THE NATIONAL HEALTH STRATEGY for Zimbabwe 2016-2020 ZIMBABWE EQUITY AND QUALITY IN HEALTH: LEAVING NO ONE BEHIND ZIMBABWE THE NATIONAL HEALTH STRATEGY for Zimbabwe 2016-2020 EQUITY AND QUALITY IN HEALTH: LEAVING NO ONE BEHIND Foreword This strategic plan has been developed through a participative and consultative process involving significant contributions and support from various individuals and institutions. A specific Technical Task Team (TTT) was established to drive preparatory activities towards this strategy. The TTT established Technical Working Groups (TWG) to focus on specific strategic pillars. Various stakeholder workshops were conducted with health workers, community leaders, development partners, government agencies and communities. The TTT also conducted a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis based on the inputs from these stakeholders. The SWOT analysis provided qualitative evidence on the status of the health sector. In addition, a Bottleneck Analysis (BNA) was conducted on selected tracer conditions to unpack the underlying bottlenecks and root causes to observed health system performance challenges. The results of the SWOT analysis and the BNA, together with a comprehensive review of the performance of the previous strategy exploring what worked and what did not was used to identify sector priorities and hence remedial strategies. The Plan provides the framework that will guide the efforts of the Ministry of Health and Child Care and all stakeholders over the next 5 years in contributing to the attainment of the Zimbabwe Agenda for Socio-Economic Transformation and the Sustainable Development Goals. The successful implementation of this plan will depend on the continued dedication of staff in the Ministry of Health and Child Care and those of its partner institutions. As a strategic policy document that we have put together, it is my sincere hope that it will become the single most important point of reference for design of service delivery programmes, resource mobilization and health financing framework, as it outlines how as Zimbabweans we will reach our dream of delivering high quality health services to the citizens. I therefore wish to extend my sincere appreciation to all those that contributed to the process of developing this plan. I wish to pay special tribute to the members of the technical team and members of the technical working groups for their significant inputs and commitment to this process. On behalf of the Ministry of Health and Child Care, I also wish to acknowledge the financial and technical support rendered to us by our Development Partners. Without the direction and valuable support of our Cooperating Partners, we could not have managed to successfully complete this plan. Finally, I wish to thank all the members of staff of the Ministry of Health, and Child Care, line ministries, Community representatives and NGOs, for their participation, contributions and support to the process of formulating this strategic plan. Dr P D Parirenyatwa (Senator) Minister of Health and Child Care National Health Strategy For Zimbabwe 2016-2020 i Acknowledgements The National Health Strategy (2016-2020) is the product of a long and complex process of intensive consultations, teamwork on specific assignments, detailed studies and information gathering. Service providers, civil society groups, community members, the private sector, co-operating partners and other stakeholders were all involved in the process. The Ministry of Health and Child Care is very grateful to those who contributed to the successful development of this strategic plan. The concerted effort of all directorates, programs and other stakeholders is acknowledged. Special thanks go to the Division of Policy, Planning, Monitoring and Evaluation that provided leadership to members of the core team tasked to facilitate the development of this document. The efforts of putting together important information, comments and suggestions have not gone unnoticed. The Government of Zimbabwe would like to appreciate the financial and technical support given by development partners for the development of this document. Last, but not least, the Ministry of Health and Child Care expresses its sincere gratitude to all stakeholders and institutions who continue to contributed one way or the other towards giving quality health services to the citizens of Zimbabwe. Brig. Gen. (Dr) Gerald Gwinji Permanent Secretary, Ministry of Health and Child Care National Health Strategy For Zimbabwe 2016-2020 iii Table of Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix 1. Overall Context for The National Health Strategy 2016-2020 . . . . . . . . . . . . . . . . .1 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.2 The constitution and its provision for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.3 National Health Strategy alignment with Government Programme of Action (GPA) . .2 1.4 The health sector and global commitments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 1.5 Socio-economic and demographic context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 2. Situation Analysis of Zimbabwe’s Health Sector . . . . . . . . . . . . . . . . . . . . . . . . . .5 2.1 Health Systems Organisation and Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 2.2 General performance of the health sector 2009 to 2015 . . . . . . . . . . . . . . . . . . . . . . . . .9 2.3 Expenditure on health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 2.4 Overall burden of diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 2.5 Priority Disease Control Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 2.5.1 Communicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 HIV and AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Sexually Transmitted Infections (STI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Tuberculosis (TB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Other diarrheal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Rabies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Anthrax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 2.5.2 Non-communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Hypertension and Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 iv National Health Strategy For Zimbabwe 2016-2020 Table of Contents 2.5.3 Reproductive, Maternal, Newborn, Child Health and Adolescents . . . . . . . . . .26 Maternal and Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Adolescent and Maternal Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Infant and Young Child Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Infant and Young Child Feeding Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Nutritional Status of Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 2.5.4 Public health surveillance and disaster preparedness and response . . . . . . . . . .29 Environmental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 2.6 Synthesis of Emerging Issues From the Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 2.6.1 SWOT analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 2.6.2 Bottleneck analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 3. Strategic Direction for Health 2016-2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 3.1 Overall Structure of the Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 3.2 Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 3.3 Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 3.4 Principles and values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 3.5 Key Result Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 3.6 Strategic Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Priority 1: Communicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Priority 2: Non-communicable