Document(s) 12 of 14

DESCRIPTION OF THE COUNTRY

Zimbabwe, a landlocked country in southern Africa bordered by Zambia, Mozambique, the Republic of South Africa, and Botswana, occupies an area of 390 756 km2. Its population in 1992 was 10.4 million, reaching 12.3 million in 1997. Despite growing urbanization, about 70.4% of the population live in rural areas (UNDP 2000). The population is youthful, with a dependency ratio of 94.4% in 1992 made up of 45% below 15 years and 3% over 65 years. Almost the entire population (98.8%) is of African origin, with MaShona and Matabele ethnic groups predominating.

In 1890, the MaShona and Matabele territories, which comprised what we now know as Zimbabwe, fell under the influence of the British empire, and the country was renamed Southern Rhodesia after Cecil Rhodes, a prominent colonialist leader. After suppressing widespread uprisings in the early 1890s, the settlers went on to establish a network of rail and road communications on the fertile highveld, forcibly displacing the African population to make room for commercial agriculture and mining. In 1923, the British government granted the small population of Europeans self-governing status that excluded the African majority. Then, in 1931, the colonial regime passed the Land Apportionment Act reserving half of the arable land area to the white population, who numbered less than 1% of the total population. This land imbalance laid the foundation for future discord among the first independent government of Zimbabwe, the British government, and white commercial farmers.

Militant nationalistic parties emerged in the 1960s clamouring for restoration of land rights and independence. To pre-empt the granting of majority rule, the white settlers rebelled against the British government, and in 1965, Ian Smith, the Prime Minister, issued a Unilateral Declaration of Independence. Nationalist parties were banned and went underground, forming guerilla armies that made incursions into the country from bases in neighbouring Mozambique and Zambia. After nearly a decade of armed struggle, the Smith regime capitulated in 1979. A year later, the British government conducted a plebiscite that brought Robert Mugabe's Zimbabwe African National Union Patriotic Front (Zanu(PF)) into power on 18 April 1980.

Zimbabwe remained a multi-party democracy, but the Zanu(PF) party dominated political life throughout the 1990s, despite the presence of about a dozen opposition parties. However, in February 2000, the Movement for Democratic Change (MDC), a broad-based party led by Morgan Tsvangirayi, a former leader of the Zimbabwe Congress of Trade Unions, campaigned successfully against a referendum supported by government to introduce a new Constitution. It won 57 parliamentary seats in the general elections of June 2000, against 62 won by Zanu(PF). Although the MDC lost the hotly contested 2002 presidential election to Mugabe, it won important urban councils, including the mayorship of Harare, the capital city. The two main pillars of MDC support are urban workers, who have borne the brunt of deteriorating economic conditions since the 1990s, and white commercial farmers, whose farms were expropriated by government for fast-track land resettlement of peasant and black farmers. The MDC, the British government, and its allies are strongly opposed to the government fast-track land reform program, arguing that land reforms were disorderly and done for political opportunism, without regard for agricultural productivity and human rights. Government has retorted that land reforms were necessary to alleviate land hunger and poverty among peasants and to deracialize commercial agriculture.

DEVELOPMENT AND HEALTH INDICATORS

At independence in 1980, Zimbabwe inherited a socioeconomic structure with gross inequalities in health status between whites and blacks, and between rural and urban residents. Social and geographical inequalities were indicative of a colonial health system designed to provide health care to the minority settler population. There were marked income disparities between whites and blacks in formal employment and peasant farmers. This system ignored major health problems of the 70% majority black population living in rural areas, where health services were inadequate and where nutritional deficiencies and communicable diseases were rife. About a third of rural children were malnourished and only a quarter were immunized. The incidence of preventable conditions was much lower among the white population.

Access to education and jobs followed the same trend, with better educational facilities and opportunities available to whites, followed by urban blacks, whereas rural blacks had little or no access. Almost all urban residents had access to potable water and sanitation facilities, as opposed to 10% among the rural population. Distribution of arable land was even more skewed, with about 4 500 white farmers owning 75% of the land, while five million peasants lived in overcrowded and low-rainfall areas with poor soils. Overcrowding in communal lands led to environmental degradation due to inappropriate or intensive use of generally marginal land.

The new government adopted a policy of "Equity in Health," using the primary health-care (PHC) strategy to redress inequities between rich and poor, black and white, and urban and rural communities. Public health expenditures were increased, shifted toward rural areas, and focused on primary and preventive services, nutrition, and family planning. Basic health indicators such as nutrition, contraceptive use, life expectancy, and infant mortality showed dramatic improvements from 1980 to 1990 (Sanders and Davies 1988). Previously deprived rural and urban populations saw their life expectancy increase from 56 years in 1980 to 61 in 1990, and 85% had access to a health facility within eight kilometres. Immunization rates for children rose from 25% in 1980 to 77.9% in 1991, while the weight-for-age indicator for malnutrition in children fell from 22% to 16%. There was a dramatic reduction in the infant mortality rate from 80 (1978) to about 55 (1994) deaths per 1 000 live births.

Public sector investments in PHC, family planning, female education, and improved access to safe water and sanitation were important tools in promoting equity in health among the rural poor. Women and children benefited most, and universal access to primary education further strengthened the program. Literacy rates increased. It was estimated from the 1992 census that over 80% of the population were literate (86% among males and 75% among females). Female education is a key proxy for household socioeconomic status, bringing better understanding of health issues, particularly of disease and its prevention. The combined effects of increased family planning services, high literacy, and education also brought about a significant decline in total fertility rate from 7 in 1969 to 4.3 in 1994. Maternal health services were among the key areas developed in the 1980s.

However, Zimbabwe's second decade of independence (1990–2000) saw an increase in child and adult mortality while maternal and child health indicators stagnated. Some analysts claim this deterioration was a result of the introduction of structural adjustment programs (SAPs), which dramatically curtailed resources to the social sector. Others point to poor governance and the failure to respond effectively to the AIDS epidemic. In 1997, it was estimated that 20% of the adult population (about 1.4 million people) were HIV-infected (NACP 1998). The national crude death rate, which had dropped from 10.8 in 1982 to 6.1 in 1987, rose to 9.5 in 1992 and 12.2 in 1997. Some projections even suggested that life expectancy would fall below 40 years in the absence of effective behaviour change (Gregson et al. 1996, 1998; Gregson et al. 1997). AIDS is now the primary cause of adult and child mortality, which led the government to introduce an AIDS Fund in 1999 through a statutory 3% levy on taxable income. It is estimated that about 15 million USD has been raised each year.

