subtotal 270 94.3 81.9 51.2 66.4 50.4 64.1 88.5
All districts 540 94.7 83.8 52.8 67.8 53.4 61.0 87.6

18
Table 6: Household knowledge on communicable diseases
% Know the % Know what to % Know malaria % Know
signs of do to manage prevention causes of
District No cholera cholera methods plague
Nothern Region
Arcturus 30 80.0 76.7 96.7 23.3
Bindura 30 90.0 93.3 80.0 36.7
Chikwaka 30 50.0 43.3 26.7 -
Chipinge 30 66.7 83.3 63.3 10.0
Chimanimani 30 43.3 63.3 76.7 20.0
Chitungwiza 20 55.0 90.0 60.0 40.0
Kariba 30 93.3 86.7 100.0 10.0
Masvingo 20 60.0 70.0 75.0 60.0
Mutare 30 70.0 63.3 73.3 10.0
Southern Region
Bulawayo 20 55.0 60.0 60.0 15.0
Chiredzi 20 75.0 95.0 95.0 30.0
Chiwundura 30 30.0 40.0 16.7 -
Gweru 30 40.0 56.7 36.7 3.3
Hwange 20 85.0 90.0 100.0 100.0
Insiza/ Filabusi 30 70.0 53.3 50.0 16.7
Kwekwe 30 53.3 60.0 80.0 16.7
Plumtree 30 26.7 40.0 33.3 6.7
Tsholotsho 30 66.7 73.3 80.0 36.7
Victoria Falls 30 53.3 56.7 76.7 6.7
All districts 540 60.9 66.6 66.1 22.9
NB; Chinhoyi data not shown as not adequately completed

Figure 6: Household knowledge on communicable diseases

80
70
60

50
40
Northern region
30
20 Southern Region

10
Total
0
% Know the % Know what % Know % Know
signs of to do to malaria causes of
cholera manage prevention plague
cholera methods
knowledge

19
Meeting the costs of health: The absence of sugar for SSS in many households
suggests that even where households know what do to for health, they may not be
able to afford or access the necessary inputs. In 2006, we identified a basket of items
needed for health “a health basket” covering
 Hygiene items (eg soap)
 Food items
 Health care items
 Public health inputs
that an average size household would require for health3 and we have been
monitoring this since then. This is a wider definition than medical care, but this is
deliberate. Being healthy requires the inputs to prevent disease, promote good health
as well as those items for managing disease.

The items in the health basket were compiled from background surveys of health
inputs, from household survey items in Central Statistical Office surveys and from
perceived items from CWGH district members. The quantity of items making up a
monthly basket were derived from the same sources. Cost information was obtained
through direct observation of prices in stores and markets, collected for each indicator
from outlets and institutions serving that community. The cost of medicines such as
for hypertension, diabetes, was divided by an estimate of the prevalence of such
conditions in the community from health statistics. It is noted that these are all
estimates so the costs obtained are not intended to be absolute measures but to
indicate changes over time or between areas. An average monthly cost for ALL items
was calculated for each area and for all areas combined. This average monthly cost is
the estimated cost of the health basket for a family.

In March 2005,the same method found the average monthly cost to be one million
Zimbabwe dollars. (At the official exchange rate of the time that was equivalent to
US$164.41 while at the parallel market rate it was US$71,42) (using Reserve Bank
rate for the official rate).

By 2009 the average monthly health basket cost was $271.58. This is an escalation of
65% on the 2005 level using the official rate and 280% using the parallel rate. The
significant level of inflation on costs in Zimbabwe dollars has been officially recorded.
This indicates that even in US$ costs of health had escalated. Health care costs
appear to have had the largest increase as a share since 2008.

Costs appeared to be higher than average in Chinhoyi, Chitungwiza, Gweru, Bulawayo

Victoria Falls and Hwange (all urban). Lower than average costs were found in
Arcturus, Chiwundura and Plumtree, all largely rural or small peri-urban areas. It would
appear that generally costs are higher in urban than rural areas.

The largest contributor to the basket at the time were food and health care items.
Basic public health items (water, shelter) were less costly at that time (noting that utility
charges increased after the survey), but were observed to be less reliably provided.
As Figure 7 shows, the share of health care costs has increased the most since 2005,
attributed both to rising health care charges and to costs associated with treatment for

3
The health basket composition and costs are more fully described in reports at www.tarsc.org.
The average family size used was from the 2006 Zimbabwe Demographic and Health Survey.

20
AIDS and other common chronic conditions. As these costs are likely to be a barrier
for lowest income households the current policy of free health care for primary care
level services needs to be more rigorously enforced.

Table 7: Monthly cost of the health basket for average family size of 4.2 people,
March 2009 (US$)
Public TOTAL
Hygiene Food items Health Care Health US$
items US$ US$ items US$ items US$
Nothern Region
Arcturus 19.90 159.69 42.68 1.00 223.27
Bindura 22.36 178.40 33.64 11.17 245.57
Chikwaka 20.67 178.00 42.22 25.00 265.89
Chinhoyi 24.65 164.00 37.29 18.00 243.94
Chipinge 33.97 181.80 34.68 11.00 261.45
Chimanimani 23.81 174.47 34.12 17.00 249.40
Chitungwiza 22.14 182.33 36.84 23.00 264.31
Kariba 29.37 208.03 30.37 31.30 299.07
Masvingo 30.40 187.53 47.90 20.65 286.48
Mutare 20.79 154.52 41.58 36.00 252.89
Sub Total 24.20 173.21 37.06 18.89 253.36

Southern Region
Bulawayo 16.50 155.25 64.35 41.50 277.60
Chiredzi 25.00 174.70 43.13 23.01 265.83
Chiwundura 22.73 160.33 20.52 13.03 216.62
Gweru 22.49 192.20 28.27 30.27 273.22
Hwange 25.80 228.30 30.40 31.50 316.00
Insiza/ Filabusi 19.60 208.93 22.53 0.33 251.40
Kwekwe 18.85 173.62 36.16 15.21 243.84
Plumtree 25.37 184.43 21.89 3.83 235.52
Tsholotsho 21.10 186.13 45.80 13.17 266.20
Victoria Falls 37.00 188.33 48.03 51.37 324.74
Subtotal 23.10 181.42 34.20 20.71 259.43
All districts 23.65 177.31 35.63 19.80 256.39

Figure 7: Share of different components in the health basket, 2005, 2009

Public Health
items

Health Care
YEAR 2005
items
YEAR 2009

Food items

Hygiene items

0 % total 20 40 60 80 21
4.2 Promotion of food safety and nutrition
Food availability was not measured as this is captured in other food surveys. We also
did not measure arm circumference or weight for age or height of children under five.
As child nutrition is a key determinant of health this should be done regularly at
community level using the shakir strip for mid upper arm circumference, and we would
propose regular community surveys of child nutrition, rather than relying only on
growth monitoring of those who visit clinics. From other surveys child (<5 year) under-
nutrition was found to increase to 17% in 2005/6, and stunting (chronic under-nutrition)
to have increased from 21% in 1994 to 29% in 2005/6. Urban, wealthier households
had lower levels of undernutrition, with urban: rural differentials of 11%: 18% and
lowest: highest income quintile differentials of 21%: 9% (CSO; Macro Int 2007). Also
of concern are relatively low rates reported of exclusive breastfeeding in the first 6
months (GoZ UNICEF 2007).These rates of under-nutrition and stunting from national
household surveys are relatively high for the national income level.

With nutrition having such an important effect on health and disease outcomes, these
statistics suggest that we need to strengthen PHC promotion of nutrition, including
through community food plots and nutrition gardens at clinics, schools; child
supplementary feeding (CSFP), growth monitoring, promotion of breastfeeding and
promotion of food security, safe food storage and marketing and healthy diets.

Some elements of these PHC interventions have wider coverage than others (See
Table 8): Almost all households reported having a child health card, although it was
not clear whether they were up to date. Most facilities implement growth monitoring,
but very few have a nutrition garden or treatment resources to manage chronic
metabolic problems like diabetes. This limits their ability to provide therapeutic
intervention for these nutritional needs.

In some districts innovative efforts were

reported that had been taken at
community level to set up nutrition
gardens that could be replicated across
all districts, with support for seed, water
and fertiliser. It was felt that every
district should have nutrition gardens for
supplementary feeding at the clinic and
school and as a means to promote
household production of vegetable
gardens in the area. For example the
youth groups in one district had
organised to prepare the land. They
obtained seed and fertilizer from a local
enterprise in their district as a donation
to the nutrition garden and had set up
the community garden for support to
vulnerable groups. © M Ndhlovu, TARSC

22
Table 8: Nutrition services at clinics ( = clinic with service)
# key informants at clinics indicating that they
Have a Implement under
# Inter- nutrition five year growth Have insulin
District views garden monitoring for diabetics
Northern Region
Arcturus 3 
Bindura 3 
Chikwaka 3 
Chinhoyi 2 
Chipinge 5  
Chimanimani 4 
Chitungwiza 4  
Kariba 3 
Masvingo 3  
Mutare 6   
Southern Region
Bulawayo 4 
Chiredzi 2 
Chiwundura 4  
Gweru 6   
Hwange 3  
Insiza/ Filabusi 3 
Kwekwe 4 
Plumtree 3   
Tsholotsho 3   
Victoria Falls 3  
% Northern region districts 36 14 94 19
% Southern region districts 35 29 94 11
% All districts 71 21 94 15

The very low level of provision of insulin for diabetics within primary care services
means that diabetics have to travel to higher level services to access these drugs.
Given that this is a chronic condition with lifelong demands for treatment, with hospitals
some distance away on some areas, and with the travel placing an additional cost and
energy demand on people already facing stress, this would appear to be a barrier to
health. With diabetes management is decentralised to primary care level in some
countries, and with a demand for patient centred care models around chronic
diseases, this raises an issue of decentralising chronic care closer to communities.