diseases (NCDs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Priority 3: Reproductive, Maternal, Newborn, Child Health and Adolescents . . . . . . .42 Priority 4: Public Health surveillance & disaster preparedness and response programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Service Delivery Platforms/Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Primary Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Enabling Environment for Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Policy and Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Multi-Sectoral Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Research and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 4. Implementation of National Health Strategy 2016-2020 . . . . . . . . . . . . . . . . . . . .61 4.1 Implementation Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 4.2 Costing scenarios and key assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 National Health Strategy For Zimbabwe 2016-2020 v Abbreviations AIDS Acquired Immunodeficiency Syndrome ARI Acute Respiratory Infection ARC AIDS Related Conditions ART Antiretroviral Therapy ASRH Adolescent Sexual and Reproductive Health BCC Behaviour Change Communication BCG Bacille de Calmente et Guérin BEmONC Basic Emergency Obstetric and Newborn Care BMI Body Mass Index BNA Bottleneck Analysis BP Blood Pressure BVIP Blair Ventilated Improved Latrine CEmONC Comprehensive Emergency Obstetric and Newborn Care CHC Community Health Centre CHW Community Health Worker CORDAID Catholic Organization for Relief and Development AID CPR Contraceptive Prevalence Rate CT Computed Tomography DHE District Health Executive DPT Diptheria, Pertussis and Tetanus Vaccine DOTS Directly Observed Treatment DR-TB Drug Resistant Tuberculosis ECCH Environmental Control Community Health clubs EH Environmental Health EHB Essential Health Benefits EHI Environmental Health Initiative EHT Environmental Health Technician EHO Environmental Health Officer EHT Environmental Health Technician EPI Expanded Programme on Immunisation ETAT Emergency Triage Assessment and Treatment FP Family Planning GBD Global Burden of Disease GDP Gross Domestic Product GPA Government Programme of Action GOZ Government of Zimbabwe HAB Hospital Advisory Board HACCP Hazard Analysis Critical Control Points HAT Human African Trypanosomiasis HAB Hospital Advisory Board HBB Helping Babies Breathe HCC Health Centre Committee vi National Health Strategy For Zimbabwe 2016-2020 Abbreviations HDU High Dependency Unit HIMS Health Information Management System HIV Human Immunodeficiency Virus HQ Headquarters HRH Human Resources for Health HTF Health Transition Fund HTS HIV Testing Services ICD International Classification of Diseases ICU Intensive Care Unit IDSR Integrated Disease Surveillance and Response IHR International Health Regulations IMNCI Integrated Management of Childhood & Neonatal Illnesses IPT Intermittent Preventative Treatment IRS Indoor Residual Spraying KRA Key Results Areas LARC Long-acting Reversible Contraceptive LF Lymphatic Filariasis LLIN Long Lasting Insecticide Treated Nets MOHCC Ministry of Health and Child Care MDG Millennium Development Goals MDR Multi-Drug Resistance M&E Monitoring and Evaluation MICS Multiple Indicators Cluster Survey MIMS Multiple Indicator Monitoring Survey MMR Maternal Mortality Ratio MNCH Maternal Newborn and Child Health MRCZ Medical Research Council of Zimbabwe MRI Magnetic Resonance Imaging NAC National AIDS Council NCD Non-communicable Diseases NHMIS National Health Management Information System NHS National Health Strategy NIHR National Institute of Health Research MTCT Mother to Child Transmission of HIV NCD Non-Communicable Diseases NGO Non Governmental Organisations NMS National Micronutrient Survey NTD Neglected Tropical Diseases ODA Overseas Development Assistance OI Opportunistic Infections OJT On-the-Job Training OOP Out of Pocket Expenditure OPD Outpatient Department ORS Oral Rehydration Salts National Health Strategy For Zimbabwe 2016-2020 vii Abbreviations PBB Programme Based Budgeting PBF Programme Based Funding PCN Primary Care Nurse PER Public Expenditure Review PFM Public Finance Management PHE Provincial Health Executive PMTCT Prevention of Mother to Child Transmission of HIV PNC Post Natal Care PPIUCD Post-partum Intrauterine Contraceptive Device PSM Procurement Supply and Management RBF Results Based Financing RCZ Research Council of Zimbabwe RDT Rapid Diagnostic Test RRT Rapid Response Team TB Tuberculosis SCH Schistosomiasis SDG Sustainable Development Goals SSA Sub-Saharan Africa STH Soil Transmitted Helminthiases STI Sexually Transmitted Diseases SWOT Strengths, Weaknesses, Opportunities and Threats TTT Technical Task Team TWG Technical Working Group UNAIDS The Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children’s Fund VHW Village Health Worker VCT Voluntary Counseling and Testing VIDCO Village Development Committee VEN Vital, Essential and Necessary Drugs VHW Village Health Worker VMMC Voluntary Medical Male Circumcision WARDCO Ward Development Committee WCBA Women of Child Bearing Age WDI World Development Indicators WHO World Health Organisation ZDHS Zimbabwe Demographic Health Survey ZEPI Zimbabwe Expanded Programme on Immunisation Zim-ASSET Zimbabwe Agenda for Sustainable Economic Transformation ZIPHA Zimbabwe Public Health Association ZMPMS Zimbabwe Maternal and Perinatal Mortality Study ZNCR Zimbabwe national Cancer Registry ZNFPC Zimbabwe National Family Planning Council ZSARA Zimbabwe Service Availability and Readiness Assessment ZIMSTAT Zimbabwe National Statistics Agency viii National Health Strategy For Zimbabwe 2016-2020 Executive Summary The vision of the Zimbabwe Ministry of Health and Child Care is to have the highest possible level of health quality of life for all its citizens. This National Health Strategy 2016-2020 – Equity and Quality of Health: Leaving No One Behind sets out the strategic direction for the health sector over the next five years in order to attain this vision. The 2016-2020 National Health Strategy builds on the 2009-2013 strategy and its extension in 2014- 15 by addressing existing gaps and, more importantly, seeks to sustain the gains achieved thus far through a comprehensive response to the burden of disease and strengthening of the health system to deliver quality health services to all Zimbabweans. The strategy lays out the health agenda for 2016- 2020 taking into account the broader policy context that is largely defined by the Zimbabwe Agenda for Sustainable Socio-Economic Transformation (Zim-Asset) and the Sustainable Development Goals. The current challenges of economic growth worsened by a turbulent global market means that this strategy cannot be business as usual as the country needs to find innovative ways of supporting the health sector. Equally important is the need to ensure that other sectors directly and indirectly linked to health align their programmes and activities to contribute towards a healthy population - hence the ZimAsset’s clusters approach. The 2009-2012 period saw the economy rebounding and beginning to reverse the consequences of near collapse of the health system in 2008. However, the period 2013-2015 saw a dramatic drop in economic growth and the prospects for the next five years are predicted to remain sluggish. Consequently, government fiscal space is likely to shrink thereby increasing the need for external funding to support the health infrastructure, retain health workers, medicines and commodities supply and distribution, amongst others. Improving the quality of health services and ensuring that these services are accessed equitably is the main challenge that this strategy seeks to address under these circumstances. A systematic review of existing reports, data