ADJUSTMENT POLICIES

In 1980, the government adopted a policy of "Growth with Equity" and at the same time promoted national reconciliation with the white minority population. The international community responded favourably and pledged about one billion USD to support the 1981 Zimbabwe Conference on Reconstruction and Development (ZIMCORD). In the first two years of independence, gross domestic product (GDP) grew in real terms, at 11% in 1980 and 13% in 1981, most likely in response to pledges made at ZIMCORD. The "Growth with Equity" policy was intended to reduce deep inequities in wealth distribution inherited from the colonial government. Foreign direct investments available to the private sector were limited. The policy was successful in promoting social equity in national development, but proponents of market forces felt it crowded out the private sector, limiting economic growth. The consequent mismatch between expenditure and revenue precipitated budget deficits of up to 10% of GDP. Other consequences included balance of payments problems, rising unemployment, inflation, and low levels of investment.

To secure balance of payments support, government was forced to undertake SAPs with the assistance of the International Monetary Fund (IMF) and the World Bank. The first of these, known locally as an Economic Structural Adjustment Programme (ESAP), was launched in 1991. Its main objective was to redress imbalances in the economy and promote growth through fundamental reforms of the economy to make it market-based. Measures were put in place to move from an inward-looking, protectionist, and state-controlled economy to one that was outward-looking and competitive, based on market forces, that would accelerate growth and lead to higher employment and improved standards of living. Poor people were cushioned from negative effects of ESAP through a Social Development Fund to assist with social services like health and education and to provide funds for income generation activities. Poor people also needed government support in dealing with the devastating droughts of 1991–92 and the growing problem of HIV/AIDS. Recent studies suggest a direct link between the deteriorating economic situation and increased disease in the population (Woelk and Chikuse 2001).

To stimulate broad-based macroeconomic stability, accelerate poverty reduction, and alleviate hardships arising from ESAP, in 1995 the government formulated a second phase of reforms embodied in the Zimbabwe Programme for Economic and Social Transformation (ZIMPREST), the focus of which was to alleviate poverty directly through land reform, indigenization, fostering small-scale enterprises, and an effective national HIV prevention strategy. However, weak implementation, droughts, HIV/AIDS, and policy differences with the international community militated against the success of the reform, such that confidence in the economy remained low. This was compounded by a slowdown in the global economy that saw a sharp decline in commodity prices, especially that of tobacco, responsible for about 30% of foreign currency earnings. Manufacturing and tourism declined by 7.5% and 3.5%, respectively.

The net effect of the reforms was to liberalize the economy, especially the financial services sector, but there was no increase in foreign direct investment, nor did unemployment or poverty decrease. Even more disturbing, the reforms ultimately led to decontrol of prices, removal of subsidies, poor supply response, high budget deficits, depreciating exchange rate, and high levels of inflation. Inflation rates had been erratic, going from 15.5% in 1990 to a peak of 42.1% in 1992, then down to 18.8% by 1997 and up again to 50% by 1999. The economy grew by less than 2% between 1991 and 1995 while inflation soared (ZIMCODD 2001). Population growth during the same period averaged 3.1%, explaining to a large extent the decline in GDP and in per capita GNP, from over 750 USD at the beginning of the 1980s to 500 USD in 1994. Earnings per employee declined 3% annually between 1980 and 1991, and unemployment went from 11% to 22% between 1982 and 1992, reflecting a significant deterioration in the standard of living. The situation was worsened in 1997 by huge, unbudgeted financial gratuities given to 50 000 veterans of the war of national liberation.

Even though the SAPs were considered by policy analysts to be good, implementation was poor and targets were often missed. This was due largely to differences between those in government who favoured the social welfare policies adopted at independence and those who had wholeheartedly accepted SAPs. The IMF, World Bank, and bilateral donors refused to bail out the government from its economic problems, because of reservations about its economic and land acquisition policies and its military commitments in the Democratic Republic of the Congo. This resulted in the steady decline of already low investments and erratic loan disbursements and precipitated the 2000 economic downturn (UNDP 2000).

Importantly, SAP policy issues were shrouded in secrecy. There was little public support for SAPs due to the lack of transparency, accountability, and public participation in their design and implementation. Indeed, after 10 years of SAP implementation (1990–2000), there was intense debate and criticism that the country's economy had been sluggish at best and otherwise contracting at an alarming rate. By the end of 2000, there were no signs of economic recovery, but rather mounting poverty and unemployment, compounded by a young population structure, the HIV/AIDS burden, rising foreign debts, and inflation. This continual deterioration forced government to adopt the Millennium Economic Recovery Programme, in a firefighting attempt to mobilize all economic stakeholders, public sector departments, business, labour, and civil society, to implement a package of synchronized macroeconomic stabilization measures that would be anticyclical and anti-inflationary.

STUDY DESIGN AND METHODOLOGY

Anecdotal evidence suggests that the health sector in Zimbabwe was seriously undermined by the SAPs, as described in the preceding paragraphs. Our aim was therefore to study the role of SAPs in health sector reform and their influence on access, utilization, and quality of health-care services. We also wished to assess the extent to which structural changes within the health-care system have arisen from socioeconomic pressures of adjustment policies, including any prejudice to the health sector under liberalization—as, for example, in the fact that its main input costs require foreign currency (e.g. drugs and equipment), while it produces for and is paid in the domestic market. The sector also lost highly skilled and experienced professionals (doctors, nurses, others) whose incomes became uncompetitive due to the rising cost of living during structural adjustment.

The existence of two distinct periods in the country's recent history facilitated the testing of the research hypothesis and related questions. First, in the decade of independence from 1980 to 1990, the country had a functioning and effective health delivery system that led to marked improvements in a number of health indicators. Then, in the decade from 1990 to 2000, when structural adjustment and health sector reform policies were introduced, there were marked declines in important health indicators.

Several methods were used to generate information, such as retrospective analysis of macroeconomic and health sector data to describe patterns and examine economic trends, social organization, and inventory of health facilities. We also reviewed the literature and analyzed reports and documents from government departments, academic and research institutions, non-governmental organizations, United Nations agencies, and related organizations. Interviews were conducted with key informants in economic and social sectors. Focus group discussions were conducted with representatives of rural and urban communities for cross-sectional understanding of the financing, delivery, and quality of health services at the local level. A household survey was carried out using a questionnaire administered to 2 000 respondents randomly selected throughout the country, with a non-response rate of 0.4%. The sampling frame for the household survey came from the 1992 Zimbabwe sample (ZMS92) developed by the Central Statistical Office (CSO) following the 1992 population census for use in demographic and socioeconomic surveys. The rural stratum consisted of communal land, large-scale farming, and small-scale farming and resettlement areas, and the urban stratum corresponded to the urban and semi-urban strata of the ZMS92.

