THE TEMPOROSPATIAL DIMENSION OF HEALTH IN ZIMBABWE by EVANS CHAZIRENI Submitted in accordance with the requirements for the degree of PHD in the subject GEOGRAPHY at the UNIVERSITY OF SOUTH AFRICA SUPERVISOR: DR A C HARMSE Date: March 2015 Declaration I, Evans Chazireni hereby declare that the thesis, which I hereby submit for the degree of Doctor of Philosophy at the University of South Africa, is my own work and has not previously been submitted by me for a degree at this or any other institution. I declare that the dissertation /thesis does not contain any written work presented by other persons whether written, pictures, graphs or data or any other information without acknowledging the source. I declare that where words from a written source have been used the words have been paraphrased and referenced and where exact words from a source have been used the words have been placed inside quotation marks and referenced. I declare that I have not copied and pasted any information from the Internet, without specifically acknowledging the source and have inserted appropriate references to these sources in the reference section of the dissertation or thesis. I declare that during my study I adhered to the Research Ethics Policy of the University of South Africa, received ethics approval for the duration of my study prior to the commencement of data gathering, and have not acted outside the approval conditions. I declare that the content of my dissertation/thesis has been submitted through an electronic plagiarism detection program before the final submission for examination. Student signature: Date: 20-03-2015________ ii TABLE OF CONTENTS Page LIST OF FIGURES ix LIST OF TABLES x APPENDICES xi ABBREVIATIONS xii ACKNOWLEDGEMENT xiv ABSTRACT xv KEY TERMS xvi CHAPTER 1: INTRODUCTION TO THE STUDY 1 1.1 Introduction 1 1.2 Background 2 1.3 Assumptions 3 1.4 Statement of the problem 4 1.5 Aim and Objectives 5 1.6 Research questions 6 1.7 Justification of the research 7 1.8 Geography and health geography 9 1.9 Paradigms in health geography 10 1.10 Study Area 14 1.11 Research Design 17 1.11.1 Data collection 17 1.11.2 Data Analysis 19 1.11.2.1 Quantitative analysis 19 1.11.2.2 Qualitative analysis 21 1.12 Validity and reliability of the study 22 iii 1.13 Ethical considerations 22 1.13.1 Beneficence 23 1.13.2 Justice 23 1.13.3 Confidentiality and anonymity 23 1.13.4 Informed consent 24 1.13.5 Privacy 24 1.13.6 Respect for persons 24 1.14 Problems in the research 25 1.15 Organisation of the thesis 27 1.16 Conclusion 29 CHAPTER 2: HEALTH CONCEPTS, MODELS AND POLICY 30 2.1 Introduction 30 2.2 The concepts of disease and health 30 2.3 Pandemic, endemic and epidemic 33 2.3.1 Endemic 33 2.3.2 Epidemic 33 2.3.3 Pandemic 34 2.4 Determinants of health 35 2.5 Regions and health regions 39 2.5.1 Regional demarcation methods 40 2.5.2 Types of regions 40 2.5.3 Health regions 43 2.6 Models of Health 45 2.6.1 Epidemiological Transition Model 46 2.6.1.1 Ages of the Epidemiological Transition Model 46 2.6.1.2 Variations in the Epidemiological Transition Model 47 2.6.2 Spatial disease diffusion models 50 2.6.2.1 Expansion diffusion 51 2.6.2.2 Relocation diffusion 52 2.6.2.3 Mixed or Combined diffusion 53 iv 2.6.3 Models of healthcare 54 2.6.3.1 The Beveridge Model 54 2.6.3.2 The Out-of-Pocket Model 55 2.6.3.3 The Bismarck Model 55 2.6.3.4 The National Health Insurance Model 55 2.7 Policies for spatial development of health 56 2.7.1 Environment and health 56 2.7.2 Food safety and health 57 2.7.3 Resources and health 60 2.7.4 Primary health care (PHC) 61 2.7.5 Complementary medicine and alternative medicine 62 2.8 Conclusion 63 CHAPTER 3: GLOBAL HEALTH SITUATION: A COMPARATIVE APPROACH 64 3.1 Introduction 64 3.2 Developed and developing countries: an overview 65 3.3 Global spatial distribution of the state of people’s health 67 3.4 Health service provision in both developed and developing countries 72 3.5 Health evolution in developed and developing countries 73 3.6 Perspectives (Approaches) to the International Health Inequalities 75 3.6.1 The natural environment and health 75 3.6.2 Material/Structuralist Approaches 76 3.6.3 Life-course perspective 77 3.6.4 Public policy 78 3.6.5 Politics and political ideology 79 3.7 Health situation in selected developing countries 79 3.7.1 Health situation in Zimbabwe 80 3.7.1.1 Health improvement strategies used in Zimbabwe 83 3.7.1.2 Evaluation of the health improvement strategies used in Zimbabwe 90 3.7.2 Health situation in South Africa 92 v 3.8 Health situation in selected developed countries 95 3.8.1 Health situation in the United Kingdom 96 3.8.2 Health situation in Canada 97 3.9 Conclusion 99 CHAPTER 4: INDICATORS AND DATA SOURCES 100 4.1 Introduction 100 4.2 Data collection 100 4.3 Data sources 104 