and evidence regarding the performance of the health sector shows that Zimbabweans still faces a double burden of communicable and non-communicable diseases. Zimbabwe is prone to epidemic diseases including diarrhoeal disease and outbreaks of anthrax and rabies are common, highlighting the critical importance of public health surveillance and a disaster preparedness and response programme. HIV prevalence remain relatively high at 15% amongst adults and gains achieved to date are threatened by the deteriorating indicators and risky behaviors amongst the youth and increasing number of teenage pregnancies. Deaths due to TB remain high due to its twin relationship with HIV and AIDS. Malaria remains a major cause of morbidity and mortality in the country and more so in some geographic areas. Non-communicable diseases are emerging as major cause of morbidity and mortality amongst both the rich and the poor in the country. The nutrition status of children remains poor. These challenges are compounded by health systems constraints related to shortages of critical health workforce, aging infrastructure and equipment, supply of medicines and other commodities, limited health funding, and considerable challenges with the service delivery platforms or entities and the enabling environment. Addressing the challenges requires strengthened service delivery platforms or entities including primary care and hospital services, and creation of an enabling environment with attention to issues of policy and administration, multi-sectoral partnerships and research and development. National Health Strategy For Zimbabwe 2016-2020 ix Executive Summary Building on this situation analysis, the strategy is structured as shown below: National Health Strategy, 2016-2020 Equity and Quality in Health: Leaving No One Behind Vision of the Ministry of Health and Child Care To have the highest possible level of health and quality of life for all its citizens Mission of the Ministry of Health and Child Care To provide, administer, coordinate, promote and advocate for the provision of equitable, appropriate, accessible, affordable and acceptable quality health services and care to Zimbabweans while maximising the use of available resources in line with the Primary Health Care Approach Priority 4: Priority 3: Priority 2: Public health Priority 1: Reproductive, Maternal, Non-communicable surveillance and disaster Communicable Diseases Newborn, Child and Diseases preparedness and Adolescents response Service Delivery Platforms or Entities Enabling Environment This structure is elaborated to include three main goals and twenty one objectives, all with defined Key Results Areas with their baselines and targets, as shown below: Key Result Area Objective Key Indicator Baseline 2014 Target 2020 Goal 1: To strengthen priority health programmes Priority 1: 1. To reduce malaria incidence from Malaria incidence 39 5 Communicable 39/1000 in 2014 to 5/1000 in 2020 and diseases malaria deaths to near zero by 2020 Malaria deaths 654 0 % of outbreaks detected 2. To ensure timely detection and within 48 hours and 30% 100% control of epidemic prone diseases controlled within 2 weeks 3. To reduce morbidity due to Schistosomiasis and soil transmitted 22.7% Prevalence of STH and SCH 10% helminthes and other NTDs by 50% by (for SCH/STH) year 2020. 4. To prevent new HIV infections and to % people who are tested 40.3% (men) 85% reduce deaths due to HIV by 50% and know their status 56% (women) % of people on ART TBD 90% % of ART patients virally TBD 90% suppressed 5. To reduce mortality, morbidity and Mortality rate 10% < 5% transmission of tuberculosis by 90% x National Health Strategy For Zimbabwe 2016-2020 Executive Summary Key Result Area Objective Key Indicator Baseline 2014 Target 2020 Priority 2: 6. To reduce the incidence of selected % reduction in NCDs Non-communicable Non-Communicable Disease (NCDs) 0% 5% burden Diseases by 50 % % increase in number of 7. To improve the mental health status diagnosed mentally ill to TBD 90% of the population the expected mentally ill patients 8. To reduce disability and dependence % patients under CBR to TBD TBD by 50% total rehabilitation patients 9. To improve the quality of life of elderly persons and improve life % of older persons that TBD 100% expectancy from 61.5 to 65 years receive geriatric care by 2020 Priority 3: 10. To reduce maternal mortality ratio MMR 614 300 Reproductive, from 614 to 300 by 2020 Maternal, 11. To reduce Neonatal Mortality Rate Newborn, Child from 29 to 20 deaths per 1,000 live NMR 29 20 and Adolescents births 12. To reduce the under-five mortality rate from 75 to 50 deaths per 1,000 live <5 mortality 75 50 births 13. To reduce mortality and morbidity Proportion of children 28% 19% due to malnutrition by 50% under 5 years stunted Priority 4: 14. To strengthen environmental health % of outbreaks detected Public Health services, early detection of disease within 48 hours and 30% 50% surveillance and outbreaks and man-made disasters controlled within 2 weeks disaster from 30% to 50% by 2020 preparedness % of districts with and response functional coordination 50% 100% mechanism Percentage of household members using improved 35% 50% sanitation facilities which are not shared Percentage of household members using improved 76.1% TBD sources of drinking water Goal 2: To improve service delivery platforms or entities Proportion of villages with Primary Care 15. To reduce morbidity by at least 50% community based health <60% >90% through the provision of accessible, workers affordable, acceptable and effective quality health services at community % districts implementing and health centre level Essential Primary Health 0% 100% Benefits 16. To ensure universal access and % of hospitals with Quality Hospital Services TBD provision of complementary package of Management Systems hospital services including emergency % of hospitals with and ambulatory curative services TBD functional theatre services National Health Strategy For Zimbabwe 2016-2020 xi Executive Summary Key Result Area Objective Key Indicator Baseline 2014 Target 2020 Hospital Services 17. To ensure universal access and % of tertiary hospitals provision of quality tertiary specialist TBD 100% with specialists curative services % of patients and families 40% 18. To promote and support provision 200,000 needing palliative care (80,000 of quality palliative care services in need who are receiving it people) Goal 3: To improve the enabling environment for service delivery Policy Planning 19. To improve health outcomes and Coordination through facilitation and co-ordination % of policies and strategies 0 100% of an effective and efficient health aligned to the NHS delivery system Human Resources Overall vacancy rate 17% 10% Finance and Number of institutions 82 TBD Administration audited against the plan cost centres Number of districts with 0 62 functional PFMS Monitoring and Harmonised M&E policy 01 1 Evaluation framework Provincial % of actual to planned PHT TBD 100% Administration reviews convened per year Procurement and % availability of essential supply chain 42% 80% medicines management Multi-sectoral 20. To strengthen multi-sectoral A policy on public/private Partnership collaboration with local and and public/public 0 1 international partners partnerships % of functional national and subnational TBD 90% intergovernmental platforms Research and 21. To improve uptake of scientific % health research Development research evidence for decision making informed by the national TBD 70% and policy development by 70% health research priorities Number of clinical trials on Traditional Medicine TBD 2 conducted The implementation framework and costing and funding options for the strategy will aid in operationalising the strategy and meeting its