Zimbabwe National Health Strategy 2008 - 2013

Foreword

Table of contents Foreword ...... 2 Introduction ...... 3 Partnerships & community participation ...... 3 Socio-economic situation, environment and living conditions ...... 8 Demographic Dynamics and Health Status ...... 15 Morbidity and Mortality trends: Burden of disease ...... 19 HIV & AIDS and STI ...... 21 Tuberculosis ...... 25 Proposed Strategy for 2008-2013...... 29 Pursue high quality DOTS expansion and Enhancement...... 30 Maternal & Child Health ...... 31 Nutrition ...... 38 Malaria and other Epidemic Prone Diseases ...... 42 Non Communicable conditions ...... 47 Mental Health ...... 56 Trends and current status ...... 56 The promotion of good mental health and prevention of mental illnesses ...... 58 Care models and partnerships ...... 59 Challenges ...... 59 Disability and rehabilitation ...... 61 Elderly & Geriatric care ...... 66 Accidents and Emergencies ...... 68 Clinical Care and Quality of Services ...... 68 Core health services by level ...... 73 Quality Assurance ...... 73 Infection prevention and control ...... 73 LABORATORY SERVICES ...... 73 Imaging services and other support services ...... 75 Health System Strengthening ...... 75 Health Resources ...... 75 HUMAN RESOURCES FOR HEALTH ...... 75 Drugs & Medicines ...... 79 Transport and Communication ...... 82 Medical Equipment ...... 84 HEALTH INFRASTRUCTURE ...... 87 HEALTH FINANCING ...... 90 Governance ...... 97 Implementation Framework ...... 106 Monitoring and Evaluation ...... 106 Health & Management Information System and Research ...... 106 Resources required to implement the strategy (Costing) ...... 110 References ...... 110 ANNEXES ...... 110 NATIONAL INSTITUTE OF HEALTH RESEARCH ...... 110 TRADITIONAL MEDICINE ...... 113 Natpharm ...... 116 ZNFPC ...... 116 BTS ...... 116 Radiation protection ...... 116 Government analyst ...... 116

Abbreviations

Executive Summary Introduction Partnerships & community participation

The National Health Strategy (1997-2007), strongly supported the need for an inter- sectoral collaboration structure at the national level, which would form a platform for state agencies, whose work, directly influence improvements in health status and quality of life. The rationale was that interventions which have potential to improving health status and reducing health risks, require a structured approach, that recognised the multiplicity of societal needs in terms of; 1. All understanding the interventions i.e. their objectives and impacts. 2. Collaboration from others, whilst recognising the value placed on their needs. 3. Design of interventions, towards increasing net benefit to society. 4. Implementation plans and monitoring mechanisms, consistent with the above. 5. Resources (Now and future), their deployment and tracking.

Some progress has been made, in that ad-hoc consultations do take place. The difficult times the country is going through, demand a robust and coherent policy and planning framework, to guide the deployment of scarce resources. The changes which have taken place so far and those proposed, have potential to improve the responsiveness of the health service. In addition, the stewardship role of the Ministry of Health and Child Welfare will be clarified and better understood, in a context stakeholders have confidence in.

Private public partnership The private sector in Zimbabwe, has potential to contribute meaningfully to the process of achieving national health objectives. Though cooperation between the private and public sectors has existed for a long time, this has been ad-hoc and informal. This potential needs to be tapped and coordinated. Opportunities exist in increasing the capacity of local manufacturers, to produce essential supplies for the health sector (e.g. drugs, equipment and sundries). Methods or mechanisms, for state support to the private sector should be investigated.

However, initiatives in this direction, require a national approach, as they can not be solely sectoral because of the wider implications, involved in designing and managing public and private sector partnership frameworks. The stewardship role of the state and the Ministry, derives credibility and visibility, from and to the extent to which the contributions of stakeholders are recognized and acknowledged.

In participating in both the provision and financing of health services, the private sector, should in reality be complimenting the work of the public sector. The private sector frees space, to allow the public sector to concentrate on the needs of majority of the population, particularly the poor and vulnerable groups. The work of the private sector is regulated partly through the Medical Services Act (19-----), which was intended to create a level playing field for patients, providers and funders. The challenges resulting from the performance of the economy, have strained this relationship, putting the health and well being of patients at risk.

The growth of the working class over the years following independence, brought with it extended growth in private medical insurance. These events also triggered the rise in the number of private medical practitioners, since their economic survival depends on the existence of an assured revenue base. This rapid growth, under the present economic situation, has given rise to new tensions, which, at times, have led to unfair practices. The patient bears the burden of these practices and this has begun to generate pressure on the government for increased regulation to protect patients, funders and providers, from financial and medical care hardship.

Medical Aid Societies have limited funds for hospital care. They therefore have an interest in employing techniques that will reduce inpatient use. It is not unusual, for example, for Medical Aid Societies, to refuse re-imbursing providers for certain types of care. On the part of providers, fearing non reimbursement, they might, for instance, discharge patients earlier, introduce pervase rationing, or worse, deny members care altogether. Private funders and providers have not fully supported calls for increased regulation, fearing that government will begin to recommend appropriate treatment and therapy for various conditions. Issues of clinical freedom have also been raised.

Community participation

The ability and capacity of communities to participate in health development activities, depends on the decision making space they enjoy and the degree to which they control the resources for them to carry through those decisions. In practice, the communities ability to make these decisions, will also depend on the quality and availability of the necessary information they require.

Since 1983, the then Prime Minister’s directive, that established local governance structures, communities have at least in theory, enjoyed political control over issues which affect their lives at the local level.

However, experience has shown that the knowledge gap between communities and service providers, remains wide, to the extent that community contributions have not always been taken on board. In other words, the creation of participatory structures, on its own, is not enough. For example, the district is the basic planning unit in matters of local development and administration, under the direction of the District Development Committees. However, success has been limited, largely because the District Development Committees, do not control local development resources. The resources at this level remains firmly in the hands of local officials, controlled by their line ministries, there by stifling synergy between the direction of planning and financing, and ultimately implementation.

Sadly, this situation has often resulted in community needs and interests, being sidelined. The Study on Access to Health Care Services 2008 found that communities are willing to support their local health institutions in cash or in kind. However, they remain uncertain as to how they should volunteer their assistance and contribution. They need guidance. The study further noted that health workers at the periphery, report that they have no parameters to guide them in mobilizing communities to support health and health related activities, feeling that they are not allowed by regulations to solicit for help from communities. The study also confirmed that dialogue between health workers at the periphery and communities is minimal.

An avenue of getting community inputs into the health sector is through local level management structures. Village Development Committees (VIDCOs) and Ward Development Committees (WADCO), are expected to input into decision making in the management of health facilities at the community and district levels. However, many districts report that in many instances, these committees are not meeting regularly and in certain instances they have been disbanded. In contrast, Health Centre Management Committees meet regularly and that from the district level to rural health centres, viable management structures are in place. However, high staff turnover tends to weaken managerial structures as new inexperienced staffs often replace those leaving.

The community’s ability to make choices, depends on their level of literacy. Investing in the education of the population, particularly women, is an important component in the exercise of community health rights.The basic elements, which form actions which communities can take to secure their own health, should be part of the education agenda. It is only when the key players in health development, have a common understanding of what needs to be done and its meaning, that progressive participation and collaboration can take place. Health promotion and education, in school curricula, in such areas as nutrition and lifestyles and the role these play in the causes of diseases, would be, for example, a good start.

It is important to recognize that getting communities on board, is not an incidental matter – it takes time and effort. The establishment of Community Health Councils, and the introduction of the Patients’ Charter, was meant to provide formal mechanisms, for the voice of communities to be heard. The Patients Charter, set out clearly a person’s rights to care within the health service, and the standards of service which the Government intended to see achieved.

The Patients Charter had a very mixed reception, coming as it did, at a time when the performance of the health system was declining. No study has been carried out to ascertain the impact of the Patients Charter. The assumption is that if the Patients Charter, has had any impact, patients should be receiving what they are entitled to. There should also be visible improvements in service standards. The public should also be more aware of their rights, and know what to expect from the health service. Information from communities, however shows otherwise. The fact that no system of monitoring or enforcing national compliance, was established and followed up, did not help development in this area.

In the case of Community Health Councils, the majority of institutions and districts have not been able to establish one. It is thought that at present, only 5 districts and institutions, have functional Councils. In addition, the majority of districts, institutions and indeed the general public, are not aware of the fact that Hospital Advisory Committees, were abolished and replaced with Community Health Councils. The Councils were meant to widen the scope of participation beyond the hospital walls.

There is considerable evidence that ambiguity, limited authority, lack of information and poor quality of representativeness, have contributed to poor results in this area. The major outcry from communities and health workers, is for policy making and mechanisms for its implementation to be accountable to them. This demand goes beyond the usual perception of community participation, as a simple act of assembling stakeholders in a workshop, in order to gather their views. Building participation in the development of health services, is, by its very nature, a social and political process, which will ultimately demand the achievement of visible results.