Food hygiene is an important issue for community health, including of informal food
markets and at household level. Monitors in Chinoyi, Chimanimani, Chiyungwiza and
Mutare raised concerns with poor food hygiene. Households in urban or peri-urban
areas generally have fridges for food storage but interrupted power supplies and
power surges have undermined their functioning. Some respondents who reported
using fridges are not using their own facilities but those belonging to neighbours.

23
If closed containers, closed cool boxes and closed fridges are relatively safe forms of
storage, then between 3% (Bindura, Tsholotsho) and 100% (Chitungwiza; Gweru) of
households were storing food safely, or 63% as a whole. Reported food hygiene is
generally better in Southern region districts than those in Northern region (Table 9).

Table 9: Household methods for storing perishable products

% using
Total Open Closed Closed
District # Container Container cool box Fridge Other (*)
Northern Region
Arcturus 30 - 30.0 3.3 36.7 30.0
Bindura 30 - - - 3.3 96.7
Chikwaka 30 13.3 80.0 - 6.7 -
Chinhoyi 20 5.0 10.0 - 15.0 50.0
Chipinge 30 23.3 70.0 - 3.3 3.3
Chimanimani 30 13.3 33.3 - 20.0 33.3
Chitungwiza 20 - 20.0 - 80.0 -
Kariba 30 13.3 3.3 - 83.3 -
Masvingo 20 - - - 80.0 20.0
Mutare 30 3.3 10.0 6.7 73.3 6.7
Sub Total 270 7.7 27.0 1.1 37.2 23.6

Bulawayo 20 10.0 - 5.0 85.0 -

Chiredzi 20 5.0 - - 85.0 -
Chiwundura 30 - 33.3 - 3.3 63.3
Gweru 30 - 13.3 - 83.3 -
Hwange 20 - 15.0 - 80.0 5.0
Insiza/ Filabusi 30 6.7 60.0 3.3 - 30.0
Kwekwe 30 - 3.3 - 46.7 50.0
Plumtree 30 26.7 46.7 6.7 3.3 16.7
Tsholotsho 30 - - - 3.3 96.7
Victoria Falls 30 20.0 40.0 - 33.3 -
Subtotal 270 6.9 22.7 1.5 36.6 28.6
All districts 540 7.3 24.9 1.3 36.9 26.1
(*) drying and salting meat and vegetables;

4.3 Safe water, sanitation and waste disposal

Environmental conditions underlie many of the common health problems in Zimbabwe,
including the diarrhoeal diseases, malaria discussed earlier. This makes access to safe water,
safe sanitation and hygienic waste disposal fundamental for health.

The ZDHS found in 2005/6 that 99.4% of urban households and 67.1% of rural households
nationally had access to a protected water source, and 78% overall. In this survey 84% of
households had access to a safe water source, lowest in Bindura, Chipinge, Chiwundura and
Arcturus. (See Table 10). As the survey had a higher share of urban households it is not

24
surprising to find slightly higher access to safe water than in the ZDHS. What is of concern is
that these water supplies were reported to have unreliable functioning, with cut offs for
prolonged periods in urban areas meaning that people are not accessing adequate water from
these sources and are resorting to unsafe sources when this happens. Hence areas like
Chitungiwza and Chinhoyi where safe water is reported from 95-100% of households,
perennial water shortages and poor water quality are still felt to undermine health. In both
urban and rural areas, preventable practices such as using different containers to draw water
from wells and not covering wells also undermines the safety of water supplies.

According to monitor reports, schools and public places primarily relied on communal
taps for drinking water, except in Chikwaka, Bindura, Insiza, and Tsholotsho where
there was greater use of boreholes for this. Access to safe water was reported to be
significantly lower in Arcturus, Chiwundura and Bindura.

Table 10 Household sources of water for consumption

% Piped % Bore- % with
% Piped water % hole/ safe % Unpro- %
water inside outside Communal Protected water tected River/ %
District No house house tap well source well dam Other
Nothern Region
Arcturus 30 33.3 10.0 56.7 - 100.0 - - -
Bindura 30 - 6.7 - 50.0 56.7 43.3 - -
Chikwaka 30 - - - 76.7 76.7 20.0 3.3 -
Chinhoyi 20 60.0 35.0 - - 95.0 - - 5.0
Chipinge 30 20.0 6.7 - 36.7 63.4 36.7 - -
Chimanimani 30 26.7 30.0 30.0 - 86.7 10.0 - 3.3
Chitungwiza 20 65.0 35.0 - - 100.0 - - -
Kariba 30 33.3 36.7 30.0 - 100.0 - - -
Masvingo 20 90.0 10.0 - - 100.0 - - -
Mutare 30 100.0 - - - 100.0 - - -
Sub Total 270 38.5 15.5 12.8 18.0 84.0 12.1 0.4 0.7

Southern Region
Bulawayo 20 50.0 45.0 5.0 - 100.0 - - -
Chiredzi 20 45.0 - 55.0 - 100.0 - - -
Chiwundura 30 3.3 6.7 - 26.7 36.7 63.3 - -
Gweru 30 100.0 - - - 100.0 - - -
Hwange 20 95.0 - 5.0 - 100.0 - - -
Insiza/ Filabusi 30 - - - 70.0 70.0 26.7 - -
Kwekwe 30 73.3 26.7 - - 100.0 - - -
Plumtree 30 3.3 - - 63.3 66.6 3.3 30.0 -
Tsholotsho 30 3.3 - - 86.7 90.0 6.7 3.3 -
Victoria Falls 30 83.3 13.3 - - 96.6 - - -
Subtotal 270 42.6 8.3 4.6 27.1 82.6 11.0 3.7 -

25
The ZDHS found in 2005/6 that 58.5% of urban households and 30.5% of rural
households had access to safe sanitation, and 40% overall. In this survey 89% of
households had access to safe sanitation (ie flush or ventilated pit latrines), lowest in
Bindura, Chikwaka, Chiwundura, Insiza and Tsholotsho, and lower in southern than
northern districts (See Figure 8). According to monitor reports schools and public
places used either flush or ventilated pit latrines, except in Chinhoyi where use of
unsafe sanitation (non vented pit latrine) was noted.

Figure 8: Percent Households with safe sources of water for consumption

All districts
Southern region districts
Northern region districts

Victoria Falls
Tsholotsho
Plumtree
Kwekwe
Insiza/ Filabusi
Hwange
Gweru
Chiwundura
Chiredzi
Bulawayo
Mutare
Masvingo
Kariba
Chitungwiza
Chimanimani
Chipinge
Chinhoyi
Chikwaka
Bindura
Arcturus

0 20 40 60 80 100

% total with safe sanitation

This is much higher than the ZDHS finding, in part due to the greater share of urban
households, partly as households may be sharing toilets with neighbours rather than owning
them themselves, but also because some wards reported some investments in sanitation.
What was of concern was the functioning of these facilities, with water shortages making
urban flush services less hygienic.

Equally use is also of importance. Households in some districts (Bindura, Chikwaka,

Chipinge, Masvingo, Mutare, Chiwundura, Tsholotsho) reported disposing of
children’s stool in the yard or with other waste and if not completely buried this may
lead to fly borne disease. Further only 45% of households reported methods of waste
disposal that ensured that waste was covered (garbage bin or burying of waste), and
others using open and closed pits or throwing waste into the yard or disposing plastic
bags in sanitary lanes or public sites outside the home, particularly given the fall in
waste collection services (Table 11). Waste disposal practices in Chipinge,
Chimanimani, Tsholotsho, Chiredzi, Plumtree, Gweru and Chitungwiza seemed more
problematic. Public facilities were reported to be using methods on site, ie garbage bin

26
(40%), pit or burying in the yard (52%), and further assessment is needed to identify
the risk to the public using these facilities from these practices.