targets, towards the vision of having the highest possible level of health and quality of life for all Zimbabweans. Key issues that will be addressed in implementation include provision of an essential health benefits package, investments in health systems strengthening, leveraging multi-sectoral actions, gender mainstreaming specifically targeting women and young girls to improve gender equity, and community participation at all levels. It is important that achievements to date are maintained and indeed improved, otherwise the vision, mission and strategy goals will not be realised by 2020. xii National Health Strategy For Zimbabwe 2016-2020 Overall Context for the National Health Strategy 2016-2020 1 1.1 Introduction The Zimbabwe Agenda for Sustainable Economic Transformation (ZimAsset) represents a blueprint for the country’s development path from October 2013 to December 2018. It provides the basis and context for all sector strategies and programmes towards the achievement of its vision, namely “Towards an empowered society and growing economy”. The National Health Strategy 2016-20 derives from this national vision and provides a framework for attaining health and health related goals and objectives. It assumes the spirit of the Zim-Asset that seeks to attain “quick wins” and is structured around the Results Based Management system that focuses on a clear vision, mission, values, key results areas, goals and objectives. Unlike past strategies, the NHS 2016-20 is complemented by a detailed monitoring and evaluation framework that will be used to assess progress through mid-term and end- term evaluations (Annex I). 1.2 The constitution and its provision for health The Constitution of Zimbabwe explicitly provides for the right to health care in Section 76, sub-section 1 to 4 that: “(1) Every citizen and permanent resident of Zimbabwe has the right to have access to basic health-care services, including reproductive health (2) Every person living with a chronic illness has the right to have access to basic healthcare services for the illness (3) No person may be refused emergency medical treatment in any health-care institution, and (4) The State must take reasonable legislative and other measures, within the limits of the resources available to it, to achieve the progressive realization of the rights set out in this section” The Constitution further provides, in Section 77 that every person has a right to safe, clean and potable water, and sufficient food (Food Security, Quality and Safety). These rights are directly related to peoples’ health as it not possible to divorce the living conditions of people from their health risks and status. This national health strategy is indeed subordinate to these constitutional provisions and the State has the responsibility to create a conducive environment in which it is possible for all people in Zimbabwe to access basic health services whenever they need them. National Health Strategy For Zimbabwe 2016-2020 1 Overall Context for The National Health Strategy 2016-2020 1.3 National Health Strategy alignment with Government Programme of Action (GPA) The Zim-Asset, a Results Based Management agenda, recognizes that socio-economic development requires substantial transformation in all sectors and that change requires multi-sectoral actions and working transversally. The Zim-Asset has four clusters and the Ministry of Health and Child Care (MOHCC) is part of the clusters on Food Security and Nutrition, and Social Service and Poverty Reduction. The outcomes and strategies set for achieving Zim-Asset goals provide a strong basis for this strategy because the MOHCC is mandated to lead and provide these services on behalf of the entire country and contribute to broader socio-economic development. For instance, key outcomes on nutrition include reduction in stunting among children, and improved availability of quality food and nutrition data; and improved enabling legal, food and nutrition policy regulatory environment. With regards to social services delivery, the MOHCC is responsible for several outcomes related to priority health interventions including in the areas of reproductive, maternal, newborn, child and adolescent health; communicable diseases (Human Immuonodeficiency Virus - HIV, Tuberculosis - TB, malaria and diarrhoea); non-communicable diseases; and creation of an enabling environment for the delivery of quality services through appropriate policy and regulatory frameworks, reduction of financial barriers, improved procurement and supply of health products and equipment, and improved infrastructures, amongst other things. The strategies in the GPA are guided by the notion of “quick wins” and this philosophy permeates the NHS 2016-2020. Although the ZIM-Asset planning horizon extends up to 2018, this strategy conforms to that planning trajectory, and also recognizes the importance of mid-term reviews in influencing the assumed trajectory. The strategy comes into effect at a time when Government is implementing Programme Based Budgeting (PBB), a reform process that will not only see alignment of resource budgeting and outcomes, but also necessary reforms to improve the performance of the health system. 1.4 The health sector and global commitments Zimbabwe still confronts the unfinished Millennium Development agenda as not all of the goals and targets were met. According to the 2014 Multiple Indicator Cluster Survey (MICS), the maternal mortality ratio remains high at 614 deaths per 100,000 live births (versus a target of 174 deaths per 100,000 live births); the under five child mortality rate is at 75 deaths per 1,000 live births (versus a target of 43 per 1000 live births); the nutritional status of children remains problematic, and HIV and AIDS, TB and malaria remain major causes of morbidity and mortality. The strategy is aligned to the Sustainable Development Goals (SDG) agenda, which also takes into consideration the unfinished MDGs agenda. Of the 17 goals, Goal 3 “Ensure healthy lives and promote well-being for all at all ages” directly focuses on health, and accordingly, the vision, mission and goals of this strategy relate to it. It is also important to highlight Goal 5 “Achieve gender equality and empower all women and girls” which brings to the fore the need to address specific challenges that affect women and girls who tend to be disproportionately affected by poverty, diseases, violence and other social ills. This strategy, as described in the SDG framework seeks to realize the human rights of all and to achieve gender equality and the empowerment of all women and girls. 2 National Health Strategy For Zimbabwe 2016-2020 Overall Context for The National Health Strategy 2016-2020 Importantly, these goals are integrated and indivisible, and balance the three dimensions of sustainable development: the economic, social and environmental. This 2016-2020 Zimbabwe National Health Strategy responds to this call for action in a variety of ways as it seeks to contribute to improving the quality of lives of Zimbabweans. 