Policy accountability, at the national level, most likely depends on the extent to which structures such as the Public Health Advisory Board, the Health Services Board and the Parliamentary Portfolio Committee on Health, are able to facilitate wider public participation and consultation. This suggests that the public’s voice is heard and brought to bear, on policy decisions taking place in and outside the health sector, including oversight, over the performance of the health sector as a whole.

At least at the local level, should involve, soliciting from the communities:
Their views on the issues to be addressed within the health sector, and experiences of issues that they have taken forward in the past;
The previous manner in which village, ward, Health Centre committees, Community Health Councils and other structures, have incorporated and addressed these issues and inputs;
The extent to which central level policy guidelines, are known and reflect the issues raised in the development of health policies.
The extent to which the local level structures have ensured, monitored and reported to the public, on the implementation of health policy, particularly on issues of quality, equity and access;
The extent to which the outputs (on priorities and monitoring) of local level health structures, have influenced the delivery of health services.
Their perception of how weaknesses in the above dimensions can be addressed and by whom.

Though not explicit in the principal law, the values enunciated by the public health system, imply that health care is a basic human right, and therefore, cooperation, in meaningful ways, between providers and those they serve, is of paramount importance. All individuals and groups providing access to services, have a continuing duty and responsibility to promote and improve the quality of services, which people need. In this regard, community participation, should be considered as an appropriate means of dealing with health problems, which should be defined in collaboration with the communities and the workforce which serves them. Organizing communities for this purpose, should be considered as a goal in its own right. Fortunately, over the years, structures for community participation have evolved, though greater use could be made of them.

Intersectoral collaboration should be based and focused on the common goal i.e. doing those things which improve the quality of life of the population, together.

This is by no means an easy task but one which can not be ignored because the primary purpose of intersectional collaboration is to ensure that national resources are allocated in ways that maximise benefit to society. At the district and provincial levels, opportunities exist for taking this approach forward. The structures are there in the form of Provincial Councils, Provincial Development Committees and District Development Committees. Perhaps, the issue to deal with is how to organise the flow of sectoral funds, in order to achieve the common goal.

Partnerships with other Ministries and sectors

Whilst the Ministry of Health and Child Welfare is mandated to lead health sector development, other ministries and sectors play a major role in promoting health and quality of life of the Zimbabweans. The Ministry of Health and Child Welfare has been working with other ministries to deal with major determinants of good health such as food, water, sanitation, education, gender etc. The Cabinet Committee on Social Welfare, Water and Sanitation committees, Nutrition Council are examples of such interministerial collaboration on issues that promote health.

Development partners

Whilst it is inevitable and indeed proper, that the health service should be dynamic and move with the changing times, the past decade witnessed an increasing pre- occupation with initiatives to re-engineer the health system, in the form of health sector reform. Reform, dominated the platform for health development debate. The key ingredients were, amongst others, decentralization, public/private collaboration, hospital autonomy (self managing units) new financing mechanisms, priority setting and resource allocation, patient satisfaction and incentives for health workers.

Some of the reforms, have brought confusion in the organizational processes of the health system. For instance, the practice of integrating vertical programmes into the on-going health system, has been shown to be at odds with the requirements of international responses to major diseases. Funding mechanisms, such as the Global Fund (TB, AIDS, and Malaria) GAVI etc, are a case in point. The development of multiple parallel systems of funding, provision and accountability, has brought with it new pressures on the health system.

It is important for the country, at the policy and planning levels, to avoid the “take all” culture, as this is tantamount to promoting short term solutions to long term problems. The consequences might work against public policy and interest and may even lead to loss of control. Promoting the principles of the Paris Declaration and that of the “Three Ones” should be able to address some of the relationships in partnerships.

Some of Zimbabwe’s traditional international partners, suspended cooperation and direct development support in 2002. A number of them, however, continue to channel development resources, through Private Voluntary Organisations, International Non Governmental Organisations and the United Nations family. Since these resources do not flow through government channels, there have been obvious difficulties in tracking them and monitoring their use. Support is mostly for HIV and AIDS and programmes related to nutrition, children and mothers. Difficulties have been experienced in accessing resources from global initiatives such as the Global Fund.

However, the bi-annual Ministry and Partners meetings have continued to be held, with some willing partners. Bilateral agreements or memorandum of understanding have also been signed with partners working with the Ministry.

Beneficial cooperation has grown over the past 8 years, with such countries as China, Cuba, D.R.C, Iran and recently, North and South Korea. The principle remains that partners are welcome to support the national health development plan. The structures for the transparent management of development support, in use up until 2002, are still appropriate for use today.

As stated elsewhere in this document, improvements in the health status and quality of life of the population do not depend solely on the interventions within the health sector. It takes the efforts, contributions and participation, of a myriad of stakeholders, involved in both financing and directing provisions of health services. Never the less, it remains the responsibility of the state, through the MOHCW to provide leadership and more importantly, stewardship and guidance in harnessing and nurturing these efforts and contributions.

Socio-economic situation, environment and living conditions Socio-economic dynamics: Trends and current status

Health and quality of life do not derive only from the health sector but are influenced by a myriad of other variables that include food availability, security, housing, safe water and employment, to mention a few. Most of these variables are outside the normally understood boundaries of the health sector. However, it is the responsibility of the health sector to identify and inform both the public at large and policy makers, of the factors that influence their health and quality of life. It is therefore crucial that such variables be considered in the implementation of this National Health Strategy.

One of the major hindrances to increasing the achievement of better health is the increasing level of poverty. From a public health point of view, poverty becomes an issue when individuals or groups, become unable to enjoy a minimum standard of living. Closely linked to poverty is unemployment, whose consequences lead to increased vulnerability, in the absence of properly targeted safety nets. Both unemployment and poverty are linked to economic development.

Zimbabwe has been experiencing an economic downturn over the last ten years, escalating over the recent past due to, such factors as, recurring droughts and floods, general international isolation and the devastating impact of the HIV and AIDS pandemic. Some of the challenges on the macroeconomic front include hyperinflation, low foreign exchange reserves, all fuelling the emergence of a widespread foreign currency parallel market. Furthermore, Zimbabwe is currently ineligible for balance of payments support from the IMF, the World Bank.

Real decrease, in public health expenditures and other resources, in the recent past, has contributed towards the deterioration of health facilities, drug shortages and a drastic decline in the quality of public health services, from which it is yet to recover.

The deepening economic recession is evidenced by real GDP which registered a negative of 7.3 percent starting in 2000 down to -5.9 percent in 2002, -3.6 percent in 2004 and an estimated decline of (-4.6 percent ) in 2007. This represents a cumulative decline in real GDP growth of above 40% since 2000. Shortages in basic food and non-food commodities such as mealie-meal, cooking oil, fuel etc. have been experienced since 2000 to date.

The decline in the economy has impacted negatively on the well being of the population directly and indirectly. The economic contraction has culminated in unemployment and inflation rates of over 80% and 26,470% respectively as of November 2007. The high inflation rate has grossly eroded the purchasing power of the Zimbabwe dollar, and coupled with the high unemployment rate, has aggravated poverty (a known negative determinant of health) within the population.

The poor tend to have more health problems and poor access to care. According to the 2003 Poverty Assessment Study Survey (PASS), poverty in Zimbabwe increased considerably between 1995 and 2003. The study found that the proportion of households below the Food Poverty Line (very poor) increased from 20 percent in 1995 to 48 percent in 2003, representing an increase of 148 percent. The proportion of households below the Total Consumption Poverty Line (very poor and poor) increased from 42 percent in 1995 to 63 percent in 2003.

PASS also found shows that proportionally urban area households were increasingly becoming poorer, due to the deteriorating macroeconomic environment. Although there has been a higher increase in poverty incidence in urban areas, rural households remained worse off.

In general, the country’s manufacturing , mining, and commercial farming sectors have not been generating sufficient employment and are operating below capacity. At the same time, real wages from formal employment have continued to decline. This decline in formal sector real wages, combined with sluggish employment growth, is translating into a decline in average house-hold incomes and an increase in the percentage of households living below the poverty line, and therefore exposed to more health problems.

Coupled with the recurrent droughts, which have occurred in 1990/91, 1994/95 and 2000-2002, the decline in economic performance has led to food insecurity in the population. This in turn has led to high levels of malnutrition. The Zimbabwe Demographic Health Survey shows that the underweight prevalence for under-fives increased from 13 percent in 1999 to 16.6 percent in 2005/6; and the prevalence of stunting, the chronic form of under nutrition rose from 26.5 in 1999 to 29.4 in 2005/6.

Education is a basic human right which enables a population to make informed decisions about its economic, social and political well-being. It is one of the areas where Zimbabwe has achieved literacy rate of well over 95%. The more literate people become the more they understand health and their responsibilities in securing their health and that of others.

The government of Zimbabwe has made remarkable strides in addressing gender inequalities that existed through legislation and socio-cultural norms. In the Health Sector, data has for a long time been captured by sex and age, making it possible to develop gender specific programmes. The Ministry, in 2001, published a strategy for integrating gender perspectives into the health sector.

Violence against women in forms of domestic violence, sexual coercion and rape, remains common in the lives of some women in Zimbabwe. A number of initiatives to curtail violence against women have been started by women groups and NGOs. These initiatives provide local safety nets and counselling services. Despite these efforts, the health care system should create more awareness and address issues of violence against women. It is thought that the health system has not adequately contributed to these issues.

A reportedly increasing cause of child morbidity, though it is not captured in the official statistics, is child abuse. The National Programme of Action (NPA) Unit of the MOHCW, reported that 2 000 children of all age groups and sexes were sexually abused in 2005. The perpetrators were reported to be mostly close relatives and neighbours of the abused children. Child sexual abuse, carries with it the increased risk of HIV transmission. This increasing phenomenon, also points to a breakdown in child care practices which will need to be attended to.

The problems of street children, prostitution, and vagrancy, are on the increase as the social safety net, has failed to protect a large number of those affected by economic adjustment.

Elsewhere in the document, different reasons for programme failure have been proffered. One important challenge is overcoming the perception that ascribes failures in the health system to internal defects of policy, whilst disregarding the external environment with which the health system has contended with in the last few years. The neo-liberal economic policies, adopted by industrialised countries after prolonged recession, precipitated an economic crisis in developing countries, including Zimbabwe, where these policies were expressed in the form of economic stabilization and adjustment programmes. These economic events have had a negative impact on the Public Health System.

Whilst it is acknowledged that a number of concerns under socio-economic issues do not fall directly under the health sector, the Ministry should play an advocacy role in promoting the under listed goals and broad objectives.

The major challenges, linked to economic performance, affecting the health service delivery system can be summarized as follows;

• Economic decline leading to hyperinflation, resulting in unaffordable rising cost of commodities, unemployment and rising levels of poverty amongst the general population; • Health determinants and risk factors to poor health and poverty on the increase, • Drastic reduction in the purchasing power of the allocated budget, resulting in insufficient resources to procure, essential drugs and antiretroviral therapy, for people who urgently need them, as well as basic health services equipment, medical and non medical and supplies; • The financial income for health workers in this challenging economy not meeting their expectations, resulting in a very high attrition rates. • Inability to access donor support, an example being the failure to get support from Global Fund Round 6 (UNAIDS 2006) as well as Round 7. • Inadequate foreign currency for health sector commodities.

The economic challenge the country is going through is adversely affecting the health and quality of life of Zimbabweans. The objective for the health sector should therefore be:

1. To increase national awareness on the impact of socio-economic factors such as resource allocation, income, poverty, adult literacy, housing, food availability and working conditions on the health and quality of life of Zimbabweans. 2. To strengthen intersectoral collaboration with relevant sector and organization in improving health and quality of life. 3. Working with other ministries, deal with major determinants of good health – food, water, sanitation, education, gender

Environment and living conditions

Trends and current status

A healthy environment and living conditions are essential for a healthy people. The on-going economic contraction is now affecting essential infrastructure such as housing, transport, water and waste disposal, causing outbreaks of diseases and other health problems. This economic challenge has led to the expansion of informal sector manufacturing industries, as a survival strategy. Food production in unregistered premises and consumption of un-inspected foods, including meat, are on the increase. This makes it difficult for the few environmental health practitioners to inspect and assess these food manufacturing sites and backyard abattoirs.

A new legal framework is needed to empower local authorities to harness and support the growth of informal sector trading, building standards etc. in order to safeguard hygiene and environmental health.

The provision of safe water and sanitation is critical to improving the living standards of the population and contributes significantly to deaths reduction from diarrhoeal diseases. Zimbabwe invested and made great progress in water and sanitation programmes, post independence. (to use more current data) I

According to the Labour Force Survey (year) , the proportion of rural households with accesses to safe water declined from 75.1 in 1999 to 66.5 in 2004. Only 42 percent of rural households had access to safe sanitation in the form of Ventilation Improved Latrines, of which 39 percent of the rural population used. Forty-three percent of households in rural areas did not have any sanitation at all. The percentage might now be higher, considering the fact that new settlements were recently established, in areas without adequate sanitary and safe water provision.

Furthermore, Cyclone Eline (2000), damaged many water and sanitation points in some parts of the country. The most recent Malaria Indicator survey, found out that most households in rural areas used borehole water (40.9%) or unprotected water wells (22.5%) and the bush latrine was the commonest form of sanitary facilities followed by the Ventilation Improved Latrines (36.0%). Poor sanitation and inadequate safe water supplies in rural and peri- urban areas, remains therefore a matter of great concern, needing priority attention especially in light of the recurrent cholera outbreaks.

There is need to provide, maintain and replace old water and sanitation systems in the cities, towns and peri –urban areas as these grow bigger. This is currently not being done due to foreign currency unavailability. The water and sanitation systems need urgent replacement in most urban areas. A situation where urban Zimbabwe was nearly 100% covered with safe water supply and sanitation services, is changing.

Urban centres have well reticulated water systems. However, the frequent power outages lead to water cuts, thus forcing urbanites to resort to alternative and less safe sources of water. Compounded with the deteriorating capacity to treat the domestic and industrial effluent effectively, the net result is increased pollution of rivers and lakes. The industry has responded to the shortages with the proliferation of bottled drinking water and repackaged scarce food products, some which have failed to meet the national standards. This, naturally, calls for continuous monitoring and surveillance of the bottled water and indeed the entire regime of stages in the ‘farm to fork’ (farming, manufacturing, processing, packing, labelling, distribution, retailing and catering) food continuum. This is not always possible due to limited availability of staff, transport and fuel.

A study commissioned by the Ministry of Health Child Welfare in 2007, noted that most sewerage reticulation systems and treatment works, were in a poor state of disrepair. This situation is conducive to the transmission of diarrhoeal diseases including cholera. Diarrhoeal disease outbreaks have been noted in a number of urban settings. Such situations are a threat to public health and need rectification as a matter of urgency, especially given the now re-current cholera outbreaks. The safe and efficient collection, removal or disposal of waste is one of the responsibilities of local authorities. The same study noted that Local Authorities were failing to provide an efficient waste management system, which was resulting in non collection and accumulation of refuse, in the central business districts (CBDs), residential areas, markets, industrial areas and other public places. The situation has resulted in fly breeding, generation of offensive odours and breeding of vectors and vermin, such as rodents, which are responsible for transmission of plague and diarrhoeal diseases, under such unfavourable conditions.

Decent housing remains a major concern. Since independence, government has been seeking to improve the housing situation in Zimbabwe. According to 2003 PASS, at national level, a comparison with the 1995 data revealed that for all poverty categories, the percentage of households, who owned dwelling units had increased from 55 percent in 1995 to 69 percent in 2003. In rural areas, the percentage of households, who owned dwelling units, had increased from 67 to 82 percent. (TO USE MORE CURRENT DATA)

In the urban areas, there is however a problem of overcrowding. According to the PASS study, nationally, the average occupation per room was 1.89 persons, which is nearly double the recommended average of one person per room. It was however observed that this was a slight improvement from 1995, where the average was 2.1. Environmental health services and others in the health promotion services and outside the sector such as schools have played a major role in increasing health literacy through health promotion. Efforts in this area need to be further strengthened, as it is now well-documented that hand hygiene, together with improved water supply and sanitation, contribute significantly to reducing illness and deaths from diarrhoeal diseases.

Key issues of concern are: • Shortage of foreign currency to purchase water and sanitation resources including water treatment chemicals. • Inadequate access to safe water and sanitation, particularly in rural areas. • Mushrooming of unplanned settlements in both the urban and peri-urban areas. • Inadequate decent housing especially in urban areas. • Air and water pollution. • Shortage of skilled human resources. • Promotion of hygienic practices. • Inadequate waste management. • Natural disasters (droughts and floods)

Goal: Contribute toward the creation of a safe and healthy environment To strengthen Environmental Health Services in particular promotion of safe water, safe sanitation, food and personal hygiene. Objective Activities/strategies Outcomes 1. Increasing access to safe ●Strengthening of programmes on safe water and sanitation. Reduction in water and sanitation. communicable diseases. 2. Increasing national ● Institutionalising environmental impact assessment in national ● Proportion of awareness on the impact of the development projects. households with environment and living ●Intensifying awareness on management of toxic substances, air access to and using conditions (settlement, and water pollution. potable water. factories, agriculture industry, ●Improving safe and efficient collection, removal or disposal of ● Proportion of mining, sewage, waste waste. households with disposal, toxic waste deposal) ●Developing and publishing a document on the impact of access to and using on the health and quality of human activity on the physical environment. safe sanitation. life on the population. ● Strengthen the lobbying and advocacy skills of the Health ● Cholera case sector in promoting environmental health. fatality rate . ● Strengthen inter-sectoral collaboration and coordination in the ● # of safe water and area of environmental health. sanitation facilities ● Strengthen inter-sectoral collaboration and coordination in the constructed. area of environmental health. ● # and frequency of ●Widening the role of environmental health services to include water sample results. regulation and inspection. ● Results of water ●Reviewing and strengthening the roles and responsibilities of sample analysis. committees/boards that handle issues on standards. Reduction in ●Identifying, supporting and strengthening programmes aimed incidence of food at improving the living conditions of people in rural, urban and borne diseases. commercial farms. ● # of food premises 2. Strengthening regulations ●Reviewing and amending existing public health requirements inspected annually. aimed at controlling and and regulations. ● # of food samples minimising contamination of ● Institutionalize the International Health Regulations and results. the environment through ●Reviewing and strengthening the roles of regulating ● Number of reports measures taken to prevent and institutions. produced on time. control air, water and ●Enforcement of the provisions in the Public Health Act and ● Quality of reports terrestrial pollution. regulations. produced. ●Strengthen the administration of the Food and Water Safety Reduced impact of and Quality Regulations to ensure availability of safe food and Environmental health water to the public. hazards. 3. To strengthen publ ic health ● Strengthen inspection food manufacturing, processing and ● Number of measures that ensure food for storage premises. radiation exposed sale to the public meets standard ● Strengthen food sampling and analysis. staff under and is sold and prepared in a ● Strengthen the capacity of both Government analyst and surveillance. manner and in premises that Public Health Laboratory. ● Number of exposed comply with public health staff under radiation- regulations. surveillance. Number of outbreaks 4. increasing awareness on ● Strengthen hygiene activities. detected and clean and hygienic living ● Promote community involvement in basic hygiene services. controlled timeously. conditions. ● Proportion of outbreaks and disasters detected within 48 hours and controlled within 2 weeks. ● Incidence and Case Fatality Rate.

Demographic Dynamics and Health Status

Trends and current status Demography helps to define those in need of health services and those who are vulnerable and at risk. It provides the denominator for comparison of the health status of the same population or against other populations.

Population issues have a close relationship between socio-economic development and population growth rate. Improved socio-economic development goes hand in hand with improved health status and quality of life which are in turn associated with a falling birth rate.

Zimbabwe’s population has increased from 10.4 million in 1992 to 11.6 million in 2002. The annual population growth rate between 1992 and 2002 was 1.1.

The male/female ratio in 2007 was 0.94 whilst the Zimbabwe’s dependency ratio has dropped to 0.79 down from 0.94 in 1992.

TABLE 2: SELECTED DEMOGRAPHIC INDICATORS. Indicator 1982 CSO 1988 1992 CSO 1999 2002 CSO 2005/6 ZDHS ZDHS ZDHS Crude birth rate (CBR). 44 - 34.5 30.8 30.3 31 Total Fertility Rate (TFR). 6.2 5.5 - 4 - 3.8 Crude death rate (CDR/1000) 10.8 - 9.5 - 17.2 - Infant Mortality Rate/1000. 86 53 65 58 - 55 Life expectancy at Birth. 57.4 - 61 - 45 43 Annual growth rate. 1969-82= 3 - 1982-92= 3 - - 1992-2002 = 1.1 Sex ratio: male -Female. 96:100 - 95 - 94 - Rural/Urban population. R64%:U26% - - - - Dependency ratio. 101:3 - - 87 11,632 -

The age structure of the population has remained young, as on average, 41% of the population is below 15 years. In the 2002 Census, 41% of the population was below 15 years of age, 55% was between the ages 15 and 64 years, and a very small proportion (4%) was 65 years of age or more. The proportion of children under 15 years of age was around 44% in 2005/6, while that of persons over 65 years of age was about 5%.

The proportion of the under 1 year which was around 3.6 % in 1992 is now 3.3 as projected from the 2002 census. The 2007 proportion of 5-14 year olds, has remained stable at around 29.9 % as was in 1992.

Population structure

Zimbabwe has a broad based population pyramid and a narrow top, which reflects a youthful population, with a large proportion of children. One of the reasons for a youthful population is relatively high fertility and increased adult mortality.

15

Figure 1.1: Population Pyramid (percent), Zimbabwe 2002 Census

75 + 70 - 74 65 - 69 60 - 64 55 - 59 50 - 54 45 - 49 40 - 44 Females 35 - 39 Males

Age Group Age 30 - 34 25 - 29 20 - 24 15 - 19 10 - 14 5 - 9 0 - 4

8.00 6.00 4.00 2.00 0.00 2.00 4.00 6.00 8.00

The total fertility rate has been declining over the years. The total fertility rate has declined from 7.9 children per women in 1969 to 6.5 in 1984. It further declined to 5.5 and 4.3 in the periods 1985- 1988 and 1991 - 1994 periods. In the 2005/6 survey, the fertility rate was reported to have further declined to 3.8 births. The table below shows trends in current fertility rates, based on successive ZDHS reports. Fertility declined by 1.7 births between 1988 and 2005-6 surveys.

Trends in current fertility rates Age-specific rates and total fertility rates, Zimbabwe 1984-2006 Age group 19 88 ZDHS 1994 ZDHS 1999 ZDHS 2005 -06 ZDHS 1984-1988 1991 -1994 1996 -99 2004-05 -2005-06 15-19 103 99 112 99 20-24 247 210 199 205 25-29 247 194 180 172 30-34 219 172 135 144 35-39 160 117 108 86 40-44 86 52 46 42 45-49 36 14 15 13 TRF15-49 5.5 4.3 4.0 3.8

The 2003 PASS reported that at national level, there was a 30 percent prevalence of Orphans and Vulnerable Children (OVCs), of whom 75 percent were orphans. The study estimated the prevalence of orphans to be 22 percent, giving a total of 1,207,645 of children below the age of 18years. The 2005/06 ZDHS found that just under one quarter of children under the age of 18 were orphaned, that is, one or both parents were dead. The survey notes that a comparison of the results from the 1994 and 2005- 2006 surveys, for this age group, indicates that there has been a dramatic increase in orphan hood. The proportion of children orphaned i.e., with one or both parents dead, more than doubled between the two surveys, from 9 percent to 22 percent. The proportion of children with both parents dead more than doubled, from less than one percent to 6 percent.

16 The study also noted that orphans, and particularly double orphans, had a higher prevalence on underweight (23 percent), followed by maternal and paternal orphans (20 percent) as compared to non orphans. The 2005/06 ZDHS confirms the same. In this study, 21 percent of OVCs were underweight, compared with 16 percent of other children. Urban OVCs, particularly those living in Harare, were particularly disadvantaged, with respect to their nutritional status compared with the rural children.

The population living in urban areas has increased from a low of only 26 % in 1982 to 31% in 1992 and 35% as of the 2002 census. This figure could now be much higher, as people have moved to urban areas in search of employment and running away from drought. There is also better infrastructure in urban areas.

The rural - urban drift has created new pressures. Urban infrastructure, specifically the maintenance of environmental standards such as in housing, safe water and sanitation and refuse disposal is deteriorating. There is also increasing pressure for expansion and creation of new infrastructure in the rural growth points and rural service centres, as well as the high density areas of towns and cities. Urban health care requires specific focus and attention. Raising awareness of the relationship between population dynamics and health continues to be a major challenge for the future.

There was however also a rural urban to rural migration due the land reform programme, which saw people taking up designated farms. The PASS study indicates that some of the urban to rural migration could be due to job loses or HIV and AIDS. The jobless, retired and the critically ill people move back to the rural areas. At the national level, 3.2 percent of the population migrated out of the country.

It is also worth noting that besides the urban – rural differences in some of the indicators, there are also differences within the urban and rural areas themselves. Both within each of these groupings access to services is different. There are areas in the rural areas that are far from health facilities; others have high incidences of particular conditions whilst others are hard to reach. These differences need to be considered in programme planning.

Mortality

Mortality indicators are key to assessing the quality of life. Within a decade after independence, Zimbabwe made impressive progress in improving the health status of its population. Since the early 1990s, however, the same indicators became either static and others even showed signs of deterioration. Multiple factors have affected the capacity of the public health sector to maintain the achievements of the first decade.

Crude Death Rate

For Zimbabwe, the crude death rate dropped from 10.8 in 1982 to 6.1 in 1987 and then rose to 9.49 in 1992. The overall crude birth rate for the country was estimated at 17 deaths per 1000 population in the 2002 census and 20 deaths per 1000 in 2003. The

17 Crude Death Rate decreased from a high of 20.1/1000 population in 2003 to 17.2/1000 population in 2007.

Figure 1: Crude Death Rate Trends

Estimated Crude Death Rates (CDR), Zimbabwe, 1980-2007

25 20 15 10 5 CDR (per 1000) (per CDR 0

85 91 97 03 981 9 987 9 993 9 999 0 005 1 1983 1 1 1989 1 1 1995 1 1 2001 2 2 Year

Source:

The HIV and AIDS epidemic has greatly affected the national crude death rate. The crude death rate is expected to rise as the age specific death rate in 15 - 45 year olds and in the under-five years increases due to HIV and AIDS. The major causes of deaths for all ages according to the 2006 National Health Profile are respiratory infections, tuberculosis, malaria, perinatal conditions and nutritional deficiencies with HIV as an underlying cause.

Infant Mortality Rate (IMR) & Child Mortality Rate (CMR)

The infant and Child Mortality Rate measures the health status of children under five years of age and it also gives a general picture of health status and the overall socio- economic development of a population. The IMR is also a sensitive indicator of the availability, utilization and effectiveness of health care, particularly perinatal care.

Infant Mortality Rates 1978-2006 Year 1978 1981 1984 1986 1988 1992 1994 1995 1999 2002 2005/6 IMR 83 79 69 64 61 66 53 80 65 67 60 Source: CSO ZDHS

According to the ZDHS, the infant mortality rate declined from 65 deaths per 1,000 live births in 1999 to 60 in 2005/6 and the under-five mortality rate declined for the same periods from 102 deaths per 1,000 live births to 82.

18 120

100 102

80 82 77 65 NMR 60 IMR 60 53 CMR <5MR

40 40 27 24 34

20 29 22 24 24

0 1994 1999 2005 2015(>MDG)

Life Expectancy At Birth Life expectancy at birth (LEB) is one of the most widely used indicators to measure general health status. There was an increase in the LEB from 56 in the 1980 to 61 in 1990 (GOZ, 1996, and CSO 1992), which was been associated with an overall initial decline in mortality from 10% to 6%. The LEB for females in 1990 was higher at 62 compared to males which were at 58.

LIFE EXPECTANCY AT BIRTH 1984 1986 1988 1990 1995 2000 2002 2006 MALE 60 61 61 58 52.6 44 43 44 FEMALE 61 61 63 65 57.2 46 46 43

TOTAL 60 61 62 62 55 45 45 43 Include recent years Source: Zimbabwe National Census Report, CSO Zimbabwe Inter-Censal Demographic Survey (ZICDS), CSO World Health statistics

Morbidity and Mortality trends: Burden of disease

Morbidity and mortality trends in Zimbabwe show that the population is still affected by the traditional preventable diseases and conditions, that include nutritional deficiencies, communicable diseases, pregnancy and childbirth conditions and the conditions of the new born.

Gains have been made in the fight against communicable and non-communicable diseases. However, problems related to health transition have continued to increase

19 the burden against a backdrop of limited resources (Human Resources, material, equipment and technology).

Of advantage today, is the knowledge of what works. Experience over the last ten years, has made us aware of high impact and low cost strategies that can be used to combat diseases and conditions responsible most illness and deaths in communities. It is therefore logical not to re-invent the wheel but immediately implement those programmes or interventions that can are cost effective.

Ten priority conditions have been identified (2007), on the basis of the number of people affected by them and the seriousness of their effects. Primary prevention and early treatment, to a lesser extent, remain the cornerstones of efforts to tackle health problems in Zimbabwe.

Ten Priority Disease and Conditions – Zimbabwe (2006)

1. HIV/AIDS and STDs. 2. Tuberculosis. 3. Acute Respiratory Infection (ARI). 4. Malaria. 5. Reproductive Health Conditions. 6. Cardiovascular conditions, e.g. hypertension, CVDs. 7. Diarrhoeal diseases. 8. Nutritional conditions/problems deficiencies (e.g. PEM, micro-nutrients, diabetes). 9. Injuries and disabilities. 10. Mental Disorders (psychiatric and alcohol, drug abuse).

The selected conditions correspond to the top five (Diarrhoea, Malaria, Tuberculosis, HIV and AIDS and Malnutrition) most commonly reported health problems according to the sampled households in the 2007/8 Malaria indicator Survey report.

From the available data (DHS 2006; census 2002, VAS 2003), programme evaluation and annual profiles 1998 – 2006, there is clear evidence that programme management can be improved. Programmes need to be based on health needs. The following measures need to be taken into account in the fight against communicable and non- communicable conditions. Specific objectives of targeted diseases and conditions, need to be developed; There is need to:

1. Ensure that health programmes are based on health needs and problems as defined in the national health profile. 2. Identify new cost effective approaches for tackling morbidity and mortality arising from existing re-emerging communicable and NCDs. 3. Adequately train all health care staff for various roles in health promotion, disease prevention, case management, follow up and rehabilitation. 4. Promote environmental health measures that will reduce the transmission of diseases. 5. Make individuals , families and communities more responsible for their own health and care.

20 6. Prevent the spread of diseases through early detection, effective case holding and adequate treatment of all cases. 7. Strengthen and equip both public health and clinical laboratories. 8. Ensure availability of emergency medicines and commodities. 9. Improve the quality of life of chronic patients through a continuum of care after discharge. 10. Improve health protection programmes. 11. Promote and encourage multi-sectoral approaches to disease prevention and control, health promotion and protection. 12. Strengthen a functional health information system, that will monitor health status and services to ensure that the information collected is used in decision making at all levels. 13. Strengthen information, education and communication strategies.

HIV & AIDS and STI

Trends and current status

HIV and AIDS remains a significant public health problem in Zimbabwe, which threatens the socio- economic fibre of the country, and places a tremendous strain on the capacity of the health sector to respond to the health needs of the population.

According to recent National HIV and AIDS Estimates of 2007, from a low prevalence of <1% in 1996, HIV prevalence in Zimbabwe peaked at 29.3% around 1997, before gradually declining to 26.5% in 2001, 23.2% in 2003, 19.4% in 2005 and 15.6% in 2007. A total of 1.32 million (adults and children) are living with HIV. Of these, about 260 000 are in urgent need of life saving ARV drugs. It is also estimated that new HIV infections peaked at 5.6% in 1993 and has since then continued to decline to the present 0.4%. This information is summarized in Figure 1 below.

Figure 1: Trends in Adult Prevalence and incidence (1980-2007)

21 Trends in the estimated adult (age 15 to 49 years) HIV and AIDS prevalence and incidence, Zimbabwe, 1980-2007

35 30 25 20 15

Percent10 5 0

0 2 0 198 198 1984 1986 1988 1990 1992 1994 1996 1998 200 2002 2004 2006 Year

Adult prevalence Adult HIV Incidence

The National Response dates back to 1987 when the National AIDS Control Programme was set up within MOHCW. The Programme’s main task was to increase public awareness about AIDS and to monitor the spread of the disease and also strengthening HIV screening services at the blood transfusion services.

Capacity constraints to treat HIV and AIDS in the 1990s, saw prevention been adopted as the primary strategy to fight HIV and AIDS. Earlier prevention interventions included Behaviour Change Communication; focus on youth, women and PLWA; prevention and treatment of STDs; condom promotion and surveillance of the epidemic. The declining trend of HIV prevalence, can, to a large extent, be directly attributed to this approach which has continued up to now.

The need to broaden the National Response beyond the Health Sector gave way to the development of a National AIDS Policy. The National HIV and AIDS Policy for Zimbabwe, was launched in 1999 following a broad consultative process which had began in 1997. In 2000, a National HIV and AIDS Strategic Framework, a working document to operationalise the policy, was developed and launched. The objective of HIV and AIDS Policy, was to lead and coordinate the country’s multisectoral response to AIDS, in a more concerted and unified manner.

An intensive Information, Education and Communication campaign, involving all sectors, has been and continues to be carried out across the country. The National Aids Council, which was established in 1999, through an act of Parliament, has been in the fore-front of coordinating this effort and recently, launched a Behavioural Change Communication Strategy for the prevention of sexual transmission of HIV (2006 – 2010), “ to provide guidance to all stakeholders on their contributions to behavioural change promotion”.

Voluntary Counselling and Testing (VCT) centres were established across the country from 1998. Intensive multimedia campaigns were used to increase access and uptake

22 of these Voluntary Counselling and Testing services. By the end on 2007, more than a million people had utilised these services across the country. At the same time, condoms have been made widely available at affordable prices in public health institutions, workplaces, formal markets and others.

The training of health workers to improve their STI diagnostic and management skills has continued at Genito-Urinary Centres (GUC) in Harare and Bulawayo while on the job training in syndromic management, targeting mainly nurses, also continues at facility or service delivery levels. Various treatment guidelines/ algorithms were developed during this period under review and have been distributed widely. STI drugs are available, at low cost, through NATPHARM and various donors. To ensure patients were exposed to safe and efficacious treatment regimens, periodic STI drug resistance studies have been carried out and the results guided the recommendations of the NDTPAC, on treatment and management of STIs.

From an initial three pilot sites in 1999, the PMTCT programme has expanded to more than 1300 sites across the country, with a target of all health facilities (1415) providing PMTCT services by 2010.

An important statutory instrument (SI 202 of 98), was developed and passed in 1998, to improve and provide a conducive environment, free from stigma and discrimination at workplaces.

The Domestic Violence Act of 2007, Criminal Procedures and Evidence Act (Amended) and the Sexual offences Act, were also enacted to curb sexual abuse and gender based violence.

In 2002, Government declared AIDS an Emergency in order to mobilise and increase efforts to make the treatment of AIDS a reality. This, together with the development of generic formulations of ARVs, and decreased prices of ARVs globally, made it possible for MOHCW to set up systems to introduce ART in Zimbabwe. Opportunistic Infections (OI) clinics were established in 2003, in preparation for the introduction of ART. ART was introduced in 2004, in a phased approach, from 5 initial sites, to all central and provincial hospitals and now has been expanded to a number of mission and district hospitals. To date, 100 000 patients are on ART countrywide. The introduction of a budget line item for ARVs and the commitment of a significant amount of resources from the NATF (AIDS Levy), have been critical and sustainable sources of funding for the ART programme. However, the sector has also received much support from bilateral partners, the Global Fund, Un Agencies, NGOs and the private sector.

The government remains committed to ensuring PLHWA have access to social services and that they are protected from human and social rights abuse. This is well enunciated in the National AIDS Policy and this commitment is further strengthened by various pieces of legislation. Furthermore, through NAC, different support services are available for PLHWA such as BEAM (for OVCs), CHBC, food and nutritional support programmes and psychosocial support services. ZNNP+ and groups affiliated to it, are well supported and recognized by Government. To further show this commitment, Meaningful Involvement of People Living with HIV and AIDS (MIPA), was established by NAC in 2004. Other social support activities are well supported by

23 various AIDS service organizations, NGOs, UN Agencies etc, with full government backing. In 2004, the Ministry of Health and Child Welfare launched the National Home Based Care Standards, to harmonise activities of NGOs across the country. Other important strategic plans that have been drawn up to improve programme coordination, include the Draft National PMTCT and Paediatric HIV and AIDS Strategic Plan; National Plan for Orphans and vulnerable Children (OVC); National Behaviour Change Strategy (2006 – 2010) and the Zimbabwe National HIV and AIDS Strategic Plan (ZNASP) – 2006 -2010.

The Business Council on AIDS has been instrumental in mobilizing resources for HIV and AIDS within the private sector, to complement Government efforts as well as influence business attitudes, towards those infected / affected – especially the workforce. The introduction of workplace HIV and AIDS Programmes, which offer VCT, PMTCT, OI, ART, as well as support activities, has taken some strain off Government programs and hence public expenditure, while also assuring the country of a constant and health labour supply. Awareness programmes, coupled with school health programmes, have meant that the youth are targeted early, imparting positively on labour supply from the various schools and training institutions.

The Zimbabwe National HIV and AIDS strategic Plan (ZNASP) 2006 -2010, was developed and launched in July 2007, by His Excellency, following recommendations made at the June 2004 National HIV and AIDS conference. The strategy gave focus to Zimbabwe‘s commitment to the “ Three Ones”, Universal Access, evidence and results based strategies among others.

There has been an ongoing exercise to train and capacitate staff in order for them to deal with various issues related to HIV and AIDS, in such areas as advocacy and lobbying. Furthermore, a number of sensitization workshops, have been held for politicians, policymakers and planners on the effects of the AIDS pandemic, with successful buy-in from the targeted audiences.

Government has supported the commissioning of various research studies on vaccines, traditional medicines, infant Nutrition etc and some studies are currently ongoing. The ministry of Health and Child Welfare, together with the University of Zimbabwe and Africa University are involved in vaccine trials.

Key issues; • Increasing access to essential medicines, including ARVs in a foreign currency constrained environment. • Meeting the increasing demand for ARVs. • Meeting the needs of a growing number of orphans. • Shortage of skilled health professionals. • How to sustain the behaviour change momentum. • Reducing new infections (including PMTCT)

Objective Activities/strategies

24 Objective Activities/strategies • Increase preventive counselling. 1.Prevent and control HIV • Promote safer sexual behaviour through an intensive IEC campaign to be and STI transmission. implemented by all sectors. • Make condoms widely available. • Prevent vertical transmission of HIV. • Improve diagnostic and management skills of health workers to prevent complications and improve their management • Ensure STI Drugs are available at all times. • Monitor STI drug resistance. • Create awareness on sexual abuse and rape and provide for stiffer penalties for offenders. • PEP for staff, rape victims. 2. Reduce the personal and • Provide access to treatment and social services for PLWHA and their families social impact of HIV & as well as protection of groups with special needs. AIDS and STIs. • Protect the Human and social rights of PLWHA and their families. 3. Reduce the impact and • Reduce the impact of HIV & AIDS and STIs on labour supply. HIV and AIDS and STIs on • Reduce the impact of HIV and AIDS and STIs on public expenditure. society. • Strengthen political commitment for effective action by leaders at all levels.

4. Improve coordination and • Advocate for the formulation of policies to address the needs of AIDS Orphans. strengthen multi- sectoral • Third Term Plan. approaches to addressing the HIV/AIDS epidemic. 5. Advocate for greater • Earmark greater resources specifically for STI/HIV and AIDS intervention in the resources allocation for National Budget. STI/HIV and AIDS • Promote local manufacture of ARVs and explore the role of traditional interaction (extra- medicines. budgetary). 6. Strengthen STI/HIV and • Build research capacity. AIDS surveillance and improve research and programmed effectiveness.

Tuberculosis

Trends and current status Tuberculosis, once thought to be on the decline, almost trebled in incidence from 96.9/100 000 in 1990 to 267.5/100 000 in 1995. The trend, heavily influenced by HIV, continued to increase to 402/100 000 in 2000. In 2006, the country reported 44 328 cases of tuberculosis (new and relapse), and had an incidence of all cases of 557 per 100 000 population (WHO, 2008). As shown in fig.1, TB case load expanded exponentially, mainly as a result of the high HIV burden but indications show that the TB epidemic may have passed its peak i.e. the incidence rate for 2005-2006 period showed a decline of -6.8%. HIV affects up to 80% of all TB patients. There were an estimated 1 390 000 people living with HIV and AIDS in 2005, with these people having an annual risk of 5-10% for developing TB. It is probably likely that even more cases of TB should be diagnosed than is currently the case.

25 Trends in the estimated number of TB cases, Zimbabwe, 1980-2007

100,000 80,000 60,000 40,000 20,000

Number of TB cases TB of Number 0

91 93 95 97 99 01 03 05 9 9 9 9 9 0 0 1981 1983 1985 1987 1989 1 1 1 1 1 2 2 20 Year

Tuberculosis, thus, remains a major public health problem for Zimbabwe, a member of the 22 so-called high burden countries, responsible for 80% of the Global TB caseload. TB is the second leading cause of death nationally and it is among the top five leading causes of hospital admission and outpatient consultation (Health Information Department, 2004). Patients with HIV and AIDS-related conditions occupy up to 70% of all hospital beds, constituting the majority of hospital deaths. TB is the commonest cause of death among PLWHA.

The National Tuberculosis Programme was established in the sixties. In 1983, the government developed a policy of integration of all TB activities into the general health services. The National Tuberculosis Programme officially adopted the Directly Observed treatment Short-course (DOTS) strategy in 1997. Staff training continues in order to improve diagnostic and case management skills.

26

Zimbabwe is currently in the process of strengthening the integration of TB and HIV activities in health care settings. In 2006, a committee on TB and HIV Collaborative activities was formed to report to the National HIV and AIDS partnership forum. The National TB manual was finalized in 2006, to incorporate TB and HIV collaborative activities. The implementation of provider initiated testing and counselling in health care settings, started in July of 2007 in 10 learning sites. It is envisaged that all TB patients, will be offered an HIV test while suspected TB cases, will also be able to access HIV testing.

TB and Gender Age and sex specific notification data for 2004, indicated that TB affects more men than women. Just as HIV, the reproductive and economically productive age group is most affected by the disease as shown in figure 2 and is also the same age group bearing the burden of HIV.

Figure 2: TB trend by age and sex TB case detection The notifications of TB rose markedly during the nineties, from less than 5,000 to a high of over 50,000 in the late nineties. From then on, the notification rate has been on the decline. Estimated case detection of smear-positive cases was only 42% in 2006 and has remained stagnant over several years (see fig.3). However, no nationally representative TB prevalence survey has ever been conducted to validate the TB case estimate by the WHO. Similarly, over the past 25 years, no tuberculin surveys were ever conducted and therefore data on estimates of annual risk of TB infection could be off the mark. A lot of work will be required to improve the case detection to meet the global benchmark standard of 70%.

27

Figure 3: Case Detection Rate over years

TB treatment outcome The Treatment success rate has been gradually declining over the years and is almost stagnant (see fig.4). Low rate of treatment success (Global Benchmark --85%) is an indicator of programmatic inadequacy and the impact of the HIV disease burden. The implications are a high risk of MDR generation and transmission.

Figure 4: Treatment success trends

The country has had reasonable stocks of TB drugs at all times. FDCs are being introduced in a phased manner to replace single dose regimens. The TB manual was revised in 2007 to include FDCs. DOTS remains the primary strategy being used by the TB control programme. A good laboratory network for TB diagnosis, is in place but is not fully utilized, due to shortages of manpower, reagents and functional equipment.

The monitoring of TB drug resistance continues to be carried out at the TBRL in Bulawayo. The laboratory is in the process of being strengthened, so that it can monitor cases of MDRTB and XDR TB. In line with DOTS, sputum smear microscopy is being used as the primary TB diagnostic test at district, provincial and central hospitals.

The Government is the major funder of all activities. Significant support is provided by bilateral agencies such as CDC in the area of Laboratory strengthening and TB and

28 HIV collaborative activities, whilst the European Union supports the provision of first line anti-TB drugs. Two main sources of multilateral support, come as management and technical assistance, from WHO and programmatic support from the Global Fund, with a Round 5 Grant worth US$ 9.2 million.

Key issues; • Funding for the National TB programme activities has consistently remained inadequate. • The case detection rate of new smear-positive cases is still only 42%, just above half the global target of 70%. • There is over-reliance on chest x-rays for diagnosis and almost a third of patients with pulmonary TB, have no sputum smear examination. • Inadequate capacity at National TB laboratory. • There is still no national external quality programme in most public laboratories. • The national treatment success rate of 67% is very far from the global target of 85%. • The high level of HIV infection, in TB patients, limits the success of treatment.

Proposed Strategy for 2008-2013

The National TB Control programme strategies are based on the WHO recommended New Stop TB Strategy, introduced in 2006. The vision is to have a TB free Zimbabwe. Goal: To reduce the national burden of TB by 2015, in line with the Millennium Development Goals and the Stop TB Partnership targets. Objectives • To achieve universal access to high-quality diagnosis and patient-centred Treatment. • To reduce the suffering and socioeconomic burden associated with TB. • To protect poor and vulnerable populations from TB, TB and HIV and MDR-TB. • To support the development of new tools and to ensure their timely and effective use. • Promote operational research.

Targets

 By 2010, detect at least 70% of new sputum smear-positive TB Cases and cure at least 85% of these cases.  By 2010 all TB patients should have access to comprehensive HIV care and support services including HIV testing, Cotrimoxazole therapy and ART.  By 2012, reduce TB prevalence and death rates by 50% relative to1990.  By 2030, eliminate TB as a public health problem (<1 case per million population).

29 . TUBERCULOSIS Goal: To reduce the national burden of TB by 2015 in line with the Millennium Development Goals and the Stop TB Partnership targets.

Strategic Activities/ Objectives strategies

Pursue high Strategy 1A- Increase political commitment for increased and ● TB treatment quality DOTS sustained financing success rate. expansion and Enhancement. Key activities- Place TB high on the political agenda, foster political ● TB case fatality will, mobilize increased and sustained financing. Support external TB rate. programme review. Finalize TB strategic plan. Set up Stop TB partnership forum at National Level. Support introduction of incentives ● TB default rate. for TB health providers. ● TB prevalence.

Strategy 1B – Improve diagnosis of TB cases through quality assured bacteriology

Key activities – Conduct laboratory services mapping for TB. Set up/Rehabilitate, equip, supply smear microscopy labs to meet the target of one smear microscopy service for 80 000 of the population. Set up/Rehabilitate at least one TB culture and DST lab in Harare. Enforce all smear laboratories to subscribe to an internationally acceptable quality assurance programme.

Strategy 1C – Develop and enhance mechanisms for patient support

Key activities – Conduct a situational analysis to correctly enumerate needs and gaps. Mobilize resources for patient incentives and enablers.

Strategy 1D – Strengthen procurement and supply management systems for TB drugs and other commodities.

Key activities – Ensure adequate supply of first line drugs for all categories of TB patients, Ensure adequate availability of TB diagnostics.

Strategy 1E – Strengthen M/E systems and Impact measurement

Key activities –Support national, provincial and district TB cohort review meetings. Hold TB expert committee meetings quarterly. Conduct periodic surveys i.e. drug resistance surveillance, TB disease prevalence survey, TB annual risk of infection survey, survey of HIV prevalence among TB patients. Pilot electronic TB register.

Strategy 1F – Strengthen Human resource capacity for TB

Key activities -- Conduct training needs assessment pre-service and in-service. Develop HR strategy for TB in line with National Ministry of Health HR strategy.

Strategic Strategy 2A – Scale up TB/HIV collaborative activities Objective 2 – Address TB/HIV, Key activities – Support quarterly TB/HIV coordination and review MDR-TB and meetings at all levels. Revise and update national policies on Isoniazid Other preventive therapy. Challenges.

30 Strategy 2B – Prevent and control MDR TB

Key activities – Conduct MDR/XDR survey. Revise National MDR protocols, policies and guidelines. Upgrade/renovate infrastructure for MDR management. Submit GLC application for second line drugs. Strategy 2C – Address TB in high risk groups i.e. prisoners

Key activities – Conduct situational analysis to identify barriers to care access. Develop/adapt strategies approaches for contact tracing, investigation, diagnosis and treatment.

Strategy 2D – Strengthen infection control of TB

Key activities --Conduct a situational analysis. Develop and implement infection control policies, guidelines and SOPs.

Strategic Strategy 3A – Introduce the Practical Approach to Lung Health objective 3 – Contribute to Key activities – Conduct a situational and needs analysis. Develop health systems guidelines and training materials. Pilot PAL. strengthening.

Strategic objective 4 – Strategy 4A – Develop and enhance collaboration for TB control with Engage all care all stakeholders providers in TB control include Key activities – Conduct situational analysis. Revise National PPM Public-public strategy, guidelines and policies to incorporate International Standards mix, Public- of TB Care. Hold annual PPM review meeting. Private mix approaches.

Strategic Strategy 5A – Strengthen ACSM activities objective5 – Empower Key activities – Develop National ACSM strategy, plans and training people with TB tools. Mobilize resources for ACSM. Develop broad based stakeholder and their platforms for TB control at all levels. communities. Strategy 5B – Strengthen Community based TB care and DOTS

Key activities – Conduct a situational needs analysis. Develop/adapt community TB care policy, guidelines and training materials. Conduct piloting for Community TB care. Conduct ACSM for community TB care. Mobilize resources for capacity building, M/E and incentives for community TB care. Promote setting up of TB patient support groups by TB patients.

Strategic Strategy 6A – Implement relevant Identified research priorities objective 6 – Enable and Key activities – Within the TB expert committee identify and priorities promote research priorities. Develop capacity for operational research. Conduct operational annual TB research dissemination. research.

Maternal & Child Health

31 Trends and current status

Maternal Health The maternal mortality rate (maternal deaths per 100 000 live births) is one of the indicators which sheds some light on health status, quality and access to health care delivery services, especially that of women. It is influenced by the general socio- economic conditions, nutrition, access and coverage of maternal health care services.

Maternal mortality remains a cause for concern, as most maternal deaths are preventable through increased access to antenatal, delivery and post natal care. The 2005/06 Zimbabwe Demography and Health Survey showed that maternal mortality has been rising from 283 Fig 3: Maternal Mortality Ratio per 100,000 live births in

600 1994 reaching a peak of 578 578 per 100,000 live 555 500 births in 1999. This sharp rise in maternal mortality 400

R is largely explained by

M

M the rapid spread of the 300 283 HIV and AIDS epidemic. 200 The ratio has slightly declined from 578 deaths 100 per 100,000 live births in 1994 1999 2005/2006 ZDHS 1999 to 555 deaths in 2005/6. However, this figure remains significantly high.

Major causes of maternal morbidity and mortality recorded in health facilities are bleeding after child birth (PPH), malaria, puerperal sepsis, HIV and AIDS, anaemia, ruptured uterus and eclampsia. Most of the major causes of maternal death are preventable if access to services is improved.

The 2004 Maternal and Neonatal Health Services Assessment in Zimbabwe found out that maternal deaths were due to three delays. The first delay was identified as the time lost in recognizing the seriousness of the situation and deciding whether or not to seek medical attention. The second delay is the time needed for reaching a health facility or a trained service provider, once a decision is taken to seek care. The third delay is that of receiving expeditious and effective care, once the challenge of referral is overcome.

Proper care during pregnancy and delivery, are important for the health of both the mother and the baby. There has been an increase in women attending at least one antenatal care visit from 81% in 1999 to 94% in 2006. Coverage of antenatal care is slightly higher in urban areas than in rural areas. Skilled attendance at delivery, declined from 73% in 1999 to 69% in 2006, while institutional deliveries declined from 72% to 68% over the same period (ZDHS 1999, 2005/6).

The Government has made efforts to create an enabling policy environment for the implementation of various maternal, neonatal and child health programmes.

32 Reproductive Health Policy and Guidelines have been developed. The MOHCW has carried out a comprehensive MNH assessment (2004), the findings of which formed the basis for the MNH Road Map. For the successful implementation of the MNH Road Map, it is necessary to adopt a multi-sectoral approach, which includes males, as essential partners of the MNH programme, mainstreaming gender, fostering community involvement and participation, and promoting behavioural change.

The MOHCW has led several initiatives to mitigate the human resource issues facing the health sector. Confronted with the worsening “brain drain” of general nurses and midwives, the Ministry has introduced a new cadre, the Primary Care Nurse. These nurses are trained specifically to function at primary health care level. In order to increase the number of nurses who go for midwifery training, qualified midwives receive a substantial allowance for their services. These initiatives are being complemented by a strategy designed to retain medical doctors at district level.

Family Planning

Perhaps the most important interventions to reduce maternal and neonatal morbidity and mortality are to develop and sustain a strong national Family Planning programme, designed to prevent unwanted pregnancies, and to encourage child spacing. In this regard, the Contraceptive Prevalence Rate or the percentage of currently married Fig 1: Contraceptive Prevalence Rate among women, using a Currently Married Women 15-49 years family planning 70% method in Zimbabwe, has 60% 60% increased steadily 54% from 48% in 1994 to

R 60% in 2006. This is P 50% 48% C now one of the highest rates in Sub- 40% Saharan Africa. The family planning 30% method most 1994 1999 2005/2006 commonly used is ZDHS the pill (43%). The Total Fertility Rate has declined from 4.0 in 1999 to 3.8 in 2006 (ZDHS, 2005- 6).

However, the unmet need for contraception has remained static at 13% for the period 1999 to 2006.

The issues • The three delays in seeking medical care, receiving care, referral to next level of care, shortages of transport and equipment for emergency obstetric care. • HIV and AIDS. • Maternal malnutrition • Negative cultural and traditional practices that influence health seeking behaviour. • Access to family planning services

33 • Gender and male involvement

Goal: To reduce the Maternal Mortality Ratio from 283 (1994 ZDHS) to 70 deaths per 100,000 live births by 2015 Objectives Activity/Strategies Targets To increase the (a) capacity building of health service providers on SRH,
Might want to revisit the availability and utilization Family Planning and comprehensive HIV Prevention baseline as 2005/6 of youth friendly Family Services; ZDHS gives a Maternal Planning and HIV (b) strengthening youth friendly SRH services; Mortality Ratio of 555. prevention services. (c) expanding Community Based Distribution systems,
Reduce Maternal (d) Integrating STI/HIV/AIDS, and FP programs and services, Mortality Ratio by XXX (e) community mobilization to increase demand and use of from xxx to xxxx SRH and family planning services.
ANC coverage To increase the (a) capacity development on focused ANC including
Skilled attendance at availability and utilization comprehensive PMTCT; (b) promotion of male/female birth
% of institutional of quality focused condom use; (c) dissemination of updated guidelines and deliveries antenatal care including clinical protocols, (d) operations research as a monitoring and
PNC coverage. PMTCT services. evaluation tool; (e) expansion of the mother/baby friendly
Contraceptive hospitals initiative, and (f) community mobilization to prevalence increase demand and use of PMTCT.
EmOC coverage: To improve access to (a) capacity development on comprehensive post-natal care BEmONC & skilled attendance at including PMTCT; (b) promotion of dual protection; (c) CEmONC/500,000 delivery; including dissemination of updated guidelines and clinical protocols, (d) population. EmONC. operations research as a monitoring and evaluation tool; (e)
Met Need for EmOC expansion of the mother/baby friendly hospitals initiative, and
Unmet need for family

(f) community mobilization to increase demand and use of planning. PNC and PMTCT services.
Stock-out rate for To improve access to (a) RH commodity security; (b) availability of skilled human selected EmONC quality PNC including resources; (c) functional health management information commodities. PMTCT services. systems; (d) improved health management capacity at all
Vacancy rates in key levels; and (e) improved financing of the MNH programme. health staff (doctors, midwives, Tostrengthen the capacity of (a) RH commodity security; anaesthetists ). health systems for the
Tetanus Toxoid planning and management (b) availability of skilled human resources; coverage for pregnant of MNH programmes. (c) functional health management information systems; women.

(d) improved health management capacity at all levels; and

(e) improved financing of the MNH programme. To improve the policy (a) the review and dissemination of the RH policy; (b) environment for provision the development of an SRH strategy, (c) the and utilization of quality development of a human resource development and equitable MNH strategy; (d) the establishment of partnerships to services. advocate for increased demand for and supply of quality services, and the funding for MNH services; (e) the lobbying for increased government expenditure for MNH; and (f) the advocacy for integrated SRH services and linkages with the HIV and AIDS strategies.

Child Health

34 Trends and current status

The child mortality rate also reflects the level and burden of poverty and is consequently a 120 sensitive indicator of

100 102 socio- economic development. 80 82 77 The graph 65 NMR 60 shows that 60 53 IMR CMR there under <5MR five mortality 40 40 27 24 34 Source: rate (<5MR) ZDHS & has been rising 20 29 22 World fit from 77 per 1 24 24 for children 000 live births 0 in 1994 to 102 1994 1999 2005 2015(>MDG) per 1 000 live births in 1999. The rate then decreased to 82 per 1 000 live births in 2005. Infant mortality (IMR) also followed the same trend. The rise in mortality is mainly attributed to the direct and indirect impact of the HIV and AIDS epidemic and the concomitant rise in poverty levels.

According to a recent study on Child Health Situation Analysis (200--), the decline in mortality rates could be linked to the overall decrease in HIV incidence and prevalence and greater access to opportunistic infection treatment for children using cotrimoxazole. The prevention of acute malnutrition, the successful EPI programme, scaling up of Vitamin A supplementation and the focus on malaria control in children are thought to be the possible contributors.

Zimbabwe IMR and CMR 1978 – 1990

Infant Mortality Rate Child Mortality Rate Year Rural Urban Total Rural Urban Total

1978 88 64 83 40 25 37

1981 85 59 79 38 22 34 1984 77 50 69 33 17 28

1986 72 47 64 30 15 25

1988 69 46 61 28 15 23 1990 71 55 66 30 20 26

1999ZDHS 65.3 47.2 59.7 36.7 22.8 32.5

2005-06 51 47 22 18

35

According to the 2006 Zimbabwe National Health Profile, the leading causes of deaths in children under five years are Nutritional deficiencies, ARI, intestinal infections, and malaria.

The commitment by Government to the welfare of children is demonstrated through the redesignation of the Ministry to include the Child health component. A National Plan of Action (NPA) for children was developed covering the decade 1990 – 2000. The children’s hospitals were established at Harare and Mpilo Central Hospitals. Other initiatives towards improving child health practices include the Baby-Friendly Hospital Initiative; the promotion of exclusive breast feeding in the first six months and the Child Supplementary Feeding Programme. Furthermore, a Child Health Unit was established at the national level.

IMCI (Integrated Management of Childhood Illnesses) The Integrated Management of Childhood Illnesses strategy, has replaced the “Super market approach”, which was widely promoted in the health sector in the early 80s as a strategy to improve child health. IMCI is an integrated approach to child health that focuses on the well-being of the whole child. It has three components: a) Training of health workers in case management with a special focus on diarrhoea, malaria, pneumonia, measles and malnutrition. b) Improving the health system including availability of essential drugs and; c) Improving family and community practices related to child health (community IMCI) A special unit was established in the Ministry to lead the development of IMCI activities in the country. The IMCI strategy was first piloted in eight districts (one in each rural province).

By 2005, the first two components of IMCI (training of health workers and health system improvement) had expanded to 21 districts, though the third component (community IMCI), was in only eight districts. Within those districts where training of health workers was carried out, improving the second component (health system improvement), is reportedly difficult because of the current economic challenges facing the country. Hence, medicines and equipment availability and referral of patients remain a problem. The community component has however lagged behind.

Zimbabwe Expanded Programme on Immunisation (ZEPI)

The ZEPI has been relatively successful, due, not only to good programme management, but also to adequate funding until recently. The Zimbabwe Expanded Programme on Immunisation (ZEPI) was introduced in 1982, with the aim of increasing coverage of all ZEPI vaccines to 90% by the year 2000. The completion of the Primary Course of Vaccination (PCV), is one of the criteria for the assessment of the quality of the programme and its effectiveness. There was a general rise in the trend of PCV coverage during the period 1992-1994. By 1997, the PCV coverage had risen to 96.6%. Vaccination coverage reached the UCI (Universal Child Immunization) target of 80 percent in 1990, then began declining in the mid 199