Table 11: Household reports of household waste disposal

%
% Pit inside % Bury it in Garbage % Throw it % Plastic
District No yard the yard bin outside yard Bag % Other
Nothern Region
Arcturus 30 16.7 20.0 46.7 13.3 - 3.3
Bindura 30 83.3 6.7 - 10.0 - -
Chikwaka 30 83.3 6.7 3.3 6.7 - -
Chinhoyi 20 30.0 10.0 15.0 - 15.0 -
Chipinge 30 16.7 23.3 30.0 26.7 3.3 -
Chimanimani 30 66.7 3.3 13.3 16.7 - -
Chitungwiza 20 15.0 20.0 30.0 5.0 30.0 -
Kariba 30 10.0 3.3 70.0 3.3 6.7 6.7
Masvingo 20 - 5.0 80.0 10.0 5.0 -
Mutare 30 20.0 10.0 70.0 - - -
Sub Total 270 35.8 10.5 34.4 9.5 4.6 1.1
Southern Region
Bulawayo 20 45.0 5.0 35.0 - 10.0 5.0
Chiredzi 20 5.0 - 5.0 85.0 5.0 -
Chiwundura 30 96.7 - - 3.3 - -
Gweru 30 40.0 26.7 - 20.0 10.0 -
Hwange 20 15.0 35.0 5.0 20.0 20.0 -
Insiza/ Filabusi 30 76.7 3.3 - 16.7 - -
Kwekwe 30 66.7 - 26.7 3.3 - 3.3
Plumtree 30 50.0 13.3 - 26.7 - 10.0
Tsholotsho 30 40.0 - 3.3 56.7 - -
Victoria Falls 30 30.0 16.7 20.0 3.3 26.7 -
Subtotal 270 48.6 9.4 8.7 21.7 6.5 1.8
All districts 540 42.2 10.0 21.5 15.6 5.5 1.5

The increase in uncollected urban waste

is a matter of concern to many
communities, and a source of disease
transmission. It is noted that bill payments
from residents include an earmarked
portion for waste collection, and residents
query whether these funds are being fully
used for waste collection or used for other
functions. It was felt that this money
should be protected for this function and
that greater monitoring be done to make
sure this was the case. While residents
can and have contributed to one off clean
up campaigns to assist with removing
waste, this doesn’t replace this core
obligation of local government.

CWGH members cleaning up public areas © CWGH 2007

27
The level of diarrhoeal disease (measured in terms of recall of diarrhoea in the past 4
weeks by age group) is shown in Table 12, with the districts with poorer performance
on water, sanitation or waste disposal shaded. From amongst them Chinhoyi and
Gweru appear to merit particular attention on environmental health (and also had
relatively lower levels of knowledge on SSS). Urban diarrhoeal disease rates are
generally higher than rural with poor water and sanitation appearing to have a greater
negative health impact in the more crowded urban areas.

Table 12: Reported 4 week recall of diarrhoeal disease by households

Diarrhoeal disease recall rate per 100 in household members aged
Nothern Region 0-11 mths 1-4 yrs 5-14 yrs 15-19 yrs 20-49 yrs 50+ yrs
Arcturus 30 - 18.2 14.6 - 8.6 12.5
Bindura 30 14.3 7.7 2.0 - 3.5 6.3
Chikwaka 30 20.0 - 4.4 37.5 8.0 50.0
Chinhoyi 20 - 75.0 27.3 100.0 46.2 100.0
Chipinge 30 - 28.6 10.5 33.3 12.5 -
Chimanimani 30 - 7.7 2.8 - 1.8 5.9
Chitungwiza 20 - 42.9 6.7 - 6.8 -
Kariba 30 - 9.1 9.7 13.3 14.5 100.0
Masvingo 20 25.0 - 5.3 13.3 10.0 -
Mutare 30 - 18.2 4.5 - 2.2 -
Sub Total 270 8.8 15.3 7.2 10.6 8.2 13.6

Southern Region
Bulawayo 20 100.0 33.3 4.5 16.7 3.8 20.0
Chiredzi 20 - - - 5.3 5.0 -
Chiwundura 30 - 6.7 - 4.4 9.3 5.3
Gweru 30 100.0 15.4 6.9 - 3.4 -
Hwange 20 - 16.7 - - 4.7 -
Insiza/ Filabusi 30 - 4.8 - 4.8 8.6 9.1
Kwekwe 30 20.0 16.7 10.0 4.2 25.4 27.3
Plumtree 30 18.2 19.2 18.9 17.5 9.4 16.7
Tsholotsho 30 - 4.0 6.9 10.0 17.5 4.8
Victoria Falls 30 - 14.3 - - 15.5 5.0
Subtotal 270 22.2 12.4 5.0 6.0 10.7 8.9
All districts 540 15.5 13.9 6.1 8.3 9.5 11.3

4.4 Maternal and child health and immunisation

There is a particular focus in PHC on health of women and
children, due to their vulnerability and to the fact that their ill
health affects the wider community. Apart from the general
inputs that all people need for health, women also need services
to support safe reproductive health, pregnancy, prevention of
mother to child transmission of infections such as HIV, child
delivery and care, including their nutrition during pregnancy.

28
© M Ndhlovu, TARSC
Maternal health: Three quarters of households report access to contraception,
lowest in Masvingo and Mutare, but in many districts (Bindura, Chinhoyi, Kariba,
Masvingo) this has to be purchased outside the health services through vendors or
pharmacies and the coverage of districts by community based distributors was low
overall (32%) (See Table 13). Where contraception is not available in the public sector
services, it imposes an extra burden on households and may discourage use. For
districts such as Mutare, Masvingo, Chiredzi and Victoria Falls, improving access to
contraception through public sector services thus appears to be necessary.

Table 13: Distribution of household responses on access to contraception

% with Community % Households % Households having
based distributor who can to buy contraception
present in the access from outside health
District No district contraception services
Nothern Region
Arcturus 30 6.7 100.0 16.7
Bindura 30 33.3 96.7 70.0
Chikwaka 30 60.0 73.3 26.7
Chinhoyi 20 55.0 70.0 60.0
Chipinge 30 56.7 76.7 43.3
Chimanimani 30 46.7 93.3 40.0
Chitungwiza 20 10.0 80.0 30.0
Kariba 30 76.7 80.0 73.3
Masvingo 20 15.0 50.0 70.0
Mutare 30 6.7 46.7 50.0
Sub Total 270 37.1 76.3 46.4
Southern Region
Bulawayo 20 5.0 65.0 40.0
Chiredzi 20 45.0 55.0 70.0
Chiwundura 30 13.3 86.7 30.0
Gweru 30 40.0 63.3 50.0
Hwange 20 40.0 90.0 50.0
Insiza/ Filabusi 30 16.7 73.3 30.0
Kwekwe 30 6.7 73.3 26.7
Plumtree 30 56.7 66.7 46.7
Tsholotsho 30 36.7 73.3 33.3
Victoria Falls 30 13.3 60.0 60.0
Subtotal 270 26.5 69.3 41.6
All districts 540 31.8 72.8 44.0

Access to antenatal care (ANC) services is relatively high (80.5% overall; higher in
northern than southern region districts), but with lower report in some urban areas:
Chitungwiza, Chinhoyi, Bulawayo, Chiredzi, Gweru, Victoria Falls and Mutare. Just over
three quarters (79%) of households access skilled health personnel for deliveries, and
86% reported being assisted by skilled worker in the last delivery (See Table 14; Figure 9).
However, there is a 16% point gap between assisted deliveries and these being done in
the district of residence. Apart from those who live on the border of districts, some chose
facilities where they can have better quality care (mission hospitals were noted), or where
they can get family support, even if outside their area of residence.

29
Table 14: Household report of maternal health services
% had % facilities
skilled % Last % Assisted in with a
% access health delivery last delivery % Access waiting
Number ANC worker for done in by skilled PMTCT in mother
District (i) services deliveries district health worker district shelter
Northern Region
Arcturus 30 86.7 96.7 60.0 93.3 90.0 0
Bindura 30 96.7 93.3 50.0 63.3 80.0 0
Chikwaka 30 93.3 60.0 46.7 73.3 26.7 33
Chinhoyi 19 78.9 84.2 73.7 88.9 100.0 0
Chipinge 30 96.7 96.7 76.7 80.0 73.3 80
Chimanimani 30 100.0 86.7 60.0 90.0 90.0 25
Chitungwiza 20 65.0 95.0 60.0 100.0 95.0 75
Kariba 30 86.7 93.3 76.7 93.3 93.3 0
Masvingo 20 80.0 35.0 45.0 65.0 85.0 33
Mutare 29 51.7 55.2 92.9 96.2 64.3 50
Southern Region
Bulawayo 20 50.0 75.0 95.0 85.0 80.0 0
Chiredzi 20 50.0 75.0 75.0 90.0 90.0 0
Chiwundura 28 89.3 89.3 75.9 88.5 86.7 25
Gweru 30 50.0 70.0 56.7 83.3 76.7 17
Hwange 20 80.0 85.0 80.0 85.0 100.0 0
Insiza/ Filabusi 29 79.3 72.4 85.7 77.8 86.7 0
Kwekwe 30 96.7 80.0 83.3 100.0 86.7 0
Plumtree 30 93.3 80.0 56.7 53.3 93.3 33
Tsholotsho 30 93.3 70.0 53.3 50.0 76.7 0
Victoria Falls 29 62.1 89.7 78.6 100.0 96.6 0
Grand Total 534 80.5 79.6 70.3 86.2 82.6 22
(i) excluding households that do not have women in the reproductive age group

Figure 9: Household report of maternal health services (% total)

100
90
80
70
60
%

50
40 Northern region
30 districts
20 Southern region
10 districts
0 All districts
Access Skilled Last Assisted Access
to ANC health delivery in last PMTCT in
services w orker for done in delivery district
deliveries district by skilled
health
w orker

30
In some areas (eg Plumtree and Tsholotsho), despite the availability of skilled health
workers for deliveries, only about half of women were assisted by a skilled health worker
for their last delivery. Women are reported to be seeking assistance from traditional
midwives who accept payment in kind. As attending ANC and assisted deliveries are key
to improving maternal health outcomes (and maternal mortality on Zimbabwe is high)
ensuring access to these services to an adequate and affordable quality in all districts
would seem to be a priority.

Reduced access to or use of skilled midwives within districts adds a cost burden or barrier
to service uptake for women, indicating the need in these areas, largely rural, to improve
the quality of maternity services within districts. Further when facilities do not have waiting
mother shelters, as is often the case (see Table 14), mothers may be discouraged from
attending services by the costs of staying in the facility while they wait for the delivery, or
the absence of a place for them to stay.

For the 14% of households overall not having an assisted delivery, the major reasons
given were that it was not necessary or that the services were too far (Figure 10).
Hence for example districts like Masvingo, Tsholotsho who have lower levels of
assisted deliveries also appear to more women travelling to services outside their
areas, suggesting that not accessing quality care within such districts and transport
barriers to what they consider to be ‘quality care’ may be suppressing uptake of
maternity services.

Figure 10: Household reasons given for failure to get assisted delivery

Lack of knowledge/
other
Poor quality service 2%
1%

Too far-, no transport

22%

Too costly Not necessary

2% 66%

Not customary
7%

While this was the case for most districts, there was some variation on this
 “Not customary” was commonly given as a reason in Bindura (40%) and Gweru
(33%)
 “Too costly” was given as a common reason in Bulawayo (50%)
 “Poor service quality” was raised in Chikwaka (12.5%)and Chinhoyi (7.1%) and
 “Lack of knowledge/ information” given more frequently as a reason in
Bulawayo (50%) and Insiza/Filabusi (15%).

31
Child health: The nutrition, promotion and environmental interventions discussed earlier
and immunization discussed in the next section are key to child health. So is early
management of child illness. Households report primarily using public clinics or home / no
treatment for their last child illness (See Table 15). (Mission clinics were noted only in
Chinoyi and Plumtree). This highlights the importance of strengthening households and
particularly mothers in promoting health and managing child illness, and strengthening the
public sector clinics as the first line of care that people use.

Table 15: Households choice of treatment facility for last child illness in past
three months
Hospital Public
in/outside /mission Private Home or no
District No (*)district clinic clinic treatment Other (i)
Nothern Region
Arcturus 14 - - 23.3 53.7 7.1
Bindura 13 - 76.9 - 23.1 -
Chikwaka 5 - 60.0 - 40.0 -
Chinhoyi 9 - 33.3 - 33.3 33.3
Chipinge 4 - 50.0 - 50.0 -
Chimanimani 8 - 50.2 3.3 25.0 12.5
Chitungwiza 5 - 20.0 100.0 20.0 -
Kariba 3 - 33.3 - 66.6 -
Masvingo 4 5.0 25.0 - 50.0 -
Mutare 12 3.3 50.0 6.7 16.6 -
Sub Total 77 0.7 40.5 4.4 31.1 6.4
Southern Region
Bulawayo 10 - 70.0 5.0 20.0 -
Chiredzi 1 - - - 100.0 -
Chiwundura 13 - 38.5 - 38.5 -
Gweru 6 10.0 - 3.3 16.7 16.7
Hwange 9 10.0 44.4 - 33.3 -
Insiza/ Filabusi 13 - 53.8 - 46.2 -
Kwekwe 24 3.3 29.2 3.3 64.5 -
Plumtree 20 3.3 90.0 - 5.0 -
Tsholotsho 17 3.3 64.7 - 23.6 -
Victoria Falls 10 3.3 70.0 3.3 10.0 -
Subtotal 123 3.3 53.6 1.5 31.7 0.8
All districts 200 9.0 48.6 8.0 31.5 3.0
(*) Number of households that had a child illness in past three months. Percentages are of
these totals (i) traditional/ pharmacy/ NGO treatment centre

A mix of cost, access/transport and drug availability are influencing these choices
(See Figure 10). While this was the case for most districts, there was some variation
on this, “staff availability” was also commonly given as a reason in Kariba (25%),
Gweru (33%), Hwange(11%) and Victoria Falls (20%). Generally, 64% of households
were satisfied with the outcome of treatment, highest in Kariba, Masvingo, Victoria
Falls Kwekwe and Chiwundura (above 80%), and with less than 50% satisfied in
Chinhoyi, Insiza, Mutare and Plumtree. Its interesting to note that staff availability is

32
less of a factor than cost, drugs and access at this level suggesting that there is scope
for improving these frontline services by addressing drug / supply inputs and enforcing
free care policies.

Figure 11: Reasons given for choice of treatment for last child illness and
reported outcome
Other
5%
Staff availability
5%

Cost of treatment
Drug availability 37%
23%

Distance/ transport
30%

4.5 Prevention and treatment of common diseases

The spread of health information, improvement of nutrition, safe living and community
environments are key to disease prevention. Prevention and management of common
diseases also depends on early detection and treatment. As noted earlier, households
are primarily using the clinics as their first point of treatment for common diseases
(public and private) so effective disease management depends first on the resources
at this level. Table 16 shows household report of availability of a sample of indicator
resources for this at the clinics, while Table 17 shows the availability of selected
indicator resources at clinics as reported by key informants.

Most commonly reported to be available are drugs for malaria, although only by two
thirds of households, with lower availability in Masvingo, Insiza, Plumtree and Mutare.
Households are not accessing antimalarials privately and only 2.6% of southern region
households reporting having anti-malarial drugs in their homes at a time when the
malaria season was high (the question was only added after the Northern region
round).

While Environmental Health Technicians (EHTs) are reported to be found by half the
households (least in Chinhoyi, Kariba, Victoria Falls, Chiredzi, Bulawayo and
Masvingo), their numbers are often very low relative to need. Very little malaria
spraying is reported, indicating that EHTs have lacked the supplies and transport to do
this. This leaves households dependent on their own resources for malaria
prevention, such as through insecticide treated nets.

33
Outreach resources are not only limited with respect to in malaria spraying. Less than half
of households (46%) report having access to a Village Health Worker in their ward (with
highest access in Chipinge and Plumtree and lowest in Chinhoyi, Kwekwe, Bulawayo,
Masvingo and Victora Falls. Less than half of households reported having had access to
an immunisation campaign, particularly low in Masvingo, Bulawayo and Mutare.

Table 16: Household report of availability of resources for PHC at clinics

Cholera Malaria Immunisation
treatment Malaria Environment spraying in VHW in outreach
District No kits drugs health tech. past month ward campaign
Nothern Region
Arcturus 30 50.0 76.7 66.7 - 40.0 40.0
Bindura 30 46.7 76.7 36.7 3.3 56.7 46.7
Chikwaka 30 16.7 43.3 86.7 - 53.3 63.3
Chinhoyi 20 60.0 70.0 10.0 - 10.0 30.0
Chipinge 30 66.7 100.0 86.7 20.0 90.0 53.3
Chimanimani 30 96.7 86.7 56.7 13.3 76.7 60.0
Chitungwiza 20 10.0 75.0 60.0 10.0 5.0 50.0
Kariba 30 90.0 83.3 20.0 6.7 6.7 46.7
Masvingo 20 10.0 30.0 30.0 - - 25.0
Mutare 30 26.7 20.0 56.7 10.0 53.3 20.0
Sub Total 270 48.9 65.8 52.1 6.6 42.5 43.7
Southern Region
Bulawayo 20 40.0 65.0 10.0 - - 10.0
Chiredzi 20 90.0 85.0 5.0 30.0 45.0 45.0
Chiwundura 30 43.3 80.0 86.7 6.7 86.7 80.0
Gweru 30 73.3 50.0 56.7 - 40.0 66.7
Hwange 20 65.0 100.0 75.0 20.0 50.0 100.0
Insiza/ Filabusi 30 10.0 33.3 56.7 16.7 86.6 26.7
Kwekwe 30 40.0 73.3 - 13.3 6.7 56.7
Plumtree 30 23.3 26.7 60.0 3.3 90.0 56.7
Tsholotsho 30 36.7 90.0 63.3 66.7 83.3 70.0
Victoria Falls 30 50.0 90.0 20.0 30.0 - 43.3
Subtotal 270 44.1 66.3 44.1 18.5 49.9 54.9
All districts 540 46.5 66.0 48.1 12.6 46.2 49.3

Notably, some of these key dimensions of Primary health care are much less available
in urban areas. Indeed it appears that urban areas do not have a coherent PHC
approach despite the increase in preventable and communicable disease and the rise
in urban poverty. Urban communities are more mixed and less cohesive, and urban
people are reported to prefer seeing a “real doctor or nurse” and to devalue the role of
VHWs. Yet as shown in earlier sections, urban health knowledge is often as low or
lower than rural on key aspects of health, and practices such as waste disposal or
food storage need to be addressed at individual and community level.