1.5 Socio-economic and demographic context Understanding the socio-economic and demographic context allows for an analysis of what is feasible in the medium to long term, and also identification of population groups that need to be targeted for health services and those that that are at risk of various diseases and conditions. Economic growth slowed down compared to what was projected in the Zim-Asset of 6.2% by 2014, and the prospects over the strategy period are that economy will remain sluggish in the short to medium term, and total tax revenues will generally remain at about 27% of GDP (Public Expenditure Revie – PER - 2015). The fiscal trends and projections are important indicators of the government’s capacity to allocate financial resources to the health sector. The World Bank revised the economic growth rate for 2015 from the projected 4.2% to 3% due to low investment levels, poor performance of the mining sector and the poor global economic environment. The country has a large debt of nearly $10 billion that needs to be serviced. Unemployment levels remain high with the majority of the people now in informal employment. This macro-economic environment requires innovation and effective partnerships between government and various partners including communities, in both funding and providing health services to the population. Population size and structure Zimbabwe covers 390,757 square kilometres and has 10 provinces and 63 districts. The total population is 13,061,239 translating to the population density of 33. The country has 6,280,539 males and 6,780,700 females. The urban population is 4,284,145 (33%) and the rural population is 8,777,094 (67%) . The total fertility rate is estimated at 4.3 children per woman, and the age-specific fertility rate for women aged 15-19 years is 120 births per 1000 women (MICS 2014). The population growth rate is estimated at 2.7% per year. Over 50% of the population is youth (see Figure 1). Figure 1: Zimbabwe’s Population Pyramid 2014 Source: Zim Census 2012 National Health Strategy For Zimbabwe 2016-2020 3 Overall Context for The National Health Strategy 2016-2020 The youth, particularly adolescents, are the future and therefore present both challenges and opportunities for addressing current and future health issues. This particular population group has shown deteriorating health indicators over the last five to ten years in terms of behavior change towards HIV and other sexually transmitted diseases, early sexual debut, unplanned pregnancies, high fertility, increased smoking habits, drugs and substance abuse, worsening perceptions about gender violence and unhealthy eating habits and lifestyles in general. The advent of new communication technologies and sedentary entertainment presents challenges and opportunities. There are now multiple-channels for communicating with the youth, which need to be used as part of the communication strategy. However, the youth are also becoming less active and this is compounded by unhealthy eating habits. With the majority of the people in rural areas, urban migration remains an ongoing phenomenon resulting in the number of the urban poor increasing. Within the rural areas, resettled farmers are a key target population given the need to improve access to water, sanitation and health services to these populations. The risk of epidemics including cholera remains high because of limited access to clean water and optimal waste management. Effective public health interventions are a priority for these key groups if health services coverage and most importantly outcomes are to improve. 4 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector 2 2.1 Health Systems Organisation and Status Zimbabwe assumed the Primary Health Care approach in 1980 and its health system is structured accordingly. The health services delivery platforms include primary, secondary, tertiary (provincial) and quaternary (central) facilities and these are shown in Table 1. The majority of these health facilities are at primary care level which refer complicated cases to the next levels of care. Mission and private sector facilities provide considerable services mostly in rural and urban areas respectively. Table 1: Health facilities profile for Zimbabwe Facility level/ Managing Authority All facilities Hospitals Primary Health Facilities Central Hospitals 6 6 Provincial hospitals 8 8 District Hospitals 44 44 0 Mission Hospitals 62 62 0 Rural Hospitals 62 62 0 Private Hospitals 32 32 0 Clinics 1,122 0 1,122 Polyclinics 15 0 15 Private clinics 69 0 69 Mission clinics 25 0 25 Council/Municipal Clinics/FHS 96 0 96 Rural Health Centre 307 0 307 Totals 1,848 214 1,634 Source: ZSARA, 2015 The status of the current health system organization and readiness is aptly described in the recent Zimbabwe Service Availability and Readiness Assessment survey (ZSARA 2015). In the ZSARA survey, general services availability was measured using facility densities such as health facility, inpatient beds, maternity beds, health workers, outpatient visits and inpatients. Three of these metrics – health facility density, core health worker density and inpatient bed density are shown in Figures 2, 3 and 4 respectively. Overall, none of the provinces met the target for health facility density. Bulawayo is the only province that exceeded the core worker and inpatient bed density target. National Health Strategy For Zimbabwe 2016-2020 5 6 Number of Core Health Workforce Number of Inpatent Beds Number of Facilities per 10000 Population per 10000 Population per 10000 Population Source: ZSARA, 2015 Source: ZSARA, 2015 0 5 10 15 20 25 30 35 40 45 0 5 10 15 20 25 30 0.0 0.5 1.0 1.5 2.0 2.5 National National National Source: ZSARA, 2015 Harare Harare Harare Bulawayo Bulawayo Bulawayo 23 Manicaland Manicaland Situation Analysis of Zimbabwe’s Health Sector Manicaland 25 Mashonaland Central Mashonaland Central Mashonaland Central National Health Strategy For Zimbabwe 2016-2020 2 Mashonaland West Mashonaland West Mashonaland West Province Province Province Masvingo Masvingo Inpatient Bed Density Masvingo Health Facility Density Core Health Workforce Density Figure 3: Inpatient bed density per 10, 000 population Matabeleland South Matabeleland South Figure 2: Health Facility Density per 10,000 population Matabeleland South Matabeleland North Matabeleland North Matabeleland North Figure 4: Core-health workforce density per 10,000 population Midlands Midlands Midlands Mashonaland East Mashonaland East Mashonaland East Target Target Target Situation Analysis of Zimbabwe’s Health Sector The study also generated evidence on general service readiness on selected basic domains (Box 1), and specific tracer services such as HIV and AIDS, MNCH, TB, malaria, diabetes and others. BOX 1: General Service Readiness indicators l Basic amenities: Sanitation facilities were available in all facilities. 96% had access to emergency transportation and an improved water source. l The item with the lowest availability was the computer with internet/email access, at only 21%. l Urban locations had a higher availability of basic amenities items compared to rural locations. Hospitals were more likely to have all basic amenities compared to primary care facilities. l Basic equipment: Thermometers were available across all facilities. Items such as stethoscope, blood pressure apparatus, and adult scale were available in nine of ten facilities nationally. Light source had the lowest availability at 58%. Four in ten facilities had all six basic equipment items. l Standard precautions: Auto disposable syringes were available in all facilities. Disinfectants, latex gloves and appropriate storage of sharps waste were available in nine out of ten facilities across provinces. l Six in ten facilities had an appropriate storage for infectious waste. Only one in three facilities had all items for standard precautions. l Capacity to conduct diagnostic tests on site was relatively high i.e. >70%. Nine in ten facilities conducted malaria rapid tests or HIV rapid tests on site. l Eight in ten facilities conducted syphilis rapid test and urine dipstick for protein/glucose. l Less than half (50%) of facilities had tests available blood glucose, urine test for pregnancy and haemoglobin. l Only 1 in 10 facilities reported having all tests available. There were no major variations between hospitals and primary care facilities in diagnostic capacity. l Essential medicines: Antibiotics such as oral Amoxicillin were available at almost all facilities (98%). Injectable antibiotics such as