The analytic challenge was to demonstrate linkages between SAPs and health sector reforms and to identify impacts on various aspects of access, utilization, and quality of care according to administrative and geographical location and socioeconomic status of the population. Such analyses provided insights into household economic indicators, ability to pay for health care, utilization of health services, perceptions, and health needs of different population groups. Interim findings and reports were prepared and discussed extensively at national meetings and workshops with key stakeholders (policymakers and planners, researchers, and public health experts) to get feedback and to attempt to reach consensus on the interpretations and conclusions.

FINDINGS AND DISCUSSION

The health system

As stated earlier, health policies, legislation, and regulations introduced after independence supported goals of equity and therefore promoted free health care to those who could not afford to pay. The key policy document, Planning for Equity in Health, and subsequent health-for-all action plans were based on PHC and thus included health as part of the development process. However, it remains difficult to assess the impact of traditional non-health inputs on health development and performance. Government demonstrated its commitment to PHC, keeping health expenditures as a percentage of GDP stable at 2–3% between 1980/81 and 1995/96, with 1990/91 being an exceptionally good year (Figure 1). During the period 1981–1994, the proportion of health expenditure as a percentage of total government expenditure was maintained at over 5%, except during the drought years of 1983–1985, when it dropped below this level. Between 1979 and 1987, public health expenditure grew by 94% in real terms and 48% in real capital terms. By the end of the 1980s, the public health sector had undergone unprecedented expansion, such that recurrent annual levels of government financial allocations were inadequate to maintain existing services.

FIGURE 1. PATTERNS OF GOVERNMENT HEALTH EXPENDITURE, ZIMBABWE, 1980/81–1995/96

Source: MAPHealth study (2001).

The Ministry of Health is the largest single provider of health care and preventive health services. It is directly responsible for 301 rural health centres (RHCs) and 55 rural hospitals, 50 district and general hospitals, 8 provincial hospitals, and 5 central hospitals.¹ It also provides subsidies to 600 health facilities of municipalities, missions, and rural district councils (RDCs) that adhere to government programs and health policies such as exempting the poor and indigent from fees for health care. Within this context, in 1980, government eliminated health services fees for those earning less than 150 ZWD (at that time, 100 USD) per month, effectively exempting 70% of the population and leading to a substantial increase in utilization of health services.

Introduction of reforms

Government initially insisted on its redistributive socialist model, but after severe foreign currency shortages in the late 1980s, it finally succumbed to the Bretton Woods institutions and introduced ESAP in 1991. Even though there is no clear documentation linking the introduction of health sector reforms to SAPs, local observers believe that once government accepted internationally-driven IMF and World Bank economic structural adjustment strategies, the link with health reforms became inevitable.

The corporate model and the management approach to health reforms were initiated internationally and introduced in Zimbabwe in the late 1980s as a package of externally funded workshops and technical assistance. The main reform objective was to decentralize power and decision-making in health services to the operational level. Under pressure from the World Bank, IMF, and bilateral agencies, cost-recovery and value-for-money policies were imposed on the public health system, with little internal consultation and debate to reach consensus. There was international pressure to increase access to health care and to improve quality by reforming and commercializing some services. This trend led to an increase in the health-care market of the private and non-governmental sectors.

There was no clear collaboration on the reforms between the Ministries of Health and of Finance, leading to dissonance between a strong political commitment to expand access to health services and a shift of national resources in favour of the private sector. Government's financial allocations to the public health sector in real terms were fairly consistent before and after the introduction of economic reforms. For example, in 1990/91, at the beginning of ESAP, public expenditure on health was 3.4% of GDP and 22 USD per capita, or 6.2% of total expenditure—one of the highest levels in sub-Saharan Africa. Indeed, allocations to the Ministry of Health increased from 6.1% of the total budget in 1990/91 to 10.4% in 1995/96. More recently, the share of expenditure on health as a proportion of public expenditure increased markedly, from 4.3% in 1996, to 10% in 2000 and 11.5% in 2001.

On the other hand, economic reforms were aimed at balancing the widening budget deficit partly caused by spiraling costs of public expenditures, including health care. With economic liberalization, the middle class, mostly urban, clamored for improvements in the quality of health care and for more responsiveness to consumer needs and preferences. Within the context of a disastrous economic situation and excessive inflation, the ensuing contradictory and confusing health policies gave the impression of a collapsed public health system. The decline was aggravated not only by unmanageable growth of the public health sector, but also by droughts, poverty, the HIV epidemic, and the decline in prices of export commodities. To complicate the picture, value-for-money and cost-recovery policies, which created barriers in access to public health services, were introduced without adequate examination of their impact on equity and on sustainability of the publicly funded health system (Hongoro and Chandiwana 1995).

Reform process

Content

Conventional wisdom suggests that health reforms were inevitable following the introduction of SAPs in the 1990s. However, we found no explicit government document or statement on the Ministry of Health's rationale for embarking on health sector reforms. Internal Ministry documents indicate that health sector reforms were being introduced in line with international trends to decentralize decision-making to the level of health service delivery. It is against this background that health sector reforms were introduced in Zimbabwe with the following objectives (Sikosana 2000):

• increase the effectiveness and quality of services, to achieve consumer satisfaction and ultimately improve health status;
  
  
• improve access to quality care for disadvantaged groups and ensure greater equity; and
  
  
• obtain greater value for money (cost-effectiveness) from health spending through targeting resources at priority activities, with better management and use of resources.

The Ministry of Health identified the following areas for reform: decentralization, health financing, regulation of the private medical sector, strengthening management, and contracting out of some services. Decentralization was aimed at providing flexible and adaptable management practices, inter-sectoral coordination, and community participation. From the perspective of central government, decentralization had political, administrative, and economic objectives. To support the reform process, the Ministry embarked on a project in 1990 aimed at developing management competency at district, provincial, and central levels.

The most important legislative changes associated with the reforms were under the Medical Services Act enacted in 1999, which provided the framework for the establishment and operation of private health providers and medical insurance schemes. The key elements of this act are:

• regulation of the establishment of private hospitals and of access to private and public hospitals;
  
  
• regulation of medical aid societies (private health insurance schemes);
  
  
• monitoring of the quality of care in private and public institutions; and
  
  
• establishment of hospital management boards (HMBs).