Comparing Tables 16 and 17 for malaria treatment, it appears that households have a less
favourable impression of the resources at their facilities than facility personnel. Its
probable that the latters’ report is more likely to be accurate, although the reasons for
communities negative perceptions may lie in supplies not being consistently available and

34
in their not having adequate information on what is or should be available at the clinics.
Facilities generally have basic services like safe water and waste disposal, with gaps in
Chikwaka (67%) and Chimanimani (75%) in safe water and a number of urban areas in
waste disposal.

Table 17: Facility reports of availability of resources for PHC at clinics

% indicating that they have
Implemented
waste A waiting Malaria TB DOTS,
disposal mother A nutrition Refrigeration treatment case tracing in
District No Safe water facilities shelter garden for cold chain drugs past 3 mths
Nothern Region
Arcturus 3 100 100 0 0 100 100 67
Bindura 3 100 100 0 0 100 100 67
Chikwaka 3 67 67 33 0 100 100 100
Chinhoyi 2 100 0 0 0 50 100 0
Chipinge 5 80 100 80 0 0 100 100
Chimanimani 4 75 75 25 0 0 0 0
Chitungwiza 4 100 75 75 0 75 100 100
Kariba 3 100 100 0 0 100 100 100
Masvingo 3 100 100 33 67 100 100 100
Mutare 6 100 83 50 50 83 83 67
Sub Total 36 92 83 36 14 67 86 72
Southern Region
Bulawayo 4 100 100 0 0 100 100 50
Chiredzi 2 100 100 0 0 50 100 100
Chiwundura 4 100 100 25 50 100 100 75
Gweru 6 100 100 17 33 83 67 67
Hwange 3 100 100 0 33 100 100 33
Insiza/ Filabusi 3 0 33 0 0 100 33 100
Kwekwe 4 100 100 0 0 100 100 25
Plumtree 3 67 100 33 33 100 100 67
Tsholotsho 3 67 100 0 67 100 100 100
Victoria Falls 3 100 100 0 0 100 67 67
Subtotal 35 85 93 8 23 93 85 65
Grand Total 71 88 88 22 18 80 85 69

There is poor provisioning of some key facilities for PHC at clinics indicating a need for an
investment in upgrading these services to a basic level of functioning. Only one area
(Mutare) reported malaria spraying in the past three months. The almost complete
absence of nutrition gardens undermines supplementary feeding and nutrition, but is also
related to the limitations on access to safe water. The variable provision of refrigeration for
the cold chain undermines routine immunisation in those areas (Chinhoyi, Chipinge,
Chiredzi Chimanimani), the absence of malaria drugs undermines treatment in
Chimanimani and Insiza at a time of peak incidence; and of TB case tracing and DOTS in
Chinhoyi, Hwange, Kwekwe and Chimanimani undermines management of TB. The low
provisioning of waiting mother shelters in almost all districts undermines uptake of

35
assisted delivery services for women who have to travel longer distances or need
monitoring and support, as discussed earlier

With HIV prevalence rates of nearly one in five adults and an AIDS epidemic that is now
entering its third decade, the demand for access to counselling and testing for prevention
and treatment and to treatment services in high. Table 18 indicates that households report
relatively high access to VCT (88%) and ART (69%), although with cost, transport and drug
availability barriers.

Table 18: Household report of access to Voluntary Counselling and Testing (VCT),
ART and barriers to access
% reporting
access to % reporting barriers to access to ART as
Availability
District No VCT ART Costs Transport Stigma of drugs Other
Nothern Region
Arcturus 30 93.3 30.0 6.7 43.3 10.0 16.7 -
Bindura 30 76.7 73.3 26.7 70.0 - 3.3 -
Chikwaka 30 30.0 10.0 13.3 3.3 10.0 46.7 10.0
Chinhoyi 20 95.0 90.0 35.0 10.0 5.0 5.0 5.0
Chipinge 30 76.7 70.0 26.7 23.3 3.3 20.0 -
Chimanimani 30 90.0 93.3 6.7 - 20.0 20.0 20.0
Chitungwiza 20 95.0 95.0 - - 15.0 30.0 -
Kariba 30 96.7 80.0 13.3 46.7 - 3.3 -
Masvingo 20 85.0 60.0 65.0 - 10.0 - 5.0
Mutare 30 80.0 53.3 6.7 3.3 40.0 26.7 -
Sub Total 270 79.0 62.2 18.0 21.6 11.3 17.5 4.0
Southern Region
Bulawayo 20 55.0 25.0 10.0 25.0 25.0 35.0 -
Chiredzi 20 90.0 85.0 5.0 5.0 5.0 45.0 -
Chiwundura 30 96.7 86.7 3.3 53.3 30.0 6.7 3.3
Gweru 30 83.3 80.0 10.0 16.7 33.3 10.0 -
Hwange 20 100.0 100.0 45.0 30.0 5.0 15.0 -
Insiza/ Filabusi 30 96.7 56.7 3.3 66.7 3.3 26.7 -
Kwekwe 30 86.7 86.7 23.3 10.0 20.0 20.0 10.0
Plumtree 30 100.0 83.3 3.3 36.7 13.3 16.7 -
Tsholotsho 30 80.0 66.7 - 66.7 16.7 - -
Victoria Falls 30 96.7 93.3 26.7 30.0 10.0 23.3 6.7
Subtotal 270 87.6 75.6 11.9 35.0 16.4 18.0 2.2
All districts 540 83.3 68.9 15.0 28.3 13.8 17.7 3.1

Facility personnel report lower levels of provisioning:

 69% report provision of VCT, with higher levels in Arcturua, Bundura, Kariba,
Masvingo, Chiredzi, Hwange, Insiza, Kwekwe, Plumtree and Victorial Falls.
 80% report providing PMTCT and all provide condoms; and
 30% report providing Anteretroviral treatment (ART), mainly in Bindura, Chinoyi,
Chimanimani, Chiredzi, Insiza, Plumtree and Tsholotsho.

36
Decentralising treatment and care services to primary care level is not yet in place. Non
government and private services play a role in access to AIDS treatment and care and
public sector access to ART is usually at hospitals. As was noted with diabetes treatment,
this is another area of chronic care that it still poorly decentralised, raising recurrent costs on
households to access treatment (and potentially affecting adherence). Key informants
identified drug supply, cost, transport and stigma barriers to service coverage (Figure 12).
This raises service factors like stock-outs of drugs and test kits and cost barriers, and
community level factors like transport, costs and stigma. It was noted that stigma is still a
factor in service use, especially in those using private sector services.

Figure 12: Facility reports of barriers to uptake of AIDS treatment resources (%

total)

Costs
Transpo rt
Stigma
Ava ilability of drugs
Oth er

4.6 Essential health services

As for the management of child illness, households report using primarily public sector
clinics as their treatment facility in their last adult illness, followed by home or no
treatment (see Table 19).

Over 90% of households report their clinics to be within 5km, so transport becomes an issue
when people have to use hospitals for primary care services, or to attend clinics outside
their area. The distance travelled to clinics is generally less than 5km, except for rural
districts (Bindura, Chikwaka, Chimanimani, Insiza, Plumtree and Tsholotsho). This is
corroborated by the reports from key informants at the facilities in these areas, who report
people coming from 8-100 km away. The nearest hospital is an even further distance for
people in the ward, with 53% of monitors reporting having to travel more than 10km to the
most frequently used hospital. Table 20 shows the preferred sources of different
treatments reported by the CWGH informants.

As for the choices around child treatment, cost and drug availability are major factors
influencing choice of treatment (See Figure 13). For clinics in Chipinge and Masvingo,
where clinic staffing levels are reported to be lower, not surprisingly staff availability is
reported to be a factor leading to people using the hospital as their primary point of
treatment.

37
Table 19: Choice of treatment facility for last adult illness in past three months
Hospital Public /
Hospital outside mission Private Home / no
District No in district District Clinic clinic treatment Other
Northern Region
Arcturus 30 - 6.7 - 26.7 30.0 -
Bindura 30 3.3 3.3 43.3 - 6.7 3.3
Chikwaka 30 - - 13.3 - 30.0 6.6
Chinhoyi 20 5.0 - 15.0 - 20.0 15.0
Chipinge 30 6.7 - 13.3 3.3 6.7 -
Chimanimani 30 - - 16.7 10.0 - 3.3
Chitungwiza 20 - - 10.0 5.0 10.0 10.0
Kariba 30 6.7 3.3 23.3 - 20.0 -
Masvingo 20 20.0 - 25.0 5.0 25.0 -
Mutare 30 3.3 - 30.0 13.3 -13.3 -
Sub Total 270 4.0 1.5 18.9 6.6 15.6 3.3
Southern Region
Bulawayo 20 5.0 - 35.0 15.0 25.0 -
Chiredzi 20 10.0 - 10.0 - 5.0 15.0
Chiwundura 30 3.3 16.7 36.7 - -16.7 -
Gweru 30 16.7 6.7 6.7 3.3 10.0 3.3
Hwange 20 15.0 - 30.0 30.0 - 20.0
Insiza/
Filabusi 30 - 3.3 20.0 - 23.3 3.3
Kwekwe 30 6.7 - 16.7 3.3 53.3 3.3
Plumtree 30 6.7 - 66.7 - 6.6 10.0
Tsholotsho 30 10.0 - 26.7 - 23.4 -
Victoria Falls 30 13.3 6.7 23.3 6.7 6.7 3.3
Subtotal 270 8.3 3.7 26.9 4.6 18.6 4.6
All districts 540 6.1 2.6 22.9 5.6 17.1 3.9