gentamycin, ceftriaxone, and ampicillin were the least available (31%) l Magnesium sulphate and oxytocin were available in 9 out of 10 facilities. Source: ZSARA, 2015 The study found a general service readiness index of 78% with urban locations having higher overall readiness scores compared to rural locations (Figure 5). Basic equipment scores were generally similar between rural and urban locations (69% rural versus 66%) urban. Worth noting was that diagnostics were the lowest at 69%. National Health Strategy For Zimbabwe 2016-2020 7 Situation Analysis of Zimbabwe’s Health Sector Figure 5: General Service readiness index and domain scores by nationally, Zimbabwe 2014 100 90 87 83 80 78 78 75 70 69 60 50 40 30 20 10 0 General Several Basic AmeniƟes Standard Basic Equipment DiagnosƟcs EssenƟal Readiness Index mean score PrecauƟons mean score mean score Medicines mean mean score score Source: ZSARA, 2015 This assessment shows that despite the threat of a near collapse of the health system in 2008, the health system has largely remained resilient enough to provide basic services to the majority of the people. However, challenges remain in terms of service gaps and more importantly quality of services to ensure effective coverage. The other key challenge affecting access is the question of direct payment for health services (Out Of Pocket (OOP) – formal or informal) which presents household hardships especially for those who are poor and vulnerable. Furthermore, improving quality of services and equitable access means that health workers must be available when needed with the right attitudes and work ethics to meet user needs. Client satisfaction surveys conducted as part of the Results Based Financing (RBF) on Out Patient Department (OPD) visits, family planning, antenatal care, labour, and delivery services showed that the average waiting time was 48 minutes, ranging from six minutes to eight hours (CORDAID 2015). Eighty percent of clients waited for an hour or less, and of these 89% thought the waiting time was reasonable. An equally high percentage (80%) acknowledged that the staff who received them at the facility were friendly. The majority of clients (84%) acknowledged that that all the prescribed medicines were available at the facility while 15% said that the prescribed medicines were partially available and 1% stated that medicines prescribed were not available in the facility. 16% of the clients paid for services, and the overall satisfaction level was high at 98%. The caveat to these findings is that this study was done in RBF intervention districts in which health workers had an explicit incentive regime to provide satisfactory services. This strategy seeks to build on the current levels of client satisfaction in these areas and enhance overall health systems responsiveness. If the Primary Healthcare Approach is to be implemented effectively, strong community systems are essential. Although community structures exist to assist in both health promotion and provision of health services, they need to be strengthened beyond supporting the Village Health Worker (VHW). The role of traditional and local leadership, community structures and community participation needs to be elevated if health interventions are to be effective and sustained over time. Communities play a major role not just in receiving the services they need, but also in co-production of these services and their funding and governance. 8 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector 2.2 General performance of the health sector 2009 to 2015 Life expectancy for Zimbabweans increased from 34 years in 2006 to 58.5 years in 2015, with women at 61.3 years compared to men at 56.2 years (WHO 2013). This positive trend is also reflected in the major health indicators such as the maternal mortality ratio which has declined from 960 per 100,000 to 614 per 100,000. However, these figures remain unacceptably high and well below the expired MDG targets (Figure 6). Figure 6: Trends in Maternal Mortality in Zimbabwe 1200 ZDHS MICS 2014 1000 960 800 695 600 614 MMR 555 400 283 200 0 1994 1999 2000 2011 2014 Source: MOHCC Child mortality trends do not show any noticeable changes since the early 1980s and it is clear that neonatal and infant mortality remain unacceptably high (Figure 7). The key strategic question is: what is driving this mortality profile? Figure 7: Trends I Child Mortality 120 ZDHS MICS 2014 100 80 Neonatal Mortality 60 Infant Mortality 40 Childhood Mortality 27 29 31 29 20 24 24 Under 5 Mortality 0 1988 1994 1999 2006 2011 2014 Source: MOHCC, 2014 National Health Strategy For Zimbabwe 2016-2020 9 Situation Analysis of Zimbabwe’s Health Sector These high mortality figures are occurring in a context in which coverage for maternal and child health services has generally improved (Table 2). The implication is that there are issues to do with the quality of services provided that this strategy seeks to address. Table 2 shows specific indicators related to maternal and child mortality since 2009. Table 2: Selected Maternal Health Indicators, 2009-2014 GOAL: To reduce the Maternal Mortality Ratio from 725 to 300 deaths per 100,000 live births by 2015 Indicator 2009 2013 2014 Target 2015 % pregnant women who have 19.4% 31.2% 44.4% 1st ANC visit in 1st trimester (ZDHS 2010/11) (MICS 2014) % of pregnant women with at 64.8% (ZDHS 70.1% 90% least 4 ANC visits 2010/11) (MICS 2014) % of deliveries which are 65.1% (ZDHS 80% 80% institutional delivery (2010/11) (MICS (2014) % deliveries attended by skilled 66.2% (ZDHS 80% 80% health personnel 2010/11) (MICS 2014) % of hospitals equipped to provide 45% 85% basic EmONC (MOHCC reports) % of hospitals equipped to provide 37.6% 80% comprehensive EmONC (MOHCC reports) 96.9% % Facilities providing PNC 98% (NIHFA 2012) 43% 83.5% % PNC attendance 80% (ZDHS 2010/11) (MICS 2014) % of public health facilities 97% 98% providing oral contraceptives (DTTU) Source: MOHCC, 2014 2.3 Expenditure on health Government funding for health has generally improved since 2009 reaching a peak in 2012 of 8% of total government expenditure (Figure 8). However, this remains below the Abudja declaration commitment of 15% of total government spend. During the same period external funding significantly increased from $167 million in 2009 to $428 million by 2012. Such funding has greatly contributed to the performance of priority health programmes and more recently to the gains made in health systems strengthening, particularly retention of health workers and procurement and distribution of essential health commodities, amongst other things. Out-of-Pocket Expenditure (OOP) contributions remain unacceptably high at 49% (NHA, 2010) given their negative effects on households. In 2009, per capita expenditure was $9 and this is estimated to have increased to $24 in 2015. Nonetheless, Cartarm house recommends per capita spend of $86, meaning that Zimbabwe is still well below this benchmark. The cost per capita for an Essential Health Benefits (EHB) package at primary care level alone is estimated at $56, which points to the need to double current per capita spend. 