Hospital facilities were to be run by HMBs with strong representation from the community, and RDCs would be responsible for health delivery services in their respective districts. Initially, the HMBs or local authorities would receive grants from the central government awarded on an agreed formula for specified numbers and types of beneficiaries. In addition, the Health Services Fund (HSF) was established in 1996, allowing government institutions to operate bank accounts into which revenues from cost recovery and donor funds were deposited. This additional source of financing was characterized by flexibility and availability for addressing local priorities and needs. Up to then, all hospital fees had been remitted to Treasury's consolidated revenue fund, reducing the incentive for institutions to collect user fees. Another important aspect of reforms was the contracting out of non-core activities such as security, cleaning, and catering services.

Capital expenditure

Annual capital spending figures are difficult to compare because of high population growth and inflationary trends that eroded the value of the local currency. Thus, real per capita expenditure declined even as capital expenditure continued to grow. Large construction programs, such as the building of more than 90 new hospitals and clinics in 1992/93, placed a strain on current funding of staff, stock, and operating costs of the new facilities. Expansion of health services in the 1980s did not match the resources available—a major challenge compounded by the emergence of the HIV epidemic and periodic droughts. Signs of this gap between demand and resources included drug shortages, poor maintenance of infrastructure and equipment, understaffing, and real decline in salaries.

During the economic reforms, the share of donor agency contributions to health expenditures remained stable at 25% of Ministry expenditure over three fiscal years (1994/95–1996/97), then registered a slight increase to 27% in 1997/98. Despite government's commitment to primary health care, a disproportionate amount of spending is on higher-level facilities, accentuating the inequitable distribution of resources in favour of urban areas, where most tertiary institutions are located.

Stakeholders

The Ministry of Health adopted an incremental, rather than radical, approach to health sector reforms. Consultations on decentralization began in 1994 involving Ministry representatives from district, provincial, and central levels, culminating in a national workshop of stakeholders in 1996. Reforms were to proceed in stages to allow staff to gain experience and to create an enabling environment for implementation. However, recent interviews indicate that health workers at the periphery believe the consultation process was inadequate and that community groups felt they were not adequately apprised of the content and implications of the decentralization (Sikosana 2000).

Consultations with RDCs emphasized the need to build on existing structures and strengthen financial and information systems. Donors such as DANIDA (Danish International Development Agency) were actively enthusiastic about decentralization, with a view to reducing the influence of centrally-based structures. Health professionals and the public were concerned about how the reforms would affect the public health sector's ability to address identified health needs. The Ministry of Finance was more interested in how the economic reforms would reduce the widening budget deficit, partly caused by spiraling costs of public health care.

Implementation status

By 2000, key aspects of the reforms had been accomplished and included:

• establishment of a Health Services Fund;
  
• development of a resource allocation formula;
  
• enactment of legal statutes to strengthen the Ministry of Health's regulatory role;
  
• approval of a new organizational structure for the Ministry; and
  
• approval for the establishment of Hospital Management Boards (HMBs).

However, by the end of 2000, health personnel at the district level had still not been transferred to the RDCs and no new HMB was in place. Even though financing proposals for a social health insurance were complete, implementation was dependent on an enabling economic and social environment.

Mechanisms and implementation arrangements

The Ministry of Health established a Strategic Development Unit to coordinate health sector reforms within a hierarchy of institutions set up to manage the process. However, a major difficulty in achieving effective decentralization is that government ministries are sectoral in nature, whereas developing linkages between capacity-building and decentralization demands an intersectoral approach. Currently, RDCs do not have the capacity to administer a comprehensive decentralized system that involves taking over some of the functions of the Ministry of Health at a local level. For decentralization to be successful, the capacity of RDCs to manage projects, float tenders, contract out services, and manage personnel and finance must be built up.

Consequences of health reforms

Broader effects

The political commitment to the health sector was not significantly reduced, yet resources available declined in real terms due to high inflation. Thus, as had happened in economic reform, health reform was undermining the functioning of the health system. Nevertheless, health reforms did improve the efficiency and effectiveness of the annual planning process for health services. This planning was strengthened substantively through a bottom-up approach involving broad consultation at district level with key stakeholders, through which inputs from all 58 districts are consolidated into a national action plan before submission to the Ministry of Finance.

To ensure uniformity, a 10-year National Health Strategy (1997–2007) has been developed, with implementation based on three-year rolling plans resourced annually. However, the planning process has been negatively affected by economic reforms that reduced civil service posts, mainly clerical and maintenance, compromising efficiency and effectiveness as health professionals were burdened with additional responsibilities. Also, skilled administrators left the public health sector to join the private sector—an internal brain drain that increased markedly in the 1990s and affected the viability of the public sector.

It is clear that the long-term sustainability of the public health system requires a new value system and greater capacity to monitor and evaluate the delivery of health care. To accomplish this, the traditional supervision by monitoring must be replaced by a process of amicable dialogue among members of a health team around mutually agreed goals. Changes in management culture should entail on-the-job training, sharing of technical and managerial information with staff, and creating conditions for obtaining feedback from subordinates and the public. Staff morale would also benefit from regular performance appraisals with appropriate bonuses and incentives.

Impact on health-care functions

The Medical Services Bill of 1999 provided appropriate conditions for regulating health providers and institutions in the private and not-for-profit sectors. These encourage an optimal mix of private and public provision of health care aimed at effective use of scarce resources. The challenge is to implement agreed-upon financing and professional standards to protect members of the public from unscrupulous health providers. It is clear that a key role of the Ministry of Health is to administer a regulatory framework that facilitates an orderly and increased participation of the private sector in provision of health care. An optimal public-private sector mix increases the range of options available to patients, reduces pressure on government health services, and minimizes cost escalation to make health care affordable.

Since the early 1990s, the Zimbabwe health system has seen rapid and massive private sector expansion that includes private-for-profit, private-not-for-profit NGOs, mission hospitals, and health insurance schemes (Figure 2). Particularly, urban areas have seen steady growth in private-for-profit health-care facilities ranging from small consulting rooms and nursing homes to tertiary hospitals. This growth has spurred the exodus of experienced medical personnel into the private market at a time when the public health system is experiencing difficulties with morale due to low wages and poor conditions of service. The migration toward the private sector has been supported by economic policies encouraging investment and entrepreneurship through deregulation of the health sector. In 1996, the National Medical Aid Society (NAMAS) estimated there was demand for an additional 1 000 private beds at a 75% utilization rate (MOH 1996–1998).