Figure 13: Reasons for choice of treatment for last adult illness

Other
Staff availability 4%
2%

Cost of treatment
Drug availability 35%
31%

Distance and
transport
28%

38
Table 20: Monitor report of place usually selected for treatment/ care for different health needs (( =report selected)

Malaria treatment Baby delivery ARV treatment Hypertension treatment

# Private District Private District Public Private District Public Private District
mon- Public Clinic hos- Public Clinic hos- Clinic Clinic hos- Other Clinic Clinic hos-
District itors Clinic % % pital % Clinic % % pital % % % pital % % % % pital %
Arcturus 3    
Bindura 3    
Chikwaka 3     
Chinhoyi 1    
Chipinge 3   -        
Chimanimani 2     
Chitungwiza 2     
Kariba 3     
Masvingo 2      
Mutare 3       
Bulawayo 2    
Chiredzi 2    
Chiwundura 3     
Gweru 3     
Hwange 2       
Insiza/ Filabusi 3     
Kwekwe 3    
Plumtree 3      
Tsholotsho 3      
Victoria Falls 2    
% northern
districts 25 84 16 - 52 20 28 20 4 52 24 32 20 48
% southern
districts 26 92 4 4 65 4 27 4 35 0 58 8 42 4
All districts 53 89 9 2 56 11 24 8 26 2 57 15 36 13
No answer makes up the missing data

39
Clinics are generally used for malaria treatment and normal deliveries, while treatment
of chronic conditions such as AIDS and hypertension is more likely to be provided at
district hospitals in northern region districts, and privately or in other facilities in
southern region districts. As noted earlier, this lack of decentralisation of care of
chronic conditions means that people are travelling long distances on a regular basis
for their care, with costs to their households. It also potentially weakens opportunities
for people with chronic conditions being seen as expert patients, with major
responsibility for understanding and managing their conditions, given the time
constraints and less familiarity with patients at district and higher level hospitals. It
would seem desirable that such chronic care be provided closer to people’s homes.

Earlier it was noted that personnel are raised less often than cost and drug availability
as constraints to service delivery. Most wards reported having basic personnel (see
Table 21), least for EHTs, (with gaps in Bindura, Kwekwe, Tsholotsho and Chinhoyi),
reported to be due to outmigration. While there has thus been some attrition, the
density of personnel in the primary care facilities did not in this survey appear to show
the level of geographical disparity, urban-rural disparity found at higher level services.

Table 21: Number of health workers in the clinics

(*) includes nurse aides, paramedical personal but not voluntary or community health workers

Average # Average # % clinics

Number of Average # of Trained Average # of other private
clinics of nurses/ Midwives/ of EHTs/ health staff/ for profit
reported on clinic clinic clinic clinic (*)
Nothern Region
Arcturus 3 4 4 1 4 100
Bindura 3 4 1 0 1 0
Chikwaka 3 4 1 1 3 0
Chinhoyi 2 5 2 0 10 0
Chipinge 5 2 1 1 2 40
Chimanimani 4 5 2 1 5 75
Chitungwiza 4 7 3 1 5 50
Kariba 3 11 3 1 24 0
Masvingo 3 3 2 1 6 0
Mutare 6 6 2 1 11 0
Sub Total 36 5 2 1 7 33
Southern Region
Bulawayo 4 5 2 1 5 0
Chiredzi 2 10 5 1.5 5 50
Chiwundura 4 2 1 1 3 0
Gweru 6 6.3 3 1 4 50
Hwange 3 5 2 1 2 67
Insiza/ Filabusi 3 3 0 1 4 0
Kwekwe 4 6 6 0 7 25
Plumtree 3 3 1 1 3 0
Tsholotsho 3 7 0 0 4 0
Victoria Falls 3 8 4 1 4 33
Subtotal 35 5 2 1 4 23
All districts 71 5 2 1 6 28
In contrast, supplies are less available. While anti-malarials, adult antibiotics are
reported to be available at clinics, with exceptions in some districts, there is much
lower reported availability of insulin for diabetics and antibiotics for children. This
compromises the functioning of services in key area where acute and urgent treatment
needs may be high (child illness), or where service contact may be regular (diabetes)
forcing families to see this care at significantly greater distances, with potential costs to
the recovery of patients. Ensuring that basic treatment resources are available at
clinics would seem to be a priority to improve curative services and avoid the costly
burden of seeking primary care services at higher level hospitals for both communities
and higher level services.

Figure 14: Facility key informant reports of availability of resources for

treatment at clinics
100

90

80

70

60
Northern region
50 districts
Southern region
40 districts
All districts
30

20

10

0
malaria cholera insulin for antibiotics antibiotics
treatment treatment diabetics for children for adults
drugs drugs

While these figures held for most districts, there was some variation on this
 Some districts had lower levels of malaria drugs - Gweru (67%) and Insiza
(33%) Chimanimani (0%)- and cholera treatment drugs, ie Chikwaka (33%);
Masvingo (33%); Chiredzi (0%); Insiza (33%) and Plumtree (33%).
 Chitungwiza and Chipinge had higher levels of insulin (above 40% reporting)
 Child antibiotic stockouts were reported in Bindura, Chikwaka, Chinoyi and for
adult antibiotics in Bulawayo in the wards surveyed.

The level of household satisfaction with services is relatively low across all districts. It
appears that satisfaction with service quality and treatment outcomes is lower in larger
urban areas (perhaps where people have higher expectations of service quality), and
issues of poor staff attitudes due to low morale and inadequate resources were also
reported to fuel poor satisfaction. As noted in the next section, satisfaction appears to
be higher in areas where there are health centre committees, possibly due to the

41
communication, improved understanding and morale support they enable between
communities and health workers.

Table 22: Household perceptions of treatment outcomes and service quality for
last adult illness in past three months

% perceiving treatment outcome as % perceiving service quality as

Very Good/ Poor / very Very Good/ Poor / very
District No good Fair poor good Fair poor
Nothern Region
Arcturus 30 26.6 13.3 13.3 50.0 43.3 6.7
Bindura 30 26.6 13.3 16.6 53.4 30.0 16.6
Chikwaka 30 20.0 20.0 13.3 40.0 53.3 6.7
Chinhoyi 20 10.0 15.0 25.0 20.0 25.0 40.0
Chipinge 30 16.6 6.7 6.6 50.0 3.3 20.0
Chimanimani 30 20.0 6.7 3.3 36.6 40.0 23.3
Chitungwiza 20 25.0 10.0 - 55.0 20.0 25.0
Kariba 30 36.6 6.7 6.7 60.0 20.0 20.0
Masvingo 20 40.0 20.0 10.0 50.0 35.0 10.0
Mutare 30 26.7 13.3 13.3 36.7 36.7 13.3
Sub Total 270 24.3 12.0 10.5 44.7 30.5 17.0
Southern Region
Bulawayo 20 50.0 35.0 5.0 5.0 60.0 35.0
Chiredzi 20 30.0 10.0 - 70.0 20.0 5.0
Chiwundura 30 46.6 13.3 3.3 86.6 10.0 3.3
Gweru 30 30.0 3.3 10.0 56.7 26.7 16.6
Hwange 20 65.0 25.0 5.0 70.0 25.0 5.0
Insiza/ Filabusi 30 - 33.3 6.7 23.3 60.0 16.7
Kwekwe 30 46.6 10.0 3.3 53.3 20.0 26.6
Plumtree 30 50.0 23.3 6.7 26.6 53.3 16.7
Tsholotsho 30 23.3 20.0 10.0 53.3 40.0 6.7
Victoria Falls 30 50.0 6.7 3.3 50.0 33.3 13.3
Subtotal 270 38.4 17.0 5.4 48.7 34.1 14.6
All districts 540 31.4 14.5 7.0 46.7 32.3 15.7
Note: Not answered makes up difference on the shares

4.7 Community participation

In Zimbabwe, Health Centre Committees (HCCs) identify the priority health problems
in communities, plan how to raise their own resources, organize and manage
community contributions, and tap available resources for community health activities.
The HCC is the mechanism by which people can become involved in health service
planning at local level. They can discuss their issues with health workers in the HCC,
report on community grievances about the quality of health services, and discuss
community health issues with health workers.

42
A Health Centre
Committee is a joint
community–health
service structure, linked
to the clinic and covering
the catchment area of a
clinic (usually a Ward or
larger area).
HCCs were originally
proposed by the MoHCW
in the 1980s to assist
communities identify their
priority health problems,
plan how to raise their
own resources, organize
and manage community
© M Ndhlovu, TARSC
contributions, and tap
available resources for
community health activities.
They are thus an important vehicle for community involvement in planning and
decision making in health. Yet, as shown in Figure 15, health centres only existed
and had met in 40%or less of districts- or in eight of the twenty districts (Bindura,
Chikwaka, Kariba and Mutare; Chiwundura, Insiza, Plumtree and Tsholotsho).
Monitors and health facility respondents largely agreed on the areas where HCCs
were absent or non functional (see Figure 15). A far smaller share discuss the health
statistics, indicating a limited role in monitoring services. In the context of current
difficulties and opportunities such mechanisms could enhance social dialogue and
planning and boost morale for health and is easily addressed through organisation.
Table 15: Health centre committee functioning

100
90
80
70
60
%

50
40
30
20
10
0
% monitors % with no HCC % facilities % indicating
saying HCC met indicating HCC HCCs discuss
in past 3 months present health statistics

Northern region districts Southern region districts All districts

43
Districts where HCCs appear to be more active and involved in health planning are
Bindura, Chikwaka, Kariba, Chiwundura and Insiza.