10 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Figure 8: MOHCC Expenditure in total and as share of General Government, 2009-2013 Source: Authors using MOFED data The current public health expenditure pattern shows that 80% goes to salaries, and curative services consume a disproportionate amount of what remains meaning that preventative services and research receive relatively less. Whilst external funding is needed, it tends to target specific programmes at the expense of others creating resource challenges in other areas. Equitable mechanisms for allocating resources across health programmes, service levels and geographies are thus necessary. Equally important is the need to ensure that allocated resources are used appropriately and efficiently to achieve intended results. Performance based funding models (e.g. Results Based Financing - RBF) present opportunities for addressing these issues. Overall, the health sector is underfunded and largely dependent on external funding for service delivery (over 40% Overseas Development Assistance – ODA - in 2012) given that most of government expenditure on health goes to salaries. This is unsustainable and necessitates looking at other innovative and sustainable ways of funding such as prepayment mechanisms and gradually reducing the share of external funding and OOP. 2.4 Overall burden of diseases Although significant progress has been made over the last few years, the country still faces a double burden of communicable and non-communicable diseases. HIV prevalence remains relatively high at 15% amongst adults, and gains achieved to date are threatened by risky behaviors amongst youth and increasing number of teenage pregnancies. Deaths due to TB remain high due to its twin relationship with HIV and AIDS. Malaria remains a major cause of morbidity and mortality in the country and more so in some geographic areas. Therefore the focus on major communicable diseases must be sustained. At the same time, non-communicable diseases are indeed emerging as major causes of morbidity and mortality amongst both rich and poor in the country. The nutrition status of children remains poor. Outbreaks of anthrax and rabies are not unusual. The challenges are compounded by health systems constraints related to shortages of critical health workforce, aging infrastructure National Health Strategy For Zimbabwe 2016-2020 11 Situation Analysis of Zimbabwe’s Health Sector and equipment, supply of medicines and other commodities, limited health funding currently $24 per capita (2015 estimate) versus the recommended $86 and general challenges with the service delivery platforms and the enabling environment. Table 3 shows the top causes of OPD utilization in 2014 with Acute Respiratory Infection (ARI) at the top at 31%. Skin diseases, diarrhea, burns and other injuries contribute considerably to the outpatient diseases and conditions. Table 3: Top ten out-patient general new diseases and conditions by all age groups (excluding STIs), 2014 Diseases/Conditions Numbers % 1 Acute Respiratory Infections 3,693,350 31.0 2 Skin diseases 959,885 8.1 3 Diarrhoea 763,136 6.4 4 Burns and Other Injuries 570,841 4.8 5 Malaria 535,931 4.5 6 Diseases of the eye 421,620 3.5 7 Dental conditions 178,948 1.5 8 Bilharzia 74,916 0.6 9 Dysentery 49,373 0.4 10 Nutritional Deficiencies 22,648 0.2 Source: MOHCC, 2014 Outpatient visits broken down by age (see Figures 9 and 10 respectively) show that the top five causes for under-fives visits in 2014 were ARI , diarrhea, skin diseases, diseases of the eye, burns and other injuries. For those five years and above, it was ARI, skin diseases, burns and other injuries, malaria and diarrhoea. Figure 9: Top ten out-patient general diseases and conditions, under-five years, 2014 Bilharzia 0.1 Poisoning & Toxic Eff 0.1 Dental conditions 0.1 Dysentery 0.3 Nutritional Deficiencies 0.5 Malaria 2.0 Burns + Other Injuries 2.8 Diseases of the eye 3.3 Skin diseases 10.3 Diarrhoea 10.4 ARI 46.6 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 "% of Total < New Cases" Source: MOHCC, 2014 12 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Figure 10: Top ten out-patient general diseases and conditions, five years and above, 2014 Poisoning & Toxic Eff 0.2 Dysentery 0.5 Bilharzia 0.9 Dental conditions 2.2 Diseases of the eye 3.7 Diarrhoea 4.4 Malaria 5.8 Burns + Other Injuries 5.8 Skin diseases 6.9 ARI 22.9 0.0 5.0 10.0 15.0 20.0 25.0 "% of Total >5 New Cases" Source: MOHCC, 2014 Table 4 shows the top inpatient diseases and conditions for all age groups. It is clear that direct and indirect obstetric causes, normal delivery, conditions of the respiratory system, poisoning and toxic effects, ARI and certain conditions originating in the perinatal period contribute the most to this inpatient burden. Slight morbidity patterns are observed for the one to four years age group, and notable differences for those under one year old. Table 4: Top ten inpatient diseases/conditions, All Age Groups, 2014 Rank Disease/Condition Cases 1 Direct & Indirect Obstetric Causes 137,286 2 Normal Delivery 84,940 3 Other Diseases of the Respiratory System 27,575 4 Poisoning and Toxic Effects 21,550 5 Acute Respiratory Infections 20,865 6 Certain Conditions Originating in the Perinatal period 16,554 7 Oral Cavity & Diseases of the digestive system 12,872 8 Parasitic Diseases 11,219 9 Intestinal Infections 10,638 10 Malaria 10,220 Source: MOHCC, 2014 The five major causes of hospital admissions in 2014 were direct and indirect obstetric causes (29.4%), normal deliveries (18.2%), other diseases of the respiratory system (5.9%), poisoning and toxic effects (4.6%), and ARI (4%). National Health Strategy For Zimbabwe 2016-2020 13 Situation Analysis of Zimbabwe’s Health Sector Table 5: Top ten causes of hospital admissions, 2014 Diseases/ Conditions Cases % Direct and Indirect Obstetric Causes 137286 29.4 Normal Delivery 84940 18.2 Other Diseases of the Respiratory System 27575 5.9 Poisoning and Toxic Effects 21550 4.6 ARI: Lower Respiratory Tract Infections & Influenza 18675 4 Certain Conditions Originating in the Perinatal period 16554 3.5 Oral Cavity & Diseases of the Digestive system 12872 2.8 Parasitic Diseases 11219 2.4 Intestinal Infections 10638 2.3 Malaria 10220 2.2 Source: MOHCC, 2014 Table 6 shows the national top twenty causes of mortality amongst Zimbabweans in 2014. The top five causes of death include ARI, conditions originating from perinatal period, TB, HIV and meningitis. Table 6: National top twenty causes of mortality, all ages Conditions/Diseases Total Deaths 1 ARI 2,034 2 Certain conditions originating in the perinatal period 1,812 3 TB 1,134 4 Human immunodeficiency virus (HIV) disease all complications, AIDS and AIDS Related Conditions 853 5 Meningitis 823 6 Diarrhoea and gastroenteritis due to other infectious diseases (bacterial, viral, protozoal) 560 7 Heart failure (congestive and left ventricular) 510 8 Symptoms, signs and abnormal clinical & laboratory findings, not elsewhere 462 9 Other anaemias 455 10 Malaria 441 11 Renal failure 439 12 Other endocrine, vitamin, nutrients and nutritional deficiencies, obesity and metabolic disorders 403 13 Congenital infections and parasitic diseases, excluding HIV 402 14 Other diseases of intestines, including peritoneum 337 15 Cerebral infarction, Cerebrovascular accident (stroke) not specified as hemorrhage or infarction 270 16 Mycoses, including candidiasis 249 17 Intrauterine hypoxia and asphyxia 234 18 Other diseases of liver 223 19 Diabetes mellitus 206 20 Other heart diseases 194 Source: MOHCC, 2014 14 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector 2.5 Priority Disease Control Programmes In response to the current burden of diseases the MOHCC has priority disease control programmes namely: a) Communicable disease programmes, b) Non communicable diseases and conditions programmes, c) Reproductive, Maternal, Newborn, Child Health and Adolescent Services, and d) Public health surveillance and disaster preparedness and response programme. The strategy seeks to sustain and improve these flagship programmes as part and parcel of a holistic response to the current disease burden and potential risks of disasters. 