In recent years, there has been growing cooperation between the public and private sectors, particularly those in the mines and in large-scale agricultural sectors, in management of human resources or in the sharing of physical infrastructure and equipment. HIV/AIDS has increased the number of patients such that the public sector cannot cope. Those in the middle class on medical aid schemes find that private health providers are more convenient and that there is less waiting time before treatment.

FIGURE 2. PATTERNS OF GROWTH OF PUBLIC AND PRIVATE HEALTH FACILITIES, ZIMBABWE, 1991–96

Source: MAPHealth study (2001).

Supply-side effects

Sharing the cost for utilizing services

The failure of economic reforms led to an increase in unemployment and in the level of poverty. In 1995, individuals contributed about 30% of health-care costs, approximately the same amount contributed by government. Employer-based benefits and private insurance schemes accounted for about 11.8% of expenditure, but this generally benefited those in urban areas. Government contribution was entirely devoted to public health facilities that benefited 80% of the population. Most beneficiaries live in rural areas and pay nominal consultation fees or are exempt from payments if they meet the criteria set by government for receiving free medical care: earning less than 400 ZWD per month (about 30 USD in 1997) and having a letter of recommendation from the Department of Social Welfare that they are eligible to have fees paid through the Social Development Fund (SDF).

Changes in provider payment mechanisms

With the introduction of user fees, individuals were expected to pay for health care at public institutions unless they met the above criteria for free services. In the health facilities survey, the majority of public health facilities in rural and urban areas reported having one or more mechanisms to provide free health services to those who were eligible. In urban areas, all surveyed facilities reported having mechanisms for patients to make direct cash payment for health services, whereas in rural areas, only half reported that patients could make direct cash payment.

Before economic reforms, most private health providers accepted payment through a health insurance scheme, but with the increasing difficulties insurance organizations have had since the reforms, many providers demand cash up front before service. Eighty percent of urban facilities had mechanisms to process payments made through medical insurance and the SDF, whereas only a third of the rural facilities could process payments through medical insurance and 16.7% through the SDF. The SDF was a form of safety net introduced to cushion the vulnerable population from the negative effects of the reforms. Access to a social welfare officer is better in urban areas, which explains why most rural people have limited access to the SDF.

Given the socioeconomic conditions in Zimbabwe, the proportion of patients who qualify for assistance through the SDF is high and has increased beyond the fund's capacity. There is a need to explore the potential for use of prepayment in rural areas where peasant families usually obtain funds seasonally from selling their agricultural produce. In the health facilities survey, only one rural facility had prepayment as a method of paying for health services.

Changes in system hierarchy

With health reforms, the central Ministry's responsibilities have been redefined as:

• health policy formulation;
  
• mobilization and allocation of resources, and budget analysis and formulation;
  
• human resources planning, development, and regulation;
  
• providing a regulatory framework for the operation of the private sector and other health providers;
  
• epidemiological surveillance, monitoring, and evaluation of the health status of the population; and
  
• liaison with international health organizations and aid agencies.

This has required streamlining the central structures of the Ministry of Health. With the devolution of authority, HMBs and provincial health administrations have more autonomy in revenue collection and administration of human and other resources. Donors have supported these reforms, particularly in providing resources to strengthen accounting procedures and developing strategies to enhance private–public sector collaboration in the delivery of health care. Since the establishment of the HSF in 1996, records indicate that fees retained at the institutional level have increased significantly. The funds have been used mainly to augment drug supplies from the government medical stores, contributing significantly to overall drug availability at the institutional level.

Changes in mechanisms for quality control and quality assurance

The health facilities survey examined a number of indicators used in quality control and quality assurance of health-care services at clinics in rural and urban areas. Health care was available at most facilities throughout the week. The majority (82%) of health facilities opened seven days a week, while 8% opened for six days and 10% opened for five days. In addition, about half (56%) of the facilities had an on-call system to attend to emergencies.

In the health facilities survey, staff members were asked about the existence of a therapeutic guide, whether in the form of a decisional tree or a medical practice guide. Staff at 83% of the facilities reported having a therapeutic guide. Of those facilities with a guide, 88% of the personnel were trained in its use and reported that it was used regularly. Most of these facilities (94%) had updated the guide, 42% within the last five years; about 40% could not give the updating date.

Regarding clients' average waiting time, health-care personnel interviewed were somewhat overly positive; only 7.5% estimated a waiting time of more than 30 minutes. This finding contradicts the view of a substantial proportion of respondents (26%) in the household survey, who indicated they had waited for more than 30 minutes before being served.

Public health interventions such as vaccinations are also indicators of the quality of the health delivery system. Gratifyingly, nearly 95% of 41 health centres surveyed provided daily vaccination services. About 66% of the facilities had a system to follow vaccinated children using follow-up cards, vaccination schedules, home visits, etc. The most common follow-up system was that of home visits by village community workers, who checked on children's vaccination cards and referred those unvaccinated to the health centre. This system was used by half of the facilities that reported a follow-up system.

Changes in cross-cutting issues

When ESAP was launched in 1991, the country had already made significant investments in human resources. There was steady growth in the number of health professionals registered with the Health Professions Council (HPC) from 1985 to 1997 (Table 1). Since the late 1990s, quality of care has been compromised through the large numbers of health professionals leaving the public health sector for the private sector or emigrating in search of better job opportunities, and the situation continues to deteriorate. The number of nurses per capita, for example, fell by 17% between 1988 and 1993. Shortages of drugs, consumables, and basic equipment continue to affect morale that is already low due to poor working conditions and low salaries. This led to stay-aways (not coming to work, but without a formal strike) and other job action, including a crippling strike by nurses and junior doctors in 1997 that negatively affected health delivery services.

TABLE 1. NUMBER OF HEALTH PROFESSIONALS REGISTERED BY CATEGORY, ZIMBABWE, 1985-1997

Unfortunately, human resources development has been focused on doctors and nurses involved in medical care at the expense of environmental and other public health workers whose inputs have broader public health impact. This led to a stagnation, beginning in 1990, in development of the grade of environmental health staff, such that the role of this important cadre involved in preventive health services has fallen to the periphery. Since 1990, health services have been oriented more to curative than to preventive services.

The majority (85%) of health facilities reported that they had an updated essential drugs list and 94% of those with the list reported that it was available in the consultation room. On quality control, 24% of the health facilities estimated that quality of care was high, mainly due to good training and the use of therapeutic guides. On the other hand, 10% of the facilities complained that quality of care was low, mainly because some supervisory activities were not being done, due to staff shortages. About two-thirds of the health facilities had a pharmacy where patients could procure prescribed drugs, suggesting that health centre based pharmacies are the most common source of prescribed drugs for patients.

Demand-side effects

Geographical accessibility

The results of the survey suggest that the government's policy of making health facilities available within eight kilometres of residence is working. The most common mode of transport to the nearest public health centre was by foot, followed by the use of vehicles. About 86% of urban respondents walked to the nearest public health facility, as did 72.5% of those in rural areas. A quarter of rural and about 12% of urban respondents used vehicles to get to the nearest health facility.

The proportion of respondents that had ever used a public health facility was high in both rural and urban areas, 87.9% and 82.2%, respectively. Similar utilization rates were recorded for public hospitals in rural (69.7%) and urban (73.7%) areas. On the other hand, urban respondents (67.1%) who used the nearest private health facility exceeded those in rural areas (43.9%). More rural respondents (44%) than urban (37.7%) used traditional and religious facilities.

Surprisingly, in terms of time taken to access antenatal care, providers in rural areas were more accessible than those in urban areas: 61.1% of rural women had access to an antenatal care provider within 30 minutes, compared to 54.2% of urban women. The explanation may be that these rural women live close to a health facility or a traditional birth attendant.

Financial accessibility

The household survey indicated that only a third of the study population were in formal employment. Data were analyzed by sector of employment and by gender to obtain an indication of an individual's economic status and likely ability to pay for health services. A higher proportion of rural respondents worked in the agricultural sector (86.1%), whereas urban residents worked in commercial, industrial, and service sectors. Women were predominantly employed in agricultural and domestic sectors and earned low wages hardly above poverty levels. Men dominated in commercial, public administration, and service industries, where wages were higher.

Interestingly, a high proportion of respondents (40–60%) spent considerable amounts of household income consulting doctors in the private sector or traditional healers. It is clear that many urban and rural households have the ability to pay for health services, an observation that supports the policy of user fees at government health facilities, as long as special arrangements are in place to ensure the poor have access to health care. Although government has stopped charging for primary care, clinics often lack basics such as drugs, trained personnel, and resources for physical maintenance. Some rural communities have started organizing themselves to generate funds for burial societies and even for upkeep of local clinics.² In spite of this effort, rural people have difficulty accessing modern health care and invariably are forced to rely on traditional healers, whereas urban people have some choice in the type of treatment.

Most of those who incurred traveling costs paid less than 50 ZWD (4 USD) per visit. For the majority of women in both rural (63%) and urban (50.4%) areas, no travel costs were incurred during antenatal visits, as the major mode of transport was by foot. Antenatal care (ANC), a key cornerstone of primary health care, has benefited from government policy on free medical care. For most rural women, ANC services were free, as their incomes were below the fee exemption threshold, which is generally not the case with urban residents. The proportion with free ANC was higher in rural areas (59.7%) than in urban areas (16.6%), while about a third of women in rural and urban areas paid less than 100 ZWD (7.5 USD). Nearly half of urban women paid more for ANC than rural women.

A majority of rural women (50.8%) thought prenatal care was inexpensive or very inexpensive, compared to 14.3% of the urban women. This is not surprising, given that the majority of women who received free treatment are from rural households. On the other hand, a significant proportion of women in urban areas (38.9%) thought prenatal care was expensive or very expensive, compared to only 18.7% in rural areas. Nevertheless, the majority from both areas indicated they were able to pay the cost of ANC.

Sociocultural accessibility

Local beliefs and customs influence access and utilization of health services. About 15% of health facilities personnel thought cultural beliefs had a negative impact on access to health services, and 9.8% noted a positive impact. For child vaccination, prenatal consultation, family planning, and nutritional follow-up of children, more than 70% of personnel reported a positive influence of local beliefs and customs. For prevention of HIV and sexually transmitted infections, 61% felt that local beliefs and customs played a positive role, and 14.6% observed a negative perception inhibiting the use of condoms in HIV prevention, as this was associated with increased prostitution in response to economic hardships.

Perceived service quality

Respondents of the household survey were asked to give their perceptions of different aspects of the quality of health care offered by providers closest to their homes, using a ranking scale from very good to very unfavourable. For the various aspects, a higher proportion of rural respondents than urban counterparts rated the public health centre and public hospital closest to their home as good or very good. Similarly higher proportions of rural respondents rated the quality of religious facilities as consistently good or very good for all aspects of quality examined. Traditional practitioners are also regarded more highly in rural areas.

Comparing private clinics with public health centres in urban areas, a higher proportion of respondents consistently rated private clinics as good or very good in most aspects of quality, except cleanliness and hygiene, for which only 55% rated the closest private clinic as good or very good compared to 69% of respondents using public health centres.

Among those who had had a health problem in the past four weeks and consulted a health facility, the majority were served within 15 minutes of waiting in both rural (42.6%) and urban areas (42.9%). The proportions of those waiting more than an hour were also similar, 12.8% in rural areas and 10.7% in urban areas. Generally, waiting time in all categories was similar in both areas. Waiting periods of more than 30 minutes were more common in public health facilities (30%) than in private facilities (18.2%) (Figure 3).

FIGURE 3. WAITING TIME BY OWNERSHIP OF HEALTH ESTABLISHMENT, ZIMBABWE

Source: MAPHealth study (2001).

More patients were not satisfied with the result of their visit in urban (21.1%) than rural areas (13.5%). At first glance, this suggests health facilities in rural areas offer better quality service than those in urban areas. A more plausible perspective, however, is that urban clientele are more sophisticated and have higher expectations than their rural counterparts, especially because they generally must pay a consultation fee, which is not the case at rural facilities.

Utilization of health services

Despite having limited resources and the least-trained health workers, the PHC level (rural hospitals, clinics, and health centres) handled an overwhelming proportion of new cases. Most were apparently minor ailments, as only a few were referred to the district level. Preventive health services constitute about a third of all health care, yet received only about 10% of public health resources. Over 50% of public resources continue to be expended at provincial and central hospitals in spite of clear evidence showing the benefits of investing in preventive care.