4.4 Indicators for spatial variation of health 105 4.4.1 Data needs 106 4.4.2 Indicators used by other researchers 106 4.4.3 Indicators for spatial distribution of the state of people’s health 110 4.5 Demarcation of health regions 117 4.6 Data for the demarcation of the administrative districts according to phases of the Adapted Epidemiological Transition Model 123 4.7 Data on evolution of the health system 125 4.8 Problems in data collection 127 4.9 Conclusion 128 CHAPTER 5: SPATIAL DISTRIBUTION OF HEALTH 129 5.1 Introduction 129 5.2 Data Analysis 129 5.2.1 Spatial distribution of the state of people’s health 130 5.2.1.1 Simple indices 130 5.2.1.2 Composite indices 132 5.2.1.3 Cartographic representation of results and discussion 134 5.3 Demarcation of regions 138 5.3.1 Indicators 140 vi 5.3.2 Clusters 141 5.3.2.1 Districts in Cluster B1 141 5.3.2.2 Districts Cluster B2 143 5.3.2.3 Districts in Cluster B3 145 5.3.2.4 Districts in Cluster B4 147 5.3.2.5 The combined dendrogram for the four clusters 149 5.3.2.6 Cartographic representation of the Health regions in Zimbabwe 150 5.4 The Adapted Epidemiological Transition Model 152 5.5 The demarcated health regions according to the Adapted Epidemiological Transition Model 153 5.6 Cartographic representation of the phases of the Adapted Epidemiological Transition Model and discussion 160 5.7 Conclusion 163 CHAPTER 6: TEMPORAL ANALYSIS OF THE ZIMBABWEAN HEALTH SYSTEM 165 6.1 Introduction 165 6.2 Data analysis 165 6.2.1 Indicators 166 6.2.2 Simple Indices 167 6.2.3 Composite Indices 167 6.3 Distribution of urban centres in Zimbabwe 168 6.4 Spatial Patterns of the health system 169 6.5 Evolution of the health economy of Zimbabwe 179 6.6 Conclusion 182 CHAPTER 7: SYNTHESIS, RECOMMENDATIONS AND CONCLUSION 184 7.1 Introduction 184 7.2 Contribution of the research to geography as a discipline 185 7.3 Findings of the research 187 vii 7.3.1 Variation in the spatial distribution of the state of people’s health in Zimbabwe 187 7.3.2 Variation in the spatial pattern of health service provision in Zimbabwe 189 7.3.3 Application of the Adapted Epidemiological Transition Model to the Zimbabwean spatial health system 191 7.3.4 Changes in health conditions in Zimbabwe: 1992 to 2002 192 7.4 Recommended health improvement policies and strategies for Zimbabwe 193 7.4.1 New policies and strategies 194 7.4.1.1 Telemedicine 194 7.4.1.2 National health insurance policy 196 7.4.1.3 Appropriate referral system 198 7.4.1.4 Appropriate public and private sector mix 199 7.4.2 Proposed adjustments of existing policies and strategies 201 7.4.2.1 Complementary or Alternative Medicine 201 7.4.2.2 Reduction in rural-urban disparities in the provision of health services 204 7.4.2.3 Transport Policy on health 206 7.4.2.4 Participatory approach 208 7.4.2.5 Tobacco and alcohol misuse 209 7.5 Recommendations for further studies 210 7.6 Main Conclusion 212 REFERENCES 216 viii LIST OF FIGURES Figure 1.1: Administrative Districts of Zimbabwe 15 Figure 1.2: Relief regions of Zimbabwe 16 Figure 2.1: Health determinants model 38 Figure 2.2: Greater Harare Area Polarised Region 42 Figure 2.3: Illustration of relocation diffusion 53 Figure 3.1: Absolute Burden of Disease: A comparison between developed and developing countries 69 Figure 3.2: Facets of Disease Burden: a comparison between selected developed and developing countries 70 Figure 3.3: Global distribution of GDP and health expenditures in developing countries, 2002 71 Figure 5.1: Spatial distribution of the state of people’s health in 2002 135 Figure 5.2: Administrative districts in cluster B1 142 Figure 5.3: Administrative districts in cluster B2 144 Figure 5.4: Administrative districts in cluster B3 145 Figure 5.5: Administrative districts in cluster B4 148 Figure 5.6: Combined dendrogram of all districts clustered in various clusters 149 Figure 5.7: Health regions in Zimbabwe 151 Figure 5.8: Administrative districts in the phase of pestilence and famine 155 Figure 5.9: Administrative districts in the phase of receding pestilence and Famine 158 Figure 5.10: Districts demarcated in the phase of degenerative and man-made diseases 160 Figure 5.11: Application of the adapted Epidemiological Transition Model on the Zimbabwean spatial health system 161 Figure 6.1: Urban centres in Zimbabwe 168 Figure 6.2: Spatial patterns of health (state of people’s health and the provision of health services) in 1992 and 2002 in Zimbabwe 170 Figure 6.3: Administrative districts that have declined in health and those that have improved in health 176 Figure 6.4: Health Conditions in Zimbabwe in 1992 and 2002 180 ix LIST OF TABLES Table 2.1: Determinants of health 35 Table 4.1: Health indicators used in the analysis of quality of healthcare in the United Kingdom 108 Table 4.2: