Dr Magure investigates the role of health delivery systems and looks at how health can be delivered in the future. Presented at 'Moving Forward with Pro-poor Reconstruction in Zimbabwe' International Conference, Harare, Zimbabwe, (25 and 26 August 2009)

1. Health Delivery Systems in the
Crisis and Beyond
Presented By
Dr. T. Magure
MBCHB,MPH,MBA

2. Introduction
• Zimbabwe's economy has declined since the
late 1990s, with real GDP estimated to have
declined by almost 30% between 1997 and
2003
• In 2006, Zimbabwe had an estimated GDP of
3.146bn USD and a projected GDP growth rate
of -4.4%
• There has been a marked decline in public
health expenditures that have resulted in
deterioration of health facilities

3. Situation Analysis
• Zimbabwe’s health status has deteriorated
since 1992
• The crude death rate dropped from 10.8 in
1982 to 6.1 in 1987 then rose to 9.49 in 1992
• The overall crude death rate was 17.2/1000
population in 2007

4. Situation Analysis continued…
Estimated Crude Death Rates (CDR), Zimbabwe,
1980-2007
25
20
15
10
5
0
1981
1983
1987
1985
1989
1993
1991
1997
1995
1999
2003
2001
2005
Year
CDR (per 1000)

5. Situation Analysis continued
• According to the ZDHS, the infant mortality rate
declined from 65 deaths per 1,000 live births in 1999
to 60 in 2005/6
• The under-five mortality rate declined for the same
periods from 102 deaths per 1,000 live births to 82
• Life expectancy has decreased from 58 years (CSO,
1982) to an estimated mid-30s (UN and US Bureau of
the Census, projection model; MOHCW 2004)

6. Situation Analysis continued
• New TB cases increased from 61 per 100 000 in
1986 to 485 in 2001
• Malaria remains a major public health problem,
accounting for 740 000 clinical cases and 3000
deaths
• In the last 3 years EPI coverage rates have been
declining rapidly due to poor health system
performance

7. Situation Analysis continued…
Trends in the estimated adult (age 15 to 49 years) HIV and AIDS
prevalence and incidence, Zimbabwe, 1980-2007
35
30
25
20
15
10
0 5
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
Year
Percent
Adult prevalence Adult HIV Incidence
Source: Draft National Health Strategy 2008

8. Situation Analysis continued
• The country has seen a decline of adult HIV
prevalence from 24.5% in 2004 to 15.6% in 2006
• This is an area which government and funding
partner efforts have given very positive
indications this could be duplicated across the
health delivery

9. Situation Analysis continued…
Figure 7.1: Households with Access to Safe Sanitation, Rural Areas, Zimbabwe 1992-2003 and
2015 MDG Target
2015 MDG Target -79%
48
56 58
42
90
80
70
60
50
40
30
20
10
0
1 992
1997
1999
2003
2 015
Year
P e r c e n t
Rate of progress required to achieve MDG Target
Actual
Source: Draft National Health Strategy 2008

10. Nutrition
• The draft National Health Strategy document
states that not much progress will be made in
reducing illness and death, unless nutritional
issues are considered as essential aspects of
human well being
• Prevalence of underweight has slightly increased
to 17.4%. wasting at 4.1% and stunting at 28.9%
• The nutritional patterns in the different parts of
the country have tended to vary from district to
district

11. Health Facilities
Provinces Primary
level
1st
Referral
level
2nd
Referral
level
3rd
Referral
level
Total
Harare 45 0 0 7 52
Manicaland 253 36 1 0 290
Mashonaland Central 130 13 1 0 144
Mashonaland East 168 22 1 0 191
Mashonaland West 128 22 1 0 151
Matebeleland North 92 17 0 0 109
Matebeleland South 105 18 1 0 124
MIDLANDS 106 28 1 0 235
Masvingo 170 23 1 0 194
Bulawayo 34 0 0 7 41
Total 1231 179 7 14 1431
Key
Primary level = Clinics and Rural Health Centers
1st Referral level = District, Mission and Rural hospital
2nd Referral level = Provincial Hospital
3rd Referral level = Central hospital and infectious diseases hospital

12. Health Facilities continued
• Health infrastructure capital investment has not kept
pace with population expansion
• Since the family Health Project financed by the
World Bank in early 1990, there has been limited
capital injection in the building of new facilities
• The bed Occupancy Rate has increased to
unmanageable positions for the hospitals to take on
the burden of HIV
• Lack of food in hospitals has resulted in in patients
being referred for home based care

13. Human Resources
Vacancy status: December 2007
Category
Establish
ment In Post 2005
% vacant
Posts in Post 2006
% vacant
Posts
In Post
2007
% vacant
Posts
Top Management 74 10 86% 7 91% 14 81%
Doctors 1761 695 61% 668 62% 667 62%
Nurses 19338 13078 32% 13495 30% 14768 24%
Environmental Health
Department 2395 1217 49% 1293 46% 1220 49%
Pharmacy 578 336 42% 338 42% 318 45%
Radiography 459 140 69% 158 66% 154 66%
Laboratory 631 293 54% 324 49% 320 49%
Administration 5759 4950 14% 4960 14% 4960 14%
Records and Information 416 335 19% 335 19% 335 19%
Program Managers 34 8 76% 8 76% 8 76%
Total for the whole Ministry of
Health and Child Welfare 35668 23552 34% 24071 33% 25343 29%
Source: Draft National Health Strategy 2008