Temporal patterns in utilization of public health services show heavy workloads throughout the 1990s for new diseases or health conditions. Also, the number of inpatient deaths has been increasing, stretching hospital facilities, such as mortuaries, that do not have adequate capacity. This situation requires further strengthening of preventive and promotive health activities, especially against HIV and other preventable diseases like polio and measles, as well as of family planning and maternal health services.

Trends in the numbers of patients visiting health facilities for different consultations are shown in Figure 4. Vaccinations peaked in the late 1980s, then decreased steadily. Each type of consultation shows a different pattern that may be influenced by one or more factors. For example, health facilities use the "supermarket approach" for immunizations, using each visit by mother and child to vaccinate babies, thereby increasing immunization coverage. This includes curative or postnatal care, as well as growth monitoring visits.

FIGURE 4. NUMBER OF CONSULTATIONS PER YEAR, BY TYPE OF SERVICE, ZIMBABWE, 1987–98

Source: MAPHealth study (2001).

Utilization of modern and traditional health services

The household survey showed that 77% of household members with a health problem had used some modern medicine since the onset of the illness; 76% had used modern medicines in the past four weeks, whereas the corresponding figures for traditional remedies were only 6% and 13%, respectively. The proportions of those using modern medicines or traditional remedies for self-treatment since the onset of illness were about the same in rural and urban areas. The proportion using traditional remedies in the past four weeks was substantially higher in rural (14.6%) than in urban (7.1%) areas.

Nearly a quarter of those who had been ill in the past four weeks used modern medicines without consulting a health professional. The use of stored modern medicines was more prevalent in urban (18%) than rural areas (11%). In urban areas, the majority of those who were ill in the past four weeks had purchased medicines from a pharmacy since the onset of the illness as well as in the past four weeks, 54.1% and 55.3%, respectively. In rural areas, however, only 12.2% of those ill in the past four weeks had bought medicines from a pharmacy, either since the onset of the illness or in the past four weeks. The purchase of traditional remedies was generally very low in both areas.

Reasons for not consulting a doctor or nurse

Respondents who were ill in the past four weeks but did not consult a health professional in modern health facilities were asked to give up to three reasons for their decision. For our analysis, we focused on respondents who did not consult a doctor or nurse in a public health centre, because these offer free services for PHC and are also readily accessible. The main reason given was that the respondents (27.7% in rural areas, 38.5% urban) did not think it was necessary, which may mean they did not think the illness was serious enough. The second most common reason (21.7% rural, 23.1% urban) was that it was either too expensive or they did not have enough resources. The cost element is an interesting paradox; as services are supposed to be free at public health facilities, this response may reflect a shortage of drugs at these facilities, requiring patients to travel elsewhere to purchase them.

Utilization of institutional health facilities

The proportion of people attended by a medical doctor was higher in urban (33.3%) than rural (14.9%) areas. In the majority of public, community, and religious health facilities consulted by those who had been ill in the past four weeks, care was provided by nurses, whereas in private health facilities care was mainly provided by doctors. The proportion of rural residents consulting a health facility for the first time exceeded that of urban residents, but the differences were reversed for second, third, and fourth visits. For example, 28.5% of urban residents had consulted a health facility for a fourth time compared with only 17.1% in rural areas. The difference indicates that urban residents are more apt to complete their treatment at modern health facilities and go for check-ups. This may be explained by the greater proximity of urban health facilities, the affordability of services (i.e., urban people being in a better economic position), and the higher level of literacy in urban areas.

Utilization of ANC and birth delivery services

Mothers who had prenatal care during their last pregnancy were asked to give reasons for choosing a particular ANC provider. In both rural and urban areas, the most common reasons for choosing an ANC provider were not linked to cost. The three most common reasons were proximity of the provider to home, availability of the necessary supplies and medicines, and competency of the care provider. The majority of women who had ANC for their last pregnancy were very satisfied with the care received, the proportion being slightly higher in rural (94.7%) than in urban (88.2%) areas. None of the women in either area reported they were unsatisfied.

The majority of birth deliveries reported by women in the sample (excluding miscarriages and abortions) occurred at public health facilities. However, more than 25% of births to rural women occurred at home, compared to only 5% among urban women. Home births were more common in rural areas, which may be an indicator of geographical differences in women's access to suitable health facilities with trained personnel. Urban women have more access to health education through radio and television and are aware of the potential hazards of home delivery. In fact, one of the reasons for providing free maternity services was the observation of very high numbers of home deliveries, reportedly up to 60% in some localities.

Private health facilities were used more by urban (10.5%) than rural (1.5%) women, likely because of differences in access, as well as differences in ability to pay. A significant proportion (11.5%) of births to rural women occurred in a religious health facility, compared to 3.1% among urban women, probably because most religious facilities are based in rural areas.

Utilization of health services for child immunization

The survey data revealed that 96.8% of children under 15 years old had been vaccinated at birth against major childhood immunizable diseases, suggesting continual high coverage since the launch of the Zimbabwe Expanded Programme of Immunization (ZEPI) in 1980. The overall difference in the proportions of vaccinated children in rural and urban areas was small, 96.4% and 98.7%, respectively.

The majority of children had been vaccinated at birth, except for hepatitis B, which was introduced into the national vaccination program later (1996–1998) than other antigens that had been part of the expanded program of immunization since independence. Also, due to the comparatively high cost of the hepatitis B vaccine, its supply has not been regular.

Contraception

The proportion of women who reported using contraception was high in both rural (56.5%) and urban (56.3%) areas. These usage rates are substantially higher than those reported in the 1988 (32%) and 1994 (35%) Zimbabwe Demographic and Health Surveys. The most common method in both areas was oral contraceptives, used by about 80% of urban and 77% of rural women. Injectables were the second most popular, used by 25% of urban and 17.2% of rural women.

Overall, oral contraceptives, injectables, condoms, and female sterilization were more popular in urban than rural areas; the "other modern methods," which include vaginal methods and implants, were also more popular in urban areas. More rural women used the IUD. Traditional methods were least popular, being used by fewer than 1% of rural women and none of the urban women surveyed. None of the respondents used male sterilization. About 45% of all women using contraception thought it was more difficult for women than for men to buy or use contraceptive methods without the permission of their parents or partner.

Women not using contraception were asked to give up to three reasons for not doing so. In both rural and urban areas, the most common response was that women did not need to use any contraception, or they cited a lack of knowledge of contraceptive methods; expense and lack of funds were the least common reasons given. The results show that economic changes have not had a major impact on the decision to use contraception.

Utilization of screening services for breast and cervical cancer

Overall, fewer than 7% of rural women had undergone a mammogram or a PAP test. Comparative proportions for urban women were slightly higher (mammogram, 8.5%; PAP test, 15.8%). This may indicate differences in knowledge about the need for such tests, or in ability to pay, or in the availability of services.

CONCLUSIONS

The impacts of macroeconomic and health sector reforms on access, quality, and utilization of health services were analyzed in the context of two main periods of Zimbabwe's recent history: the first decade of independence (1980–1990), with its expansionist social programs, and the second decade (1990–2000), when macroeconomic and health sector reforms were introduced. In the first period, the country had an effective health delivery system due to heavy investments in health and other social sectors, resulting in marked improvements in health indicators such as life expectancy, nutritional status, and infant and maternal mortality rates. The macroeconomic policies guiding government during the first decade were "Growth with Equity" and "Equity in Health". In the second period, structural adjustment and health sector reform had negative effects on the health system. Foreign currency and devaluation of the local currency affected supplies of drugs and related consumables. This demoralized health personnel at a time when conditions of service and remuneration were declining, precipitating the resignations of highly experienced personnel, strikes, and stay-aways by doctors and nurses. It is against this background that there were marked deteriorations in life expectancy and in infant and maternal mortality rates.

Thus, a key conclusion from this study is that the health sector in Zimbabwe has been seriously undermined by the effects of MAPs introduced with the aim of boosting economic growth through trade liberalization and institutional reforms. Since independence, the evolution of the health system has been part of the national development process, although inevitable links with economic structural adjustments were not acknowledged. The clearest correlation between MAPs and health sector reforms was seen in the deterioration of health systems at a time of worsening macroeconomic indicators. Health sector reforms based on decentralization involving cost-recovery and value-for-money policies were implemented without assessing the ability of communities or households to pay for services. Introduction of user fees in the 1990s, a key aspect of health sector reforms, led to marked reduction in utilization of health services (Hongoro and Chandiwana 1995). Analysis of data collected before and after the introduction of MAPs indicated increases in geographical and social inequities in delivery of health care and in population health status (Chandiwana et al. 1997).

Interestingly, the study revealed contradictions between the government's objectives of economic liberalization under SAPs and its strong political commitment to expand the public health sector and improve access to health care. Macro-level data suggest that MAPs and health reforms may have had profound effects on access and quality, and thus on utilization of health-care services. This situation has been aggravated by the pervasiveness of AIDS and poverty in Zimbabwean society since the 1990s. Even without economic reforms, the AIDS epidemic was bound to increase significantly the resources needed to meet the national health workload. There were also exogenous factors such as droughts and marked declines in world prices of primary commodities, particularly tobacco and gold, as well as policy disagreements with the IMF, the World Bank, and bilateral agencies that led to the withdrawal of balance of payments support. The combined effects of these factors precipitated the current economic downturn.

It is clear that SAPs had a negative impact on social equity in national development, as seen in the economic decline through devaluation and inflation, which eroded savings and spending power, including on health services. Under these circumstances, it can be argued that Zimbabwe has averted the total disintegration of its health services through the government's internal policy of maintaining high expenditures on health care, thus cushioning the poor from the negative effects of SAPs. Even in the midst of economic crisis, internal policies have thereby preserved some of the positive elements of the hitherto successful health system.

Paradoxically, the household surveys showed continued high utilization rates and general satisfaction with the health delivery system, particularly in rural areas. The better perception of public health services by rural people was likely reinforced by the government's fee exemption policy. However, this positive view may simply reflect a time lag between the adoption of MAPs and their eventual effects. Urban households felt the early direct effects of economic reforms as local authorities began to charge for most health-care services. Those who paid for health care expected a high standard of service and value for money spent. Nevertheless, urban residents preferred the private sector because of perceived higher quality and shorter waiting periods.

Utilization of findings

Initial and interim drafts of this report were discussed at the national level and widely disseminated to as many stakeholders as possible, particularly policymakers, researchers, and program planners. Key findings were also presented at seminars and public health meetings. The aim was to make policymakers and other stakeholders conscious of links between MAPs and health sector reform policies, on the one hand, and access, quality, and utilization of health care, on the other. From the ensuing debate and discussions, stakeholders at different levels have been able to extract lessons and information upon which to base changes in policies and programs to improve the health-care system. In this context, the MAPHealth research should be an integral element of strategic planning within the Ministries of Economic Planning and of Health, to ensure such research is linked with policy and action.

Future perspectives

Future directions of the MAPHealth study should build on the research databases developed over several years by a consortium of local institutions and a multidisciplinary study team. Country-specific expertise has been developed on MAPs, health sector reforms, and their impact on access, quality, and utilization of health care. Of significance are the large amounts of retrospective macro-level data on MAPs and health sector reforms collected mostly from fugitive sources that should form essential reference material for future studies. The nationwide health facility and household surveys provide hitherto unexplored insights into the local economy, social organization, inventory of health facilities, financing, delivery, and quality of health services. Valuable data was collected on household economic indicators, individuals' ability to pay, health services utilization, health perceptions, and health needs. This database offers vital baseline information to compare with subsequent surveys to assess the performance and effectiveness of national health systems. Such evaluation should promote transparency and accountability in planning and implementing sustainable health delivery systems under varying MAP regimes.

An agenda for future research could have as a starting point further analysis of the existing database to assess the impact of changes in health care brought about by MAPs and health sector reforms. Particularly pertinent is how current information can be used in shaping appropriate policies and best practices in different regions of the country and in different socioeconomic and sociocultural contexts. A number of key questions would set the framework for the agenda for future research:

• What have we learned about the links between structural adjustment, health sector reform, access, and utilization of services? How can we analyze the database to obtain additional information?
  
  
• Using available data, can policymakers and implementers find better options to put in place appropriate MAPs that enhance equity and improve health status?
  
  
• Where are the information and knowledge gaps? In particular, there is a need to explore roles for politicians and parliamentarians, researchers, health planners and program managers, civil society groups, and NGOs in relation to:
  
• research to
  gather information, knowledge, and understanding;
  
• policy to translate research into action; and
  
• action to translate policy into programs (e.g. lobbying, advocacy, networking).

Notes

¹ The country is divided into administrative subdivisions—eight rural and two urban provinces (six or seven districts comprise a province). A provincial administrator coordinates activities in a province, while a civil servant with the title of district administrator heads each district.

² Edwin Zishiri, Ministry of Health, Provincial Medical Director, Midlands Province, Zimbabwe, personal communication, 2001.

References

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