2.5.1 Communicable Diseases HIV and AIDS HIV and AIDS remains a significant public health problem in Zimbabwe, threatening the socioeconomic fibre of the country and placing a tremendous strain on the capacity of the health sector to respond to the health needs of the population. The HIV prevalence for adults (15-49 years) has declined by 5.6% from 2011, to 15% in 2014 (UNAIDS 2014). A similar trend has been observed in younger adults (15-24 years) both male and female from the period 2011 to 2014 (Figure 11). Figure 11: Trends in adult (15-49 years) HIV prevalence with ZDHS data points Prevalence Adult Prevalence, ZDHS 35 30 HIV Prevalence (%) 25 20 ZDHS, 2005, 15 ZDHS, 2010 10 5 0 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Year Source: ZDHS, 2005, 2010 National Health Strategy For Zimbabwe 2016-2020 15 Situation Analysis of Zimbabwe’s Health Sector HIV prevalence is consistently higher in urban areas compared to rural areas from 2011 to 2014. However, both urban and rural prevalence is gradually increasing (Table 7 below). Table 7: HIV prevalence by geographic location Place of residence 2011 2012 2013 2014 Urban 16.63 16.85 17.04 17.23 Rural 15.40 15.56 15.66 15.75 National 17.66 17.36 17.04 16.74 Source: MOHCC, 2015 The estimated HIV prevalence in adults by province is shown in Figure 12. The distribution of adults with HIV across provinces is variable, with Bulawayo having the highest prevalence and Mashonaland Central having the lowest (MOHCC, 2015). Figure 12: Estimated HIV Prevalence in adults by province Bulawayo 18.6 Harare 17.6 NaƟonal 16.7 Mashonaland West 16.7 Province Mashonaland East 16.7 Masvingo 16.6 Midlands 16.5 Matabeleland South 16.5 Matabeleland North 16.3 Manicaland 15.9 Mashonaland Central 15.7 12 13 14 15 16 17 18 19 HIV Prevalence (%) Source: MOHCC, 2015 It is estimated that there were 63,848 new HIV infections in 2014 of which 9,086 (14%) were in children 0-14 years old. Generally there is a decline in the number of new HIV infections among both adults and children over the years (Table 8). 16 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Table 8: Estimated number of new HIV infections by year 2011 2012 2013 2014 80,626 69,177 65,425 63,848 Total New infections (74,746 - 86,588) (63,543 - 74,998) (59,325 - 71,866) (57,287 - 71,327) 62,715 59,600 55,437 54,762 New infections Adults 15+ (57,630 - 68,048) (54,517 - 65,121) (49,974 - 61,110) (48,774 - 61,392) 17,911 9,577 9,988 9,086 New infections (0-14) (16,093 - 19,841) (8,237 - 11,174) (8,518 - 11,609) (7,633- 10,622) Source: MOHCC, 2015 The estimated number of adolescents (aged 15-19) that are expected to have new infections has been declining, and it is anticipated to continue declining in the next five years (Figure 13). However, the decline by 2020 is expected to still be below the target number of 2,000 new infections. Therefore interventions targeting this group are critical. Figure 13: Estimated number of adolescents (aged15-19) newly infected with HIV, 2001-2020 National Health Strategy For Zimbabwe 2016-2020 17 Situation Analysis of Zimbabwe’s Health Sector It is estimated that 1,550,250 adults and children were living with HIV in 2014. Of the total number of people living with HIV in 2014, 9% (146,824) were children 0-14 years. In the same year, the proportion of women (above 15 years) living with HIV was 54%. The estimated population of adolescents (age 10-19) living with HIV is 108,484 while 117,299 young people (age 20-24) are living with HIV. The majority of adolescents living with HIV are female, and the gender disparities in HIV are wider in the 15-19 and 20-24 age groups. Based on the total population living with HIV, Antiretroviral Therapy (ART) coverage for both adults and children has increased steadily between 2011 and 2014, from 36.8% to 51.9% and 23.5% to 34.2% respectively (Table 9). However, the number of people on ART in the private sector is unknown. Prevention of Mother-To-Child Transmission (PMTCT) coverage increased from 75% in 2013 to 78% in 2014. The estimated number of adolescents (age 15-19) newly infected with HIV in Zimbabwe has been declining gradually over the years. Table 9: National ART programme coverage by year People receiving ART as a percentage ART Coverage - National HIV Mothers receiving of total HIV population (%) Eligibility Criteria (%) PMTCT (% Year Adults Children Adults Children Coverage) Estimate 95 % C.I Estimate 95 % C.I Estimate 95 % C.I Estimate 95 % C.I Estimate 95 % C.I 2011 36.8 36.7 - 36.9 23.5 23.5 - 23.3 73.8 73.7 - 73.9 55.8 55.4 - 56.2 50 46 – 54 2012 40.5 40.4 - 40.6 28.4 28.4 - 28.2 77.4 77.3 - 77.5 65.8 65.4 - 66.1 78 72 – 84 2013 45.9 45.8 - 46 27.7 27.7 - 27.5 83.6 83.5 - 83.7 57.8 57.4 - 58.1 75 69 – 81 2014 51.9 51.8 - 52 34.2 34.2 – 34 62.7 62.6 - 62.8 63.9 63.6 - 64.3 78 72 – 85 Source: MOHCC, 2015 Sexually Transmitted Infections (STI) There has been a general decline in the number of clients presenting with STIs (Figure 14). In spite of the downward trend, these remain an important driver of HIV and the country needs a concerted effort to address the high numbers still being recorded. The number of unreported cases treated in the private sector, though unknown, is also a contributing factor to new HIV infections. 18 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Figure 14: Trends in STI by type, 2009-2015 180000 160000 140000 Genital ulcers STI Episodes 120000 Ophthalmia neonatorum 100000 Other forms of sƟ 80000 Pid 60000 Repeat sƟ visits 40000 20000 Urethral vaginal discharge 0 2009 2010 2011 2012 2013 2014 2015 Year Source: MOHCC, 2015 Tuberculosis (TB) The number of new cases of TB notified has generally declined in the last few years, as seen in Figure 15 below. However, a figure of 269 per 100,000 population is still high by regional and global standards. Figure 15: Trends in TB cases, 2010-2013 400 378 350 319 100,000 populaƟon 298 300 269 250 200 150 100 93 97 94 86 50 0 2010 2011 2012 2013 Year Bact Confirmed All forms Source: MOHCC, 2015 National Health Strategy For Zimbabwe 2016-2020 19 Situation Analysis of Zimbabwe’s Health Sector The country has seen an increase in the cure and treatment success rates of TB. However, this is still falls short on the national target of 87% (Figure 16). The mortality from TB remains high at 10%, and may be due to the HIV TB co-infections and rising incidence of drug resistant TB. ART coverage among HIV infected TB patients has improved significantly (Figure 17). Figure 16: TB cure rates 2009-2013 90 81 82 81 83 80 77 75 74 72 69 71 70 60 Percentage % 50 40 Cure rate 30 Success rate 20 10 0 2009 2010 2011 2012 2013 Year Source: MOHCC, 2015 Figure 17: TB cases on ART, 2009-2013 400 378 350 319 100,000 populaƟon 298 300 269 250 200 150 100 93 97 94 86 50 0 2010 2011 2012 2013 Year Bact Confirmed All forms Source: MOHCC, 2015 20 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Malaria Malaria still remains an important communicable condition in Zimbabwe. Of the 63 districts, 47 are high burdened, with the eastern and northern border districts being the worst affected (Figure 18). The incidence of malaria has declined from 58 per 1,000 population in 2009 to 39 per 1,000 population in 2014 (Figure 19). The incidence has however been rising again since 2012. The number of deaths from malaria in children below the age of five years has fallen from 166 in 2009 to 59 in 2014. However, the number of deaths in those older than five years has increased from 209 in 2009 to 347 in 2014. Figure 20 shows that the overall malaria cases have noticeably increased since 2009. Malaria case fatality rate reached its lowest at 6.1% in 2012 but has since exceeded its 2009 levels to 13.8% by 2014. Figure 18: 2014 Malaria incidence by district Source: MOHCC, 2014 National Health Strategy For Zimbabwe 2016-2020 21 Situation Analysis of Zimbabwe’s Health Sector Figure 19: Malaria Incidence 2004-2014 70 Rate per 1000 populaƟon 60 58 50 49 40 39 30 29 25 22 20 10 0 2009 2010 2011 2012 2013 2014 Year Source: MOHCC, 2015 Figure 20: Malaria Cases and Case fatality rates 2009-2014 