14. Human Resources continued
• The average vacancy rate of 81% among the
senior positions in the MoHCW
• The high vacancy rates of 73% is amongst
consultants at central hospitals
• More than 55%, 40% and 70% of respectively
doctors, nurses and pharmacy technician posts
are vacant
• Rural areas health facilities are being manned by
an average 50% of the required skilled staff

15. Medical Equipment and Laboratories
• Zimbabwe used to have such medical equipment and
laboratory services in the decentralized health
delivery service
• District hospitals had all the services that would
meet the priority diseases in the country
• There has seen a general deterioration of laboratory
services where the tiered system has failed
• This has resulted in patients seeking services from
the private sector where the costs are unaffordable

16. Medical Equipment and Laboratories cont
• Tests such as CD4, liver function and some
related tests for screening patients before
enrolment into the national ART programme
continue to have logistical challenges
• It should be noted that where there is external
support, in districts supported by the Global Fund
and the Expanded Support Programme, some
new pieces of equipment have been procured

17. Stock Status of VEN Items from
NatPharm
2222000000004444 2222000000005555 2222000000006666 2222000000007777
Vital 63% 72% 82% 42%
Essential 21% 56% 62% 23%
All drugs 41% 65% 68% 31%
• Availability for the first half of 2008, shows a
declining trend
• There are no more medical and surgical items for a
service to be delivered
• ART commodities have been provided through the
Global Fund, USG and the Expanded Support
Programme and some NGOs

18. Beyond The Current Situation

19. National Health Strategy (2008)
Summary of the Current Situation
Level of Health
• The HIV and AIDS epidemic and related
TB epidemic and other opportunistic
infections, are having a serious adverse
impact on health.
• The increasing frequency of epidemics
(e.g. cholera, malaria) is contributing to
high burden of disease.
• Due to recurring droughts, malnutrition
on the increase.
• Though declining, infant mortality rate
and maternal mortality ratio still
unacceptably high.
• Increasing level of non-communicable
diseases
• Increase of crude death rate.
• The gap in the level of health between
urban and rural areas is static or getting
worse
Health Services delivery
• Increased workload and overcrowded
facilities.
• Shortage of staff/ inability to retain
staff
• Inadequate and if available obsolete
essential medical equipment.
• Poor maintenance of equipment and
physical facilities.
• Inadequate financial resources,
especially foreign currency, which at
least above inflation in real terms.
• Inadequate mid level leadership due to
continuous loss of key staff.
• Shortage of in inputs such as fuel,
vaccines, drugs, and transport in the
public health services.

20. SWOT Analysis of the Health Sector of
the Zimbabwe Health Sector
Strengths
• Commitment to have the highest
possible level of health and quality
of life for its citizens
• Decentralized health system
• Commitment to Primary Health
Care approach
• Public health network covering the
whole country.
• Clear health policies and guidelines.
• Committed health professionals.
• High health literacy.
• Availability of Professional
standards.
• Demand for health services high
Weaknesses
• Inadequate skilled human
resources across the board.
• Low staff morale and high
attrition rate
• Poor remuneration packages and
retention strategies.
• Inadequate experienced
managerial capacity at all levels
• Core health services for each
level not costed
• Weak inter-ministerial
coordination
• Inadequate monitoring and
evaluation of programmes

21. SWOT Analysis of the Health Sector of
the Zimbabwe Health Sector continued..
Opportunities
• Free health services for targeted
population groups.
• Parliamentarians interest in
health issues
• Introduction of Results Based
Management
• Incentive packages for some
districts District Health Executive
staff
• A strong private health sector
• Funding partners committed to
funding health sector.
• Globalisation encouraging
exchange of ideas.
Threats
• High levels of attrition
compromising quality of services
• Unstable economic environment
reducing resources to the health
sector.
• HIV/AIDS pandemic affecting all
activities.
• Poverty and food security
• Drug resistance
• New disease patterns

22. Support from Funding Partners
• Strength in good relationship between
funding partners and MoHCW
• CDC and USAID have continued to support the
country on HIV and AIDS issues and have
provided support in training, equipment and
reagents for the laboratory services

23. Priorities For The Funding Partners
and the Health Sector
• Arresting the brain drain through retention
schemes
• Revitalize the capacity of training facilities
• Significantly increase funding to health
services delivery
• Strengthen expenditure management and
budget planning
• Continue with medical and surgical supplies

24. Short term Possibilities for the health
delivery service
• Human Resources
Ministry has taken a more proactive stance on the
issue of human resources as they have managed to
make use of the resources in the Global Fund to
improve on the human resources
• Drugs and medicines
The main funding partners in Zimbabwe have come
together to form a basket funding for vital and
essential medicines

25. Short term Possibilities for the health
delivery service continued…
• Health Information Systems
Need to prioritized in the short term for the design
and identification of the gaps and then with a good
measure of resources be put in the long term
activities for both donors and Ministry to work on

26. Information on Status of the
infrastructure
• There is no likely capital injection that will be used
on infrastructural development
• There is need to invest in collection of information
on the state of the different infrastructure
• This status information could best be collected by a
neutral body such as the UN which might need to
look at all basic infrastructure which will require
capital injection

27. Medium to Long Term
• Plan and fund the revitalization of training capacity
• Health information system
• Technical assistance in health planning
• Revitalize systems and institutional arrangements for
logistics for medical supplies
• Rejuvenating communities demand for care
• Health Infrastructure
• Medical and surgical
• Radio and communication

28. Conclusion
• The major priorities in the short term are activities
which will guarantee a minimum package for human
resources for health, the policy, strategy, training
and retention packages
• Improvement of the medical supplies and thereafter
the other issues can be considered in the medium to
long term
• Need to inject capital in the Health Delivery System
as its key pillars are still in place