4.8 Perceived priorities

The monitors, health workers and households were asked about their own perceived
priorities for improving health and health care in their areas. The feedback from the
three groups on problems they perceive in their districts and the priorities they identify
for action are shown in Tables 23 and 24.
Table 23: Perceptions of priority health problems in wards

District Monitor report Facility report Household report

Northern Region
Poor sanitation, water Staff and drug shortages, Water supply, drug
supply and waste no ambulance, poor staff shortages, sanitation
Arcturus disposal pay
Communication, drug, Water supply, drug
Poor sanitation, water electricity, transport shortages, sanitation, health
supply, and drug shortfalls; poor staff education
Bindura availability salaries
Poor sanitation, water Drug, finance and Water supply, drug shortage,
Chikwaka and food shortages stationary shortages sanitation, infrastructure
shortage of drugs, Drug shortages, health
shortage of transport, staffing and transport
Chinhoyi Food shortages; shortage of stationary
drug shortages, costs Water supply, drug
inadequate safe water, shortages, sanitation,
Poor water supplies; staff shortage; low staff infrastructure
Chipinge malaria control incentives
Health education, Water supply, drug supply,
sanitation, water supply, sanitation, health education
health, drug shortages; Drug, transport, funds
Chimanimani malaria control and staff shortages,
Waste disposal and Equipment, drug Sanitation, health staffing
Chitungwiza sewerage system; shortages, service costs
Poor sanitation and drug and transport Drug supply, staffing
Kariba malaria control; (ambulance) shortages
Poor sanitation; food drug and funds shortage, Water supply, drug supply,
Masvingo shortages; staff- skills and numbers sanitation, health education
drug, staff numbers and Drug supply, sanitation,
Refuse disposal; drug skills, equipment health staff
Mutare supplies shortages, transport, fees
Southern Region
Drug supplies and Staff shortages, water Drug supply, sanitation,
Bulawayo services shortages, power cuts health staff
Water supply, sanitation Water supply, sanitation,
Chiredzi and malaria control Drug shortages disease control
Drug, staff shortages, Water supply, drug supply,
Poor water supply, drug electricity supply sanitation
Chiwundura shortages communication problems
Gweru Poor water supply, drug Sanitation, water Health staff, drug supply

44
 shortages
Shortages of drugs, Drug supply, sanitation,
Garbage disposal, drug water, staff, consumables health education
Hwange shortages, eg detergents
drug shortage, poor Water supply, drug supply,
Poor water supply, drug communication, water sanitation, transport
Insiza/ Filabusi shortages, and sanitation,
Drug shortage, health Water supply, drug supply,
Water supply, sanitation, staffing, water supplies, sanitation
sewerage and drug poor sterilization
Kwekwe supplies equipment, no transport
Poor water supply, drug inadequate safe water, Water supply, drug supply,
Plumtree and food shortages drug, power shortages health education
Drug, accommodation, Water supply, drug supply,
staff shortages, water sanitation, health staff
cuts due to power
Poor water supply, drug blackouts, low staff
Tsholotsho shortages, transport morale, transport
Health literacy, drug Water supply, drug supply,
supplies, sanitation, sanitation, health staff
service quality, drugs and equipment,
Victoria Falls infrastructure health staff shortage

The problems raised in Table 23 commonly relate to shortfalls and erratic supplies of
water and sanitation shortfalls; shortages of drugs, staffing and other consumables;
the outmigration, inadequacy, and low morale of staff, inconsistent power supplies;
transport and communication shortfalls. There is some consistency across monitors,
facilities and households, although facility personnel are more likely to raise pay and
conditions of health workers as a problem and households are more likely to raise
health education and food shortages.

Table 24: Perceptions of priority health interventions in wards

District Monitor report Facility report Household reports

Northern Region
Strengthen health literacy, Improve drug supply, health
improve water supply and Increase and pay staff staffing, water and sanitation
Arcturus sanitation; food security more, provide drugs
Increase drugs, Improve drug supply, health
equipment for staffing, water and sanitation
deliveries, reduce
Bindura Improve drug supplies maternity costs
Increase drugs, water Improve drug supply,
and electricity, fence infrastructure , water and
infrastructure, sanitation
Chikwaka Improve food security supplementary feeding
Increase staff, provision Improve drug supply, health
of materials, improve staffing, water and sanitation
Chinhoyi Strengthen health literacy service, provide funds
Improve drug, water Improve drug supply, health
supplies, electricity, staffing, reduce charges
transport,
Chipinge Improve service infrastructure communication and

45
 conditions of service
Improve funds, drugs, Improve drug supply, health
trained staff, transport, staffing, water and sanitation
Chimanimani Improve drug supplies food for patients
Increase salaries for Improve drug supply, health
health staff, supply of staffing, water and sanitation
Chitungwiza Nil drug equipments
Strengthen Improve drug supply, health
Improve service infrastructure infrastructure, drug staffing
Kariba and drug supplies supply, transport
Increase, motivate Improve drug supply, health
skilled staff, improve staffing, water and sanitation
Masvingo Malaria control; drugs and equipment
Improve drug provision, Improve drug supply, health
transport, refuse staffing, sanitation
collection; motivate and
Strengthen health literacy, improve qualified staff,
improve drug supplies, reduce costs, malaria
Mutare sanitation and service quality awareness control
Southern Region
Improve staff quality, Improve drug supply, reduce
numbers and rewards, charges, sanitation
Improve drug supplies and drug and other
Bulawayo services materials supply
Improve water supply, Strengthen proper Reduce charges; water and
Chiredzi sanitation and malaria control management sanitation, disease control
Improve infrastructure, Reduce charges; water and
health staff numbers, sanitation, infrastructure
transport and
Improve water , food and communication, drug
Chiwundura drug supply, provision
Make services user Improve drug supply,
Gweru Improve water, drug supplies friendly infrastructure
Improve drug supplies, Reduce charges, sanitation,
Hwange sanitation, malaria control Improve drug supply disease control
Improve drug supply, Reduce charges,
infrastructure, security, infrastructure
transport and
Insiza/ Filabusi Improve water, drug supplies communication
Improve drug supply, Reduce charges; water and
Health staffing, refuse sanitation
Improve water, drug supplies collection, water,
Kwekwe sanitation and sewage electricity, transport
Improve drugs and Reduce charges, drug supply;
equipment, water and water and sanitation, health
Plumtree Improve water, drug supplies power supply, education
Improve drug supply, Improve staff numbers; water
water, communication, and sanitation, infrastructure
Improve drug supplies, resources, transport,
Tsholotsho service availability and quality health staff.
Health literacy, Improve drug Improve equipment and Reduce charges, drug supply
supplies, sanitation, drugs, improve staff
Victoria Falls infrastructure levels

46
The proposals in Table 24 refer primarily to improving facilities (staffing, drug and
equipment supplies, staffing numbers and incentives; communications, transport).
Households commonly raise the need to reduce charges, and monitors and
households commonly raise the need to male community level interventions, such as
for disease control, transport, water supply and sanitation.
While there are consistent areas across the districts, there are also issues specific to
districts suggesting a need for responsiveness to local plans and priorities.
Notable too is that while there is consistency of perception across communities and
providers in some respects, there are differences that need to be discussed through
shared mechanisms for planning like the health centre committees. Leaving out
community perceptions would increase the bias towards prioritising clinical services
and health service interventions.

The next section with the conclusions summarises the spectrum of problems and
priorities raised by the assessment as a whole, including these.

5 Discussion and recommendations

This survey found that households were struggling with meeting the costs of health. A
standard basket of basic food, hygiene, public health and health care items has risen
from US$71 in 2005 to US$272 in 2009. Health care costs became a larger share of
household spending on health in the period. Protecting from impoverishing effects of
health care in poor communities calls for the current policy of free health care for
primary care level services to be more rigorously enforced. It also calls for a health
system able to prevent, promote health and manage ill health, particularly for those
with least personal income. Less than half of households were satisfied with the
performance of health systems (service quality and outcomes) in this survey, lower in
larger urban areas (perhaps where people have higher expectations of service quality).

There were a number of problems in the environments for health: While safe water and
sanitation infrastructure was present there is need to monitor functioning and use of
these services as this was much poorer. In urban areas unreliable functioning,
prolonged cuts leading to use of unsafe alternatives, and in rural areas untreated poor
quality water sources undermine health, as do waste disposal in open pits and public
sites. Improving access to safe water, sanitation and waste disposal is a widely shared
priority across rural and urban areas. Reported urban diarrhoeal disease rates (recall)
were generally higher in urban than rural areas indicating the potential for epidemic
outbreaks in more crowded urban areas.

