A large part of the health service in Zimbabwe is provided by the Ministry of Health, local government authorities and voluntary agencies such as mission hospitals, especially in rural areas. Medical services are also provided by industrial corporations and private practitioners. This section describes the condition of and developments in the public health service system in Zimbabwe, with particular emphasis on maternal and child health. The public health delivery system in Zimbabwe is graded into hierarchies of care, with each lower level referring difficult cases to the next higher level. Clinics and rural health centres (primary care facilities) are at the bottom, staffed by nurses, nurse midwives and environmental health technicians. Above these in the hierarchy are rural hospitals, followed by district hospitals, provincial hospitals and central hospitals, in that order, with nurses and doctors.
Before Independence, the health care system in Zimbabwe was highly inequitable. Health services were divided by race, class and geographical location. The minority white population and a relatively small group of elite non-whites enjoyed better health and longer life expectancies. The majority of the population, especially peasants in rural areas, suffered from preventable communicable diseases due to unhealthy living conditions, poor diets and lack of access to basic health. According to Sanders and
Davies (1988:195), measles, pneumonia, tuberculosis, diarrhoeal diseases, neo-natal tetanus and other infections of the new bom accounted for most of the infant and child deaths. Nutritional deficiency affected a large proportion of infants and young children. Under-five malnutrition was greatest among children of labourers on large-scale commercial farms, followed by children of peasant farmers in communal areas and children of mine workers, with urban children having the lowest levels of malnutrition (Loewenson et al., 1991:1080).
The development and distribution of modem health services during colonial times followed the pattern of European settlement and thus was concentrated in cities. The colonial government provided highly modernised health services, especially for the white population in urban areas. The central, provincial and district hospitals were located in urban areas and were staffed by trained medical personnel and equipped with advanced technology, while the rural hospitals and clinics were often inadequately equipped and people travelled long distances to reach the facilities.
The provision of preventive services to the rural population was very limited because the clinics operated basically as curative centres and were often inadequately staffed. As a result, a large number of people suffered from diseases that could be prevented (Agere 1986:362-63). In the 1976/77 financial year, only 10 per cent of the health budget was allocated to preventive services, and of this, only 17 per cent went to field operations intended to cover the rural population (Ministry of Health, 1979:47, cited in Agere, 1986:362). During the Independence war, the inadequate basic health service infrastructure in rural areas was devastated and some hospitals and clinics were forced to close. For example, in 1980, an estimated 60 per cent of rural clinics on the Ministry of Health list were out of commission due to the war (Faruqee, 1981:59). As a result, the years leading to Independence saw the return of traditional diseases such as sleeping sickness, which had been nearly eradicated, and infectious diseases associated with poor living conditions in most rural areas.
The government in 1980 was faced with the problem of redistributing and increasing health care resources in order to ensure improved conditions for the majority of the population. The government adopted a policy of 'Equity in Health' which primarily aimed to redress inequity in health care through a comprehensive integrated strategy based on the primary health care approach and focusing on the goal of 'health for all by the year 2000'. The new approach involved a shift of resources from urban to rural areas and from curative to preventive services. As a first step in improving access to health services for the economically disadvantaged, public health services were made free for low income groups earning less than Z$150 per month (which was increased to Z$400 in 1992). At that time, this covered almost all rural Africans and the majority of urban Africans. However, the cut-off point set in 1980 was not revised until 1992, although nominal wages were increased in response to inflation, thereby reducing the number of eligible beneficiaries. In 1986 the minimum wage had risen to Z$158 so that, theoretically, only the unemployed benefited from free health care (Sanders and Davies, 1988:198).
The primary health care (PHC) approach envisaged the establishment of a rural health centre within an eight kilometre radius of every household. In addition to construction of new rural health centres, the existing rural clinics, which were primarily curative outpatient stations doing no outreach work and limited preventive care, were upgraded to function as rural health centres. The rural health centre provided basic but comprehensive preventive, curative and rehabilitative services, concentrating on maternal and child health (ante-natal care, delivery of uncomplicated births, family planning, child health, nutrition and routine immunisations), environmental sanitation, control of communicable diseases and general curative care. The PHC program included the training of village health workers chosen from their respective villages. These were trained in basic preventive, promotive and curative interventions in rural areas. Their main roles included promotion of basic hygiene and encouraging villagers to be self- reliant, by contributing labour in the construction of toilets, wells and boreholes, and clinics. By 1984, 3,800 village health workers had been trained (Agere, 1986:372).
The adoption of the PHC strategy and the integration of its components into the health service system after 1980 was a turning point in the provision of health care in Zimbabwe. The main components of the PHC strategy included maternal and child health services, health education, nutrition education, immunisation and control of communicable diseases, provision of basic preventive and curative care. A more detailed review o f the successes and problems facing the various components of the PHC in Zimbabwe is given in a report by the Ministry of Health (1987).
One of the major successes of the PHC program in Zimbabwe is probably the strengthening of immunisation, resulting from the initiation in 1981 of the Expanded Program of Immunisation. The program aimed to immunise children against the six major childhood infectious diseases: measles, diphtheria, whooping cough, neo-natal tetanus, poliomyelitis and tuberculosis. About 53 per cent of children under age five were immunised against measles in 1984 (UNICEF, 1985:40). According to the 1988 ZDHS, 60-85 per cent of children aged 12-59 months at the time of the survey, had all the required vaccinations, with only minor differences between rural and urban areas (CSO,
1989:86).
Substantial progress was also made in educating mothers on the management and control of diarrhoeal diseases, which are among the major child killers in developing countries. According to the 1988 ZDHS, knowledge of oral re-hydration therapy (ORT), that is, the salt, sugar and water solution, among mothers with children under age five years was almost universal as 97 per cent of these women knew about the solution (CSO, 1989:91). Differences by rural-urban residence and maternal education were negligible. The 1989/90 Zimbabwe Service Availability Survey (ZSAS) revealed that by the time of the survey, 80 per cent of rural and 96 per cent of urban married women lived within eight kilometres of some health facility offering maternal and child health services (CSO, 1991:35-37). In the rural areas, 70 per cent of all children lived within eight kilometres of a health centre. However, some of the facilities were often faced with shortages of vaccines and medicines.
It is clear that substantial improvements occurred in the provision of maternal and child health services in Zimbabwe in the decade following Independence, with greater emphasis being on rural areas and preventive care. However the success achieved in the health sector was short lived. As noted by W oelk (1994:1027), at the beginning of the 1990s, there appeared to be a stagnation in immunisation rates and malnutrition remained one o f the major causes of child death.
Four reasons for the short-lived successes of the health sector are cited by Woelk (1994:1027). First, community mobilisation and self reliance to achieve better health is lacking. Second, the bureaucracy and centralisation of decision making which led both health workers and the communities serviced to perceive the Primary Health Care program as health care provided by the government with little stress placed on community participation. Third, the lack of drugs and medicine has resulted in lack of credibility of the program; when patients go to a clinic they may be told that there are no drugs or may be given a prescription to obtain drugs from a pharmacy. Finally the cost recovery policies and inflation associated with the economic structural adjustment program adopted in 1991 and the increase in the minimum wage for eligibility for free
medical care reduced access to health services for most of the poor families.
The stagnation in health in the early 1990s in Zimbabwe occurred at the time when an increasing number of people in Zimbabwe needed medical care due to infection with the Human Immuno-deficiency Virus (HTV), the etiologic agent of the Acquired Immuno-Deficiency Syndrome (AIDS) (see UN, 1994:66). The impact of HTV and AIDS particularly on infant and child mortality are examined further in the concluding chapter.