Addressing this means boosting the number of Environmental Health Technicians

(EHTs) and supporting them with resources (fuel, materials) to monitor, treat water
and organise improvements. Local government earmarked revenue for waste
collection should not be reallocated to other spending, and residents should be
brought into monitoring waste dumping. Residents and business can provide initial
support with clean up campaigns, as CWGH districts have done, but routine waste
collection, water treatment services and more reliable provisioning need to be
improved as a public health priority.

47
The current social and economic conditions mean that households face challenges in
meeting nutritional needs, and that particular vulnerable groups like women and children
need to be protected. Some elements of PHC were found to be widely present, and to offer
good entry points for revitalizing the system to achieve universal coverage of health
promotion, prevention and early detection and management of health problems, particularly
for these vulnerable groups. For example: Almost all (90%) households reported having a
child health card, 94% of facilities report implement growth monitoring, 81% of households
access Antenatal care (lower in urban than rural areas) and 86% were assisted by a skilled
health worker in delivery, although falling as low as 35% in some areas. Access to
Voluntary counseling and testing (VCT) was high (88%), although reported availability of
ART treatment was lower (69% falling to 10% in some sites). These are examples of high
coverage services that are useful entry points for expanding uptake of other services,
including through integrated management models.

These services have high coverage because they are provided close to communities
by primary care clinics, and over 90% of households report their clinics to be within
5km. This presents a major opportunity for rapidly improving access to essential
services, if resources are provided for the functioning of these services. At this primary
care level, while numbers of categories of personnel, like EHTs, VHWs, Community
nurses, need to be improved, this survey did not find the level of geographical, urban-
rural disparity in personnel found in higher level services. Staffing was also raised less
often than cost and drug availability as constraints to service delivery, while for facility
personnel improving access to supplies, communications and improved staff
incentives were seen to be important.

We suggest that a package of essential services and resources be defined and costed
at primary care level (including community outreach) and that a priority be given to
ensuring that this basic level of provisioning is funded and universally delivered by all
providers of primary care clinic services (central, local government, mission and other
private) through budget, resource allocation and incentive mechanisms, monitored by
communities, local government and health workers. Further:
 Central government financing obligations to local government need to be clarified
and reliably honoured so that services are not compelled to unfairly charge poor
communities in contradiction to national policy.
 Fee barriers at primary care services need to be removed.
 Financial mechanisms need to be found for allocating, ringfencing and monitoring
the resources for clinics and community health (given that it is currently buried in
district budgets and managed at that level) that are acceptable and trusted by
funders and communities.
 Logistics problems such as communication need to be addressed. There are
opportunities for innovation: Cell-phones can for example be used for emergency
or medical communications, for passing information, tracking services and
reporting outbreaks, to update on drug stocks, orders, or through handheld
personal digital assistants (PDA), to communicate data in the health information
system. There are opportunities in this for moving away from old paper based
health information data flows to less cumbersome electronic forms.

There are gaps and shortfalls in some areas that undermine PHC. These often relate
to resource gaps to primary care services, and people having to travel to further

48
services for care (with 53% of monitors reporting having to travel more than 10km to
the most frequently used hospital):
 There are gaps in the resources and support for prevention and promotion
activities by EHTs, VHWs and clinics that leave communities susceptible and
dependent on curative care. For example: Less than half of households (46%)
report having access to a Village Health Worker in their ward, coverage of
malaria spraying and TB contact tracing is relatively low; 20% of facilities were
reported to lack refrigeration for the cold chain undermining routine
immunization.
 Very few facilities have a nutrition garden to provide therapeutic or community
intervention for nutritional needs. The report describes community initiatives
drawing local support for seed and fertilizer to set up nutrition gardens that
could be replicated in all health centres and schools.
 Nearly one in three maternal deliveries were done outside the district of
residence, as people search areas where they have better quality or more
affordable care. Only 22% of facility interviews reported having a waiting
mother shelter, so that costs of staying in the facility while they wait for the
delivery, or the absence of a place for them to stay can discourage uptake of
assisted deliveries. Clinics need resources to provide adequate quality
maternity services for normal deliveries without charge, backed by improved
referral and waiting mother facilities at hospitals.
 Drug supply stockouts and shortages were reported in a range of areas.
Improved drug supplies are a priority for health workers and communities and if
provided at primary care level would avoid people seeking care from higher
level services at significantly greater distances, with higher costs to households
and services.

Some areas call for policy or management review:

 Currently people with HIV, diabetes and other chronic conditions travel to
hospital or private facilities to obtain treatment, adding the burden of cost and
transport to the existing demands for managing their conditions and raising
barriers to uptake and adherence. It would be important to discuss
opportunities and means for decentralizing chronic disease care so that
resources to manage chronic metabolic problems like diabetes, hypertension,
HIV are brought closer to communities strengthening possibilities for building
expert patient roles in patient centred care.
 Key dimensions of PHC are much less available in urban areas and a coherent
approach to PHC for urban areas appears to be missing, despite the increase
in preventable and communicable disease and the rise in urban poverty. There
are signs of this gap: Urban communities are more mixed and less cohesive,
urban health knowledge is often as low or lower than rural on key aspects of
health, and practices such as waste disposal or food storage need to be
effectively addressed at individual and community level. We need to develop
and implement an effective and appropriate approach to PHC in urban areas,
through dialogue with urban health services, residents, local authorities and
other stakeholders.

While district health systems anchor PHC, and effective primary care level services are
vital to deliver and support PHC approaches, the core and centre to the approach is
the people. This survey highlights that the way people manage their environments,

49
their health choices and responses to illness is the entry point for the rest of the
functioning of the health system. Nearly one in three households self treat child and
adult illness so that households are also a first point of care. This highlights the
importance of strengthening households and individuals in promoting health and
managing illness and we need to more effectively integrate this into the functioning of
health systems.

Information is fundamental. The assessment found that people have a reasonable

knowledge of common health conditions, but lack the specific knowledge needed to act in
an informed way to promote and protect their health, (such as to make and use SSS to
manage dehydration). Communities need consistent, regular, specific information flows
and ad hoc one off information to communities needs to be integrated into a more
comprehensive health literacy programme, as is currently being implemented in the
CWGH districts. Support for the functioning of Village Health Workers and other
community based health workers; person to person health information and mass media
also provide a means to improved health information flows. The high level of radio
ownership is currently an under-utilised resource for health, given gaps in transmission
coverage and perceived poor quality programming. Addressing this and also promoting
health information flow through community newspapers, community radio and schools
would significantly enhance people’s role in health if appropriately designed and
disseminated. Technologies such as cell-phones are found to be widely available and
SMS messages through cell-phones can send specific targeted messages on health
actions.

However PHC approaches seek to build a higher level of ownership and participation
than information exchange. There are a number of approaches that have empowered
communities to advance health that can be shared across districts. A more consistent
formally recognized mechanism for dialogue between communities and authorities and
providers is needed, such as the health centre committees (HCCs) that are found in
40% of sites in this survey. While present, these were found to lack coherent
integration with planning systems, and to be functional in only a third of sites. The
investments needed to activate these mechanisms is not high, with returns for social
dialogue and planning, health worker and community morale and empowerment.
HCCs were found in the survey to be associated with higher levels of satisfaction with
services, possibly due to the communication, improved understanding and morale
support they enable between communities and health workers. They offer an
opportunity to take forward the shared local priorities across health workers and
communities as found in this survey and also to discuss how to accommodate differing
priorities between them.
This assessment signals the potential for rebuilding Zimbabwe’s health system
from the bottom up. While we recognize its limitations, we present the issues and
options that it raises from local level for wider discussion and input. Putting in place a
national PHC strategy, backed by clear service entitlements, with resources
effectively applied to community and primary care levels of the health system, could be
an entry point to wider PHC oriented changes. As the report argues, experience from
Zimbabwe and from a wide range of international settings suggests that this is money
well spent, with high health and social gains. And for communities and local health
workers, it’s a matter of common sense to address health where it matters most – as
close to the people as possible.

50
References

1. CSO and Macro International Inc. (2007). Zimbabwe Demographic and Health
Survey 2005-06. CSO and Macro International Inc.: Calverton, MD.
2. Government of Zimbabwe (GoZ), UNICEF (2007) ‘World Fit for Children Mid-
decade Progress Report Zimbabwe 2002-2006’ UNICEF: Harare.
3. Loewenson R, Masotcha M (2008) EQUITY WATCH: Assessing progress
towards equity in health in Zimbabwe, 2008 Training and Research Support
Centre, Regional Network for Equity in Health in East and Southern Africa
(EQUINET), Harare.
4. Perry, H., Shanklin, D., Schroeder D. (2003). Impact of a Community Based
Comprehensive Primary Health Care Programme on infant and child mortality
in Bolivia. J Health Pop Nut, 21(4), 383-395;
5. Wakerman et al (2008) PHC delivery models in rural and remote Australia – a
systematic review BMC Health Services Research 8:276
6. WHO Commission on the Social Determinants of Health (2008) Closing the
gap in generation Final report of the WHO CSDH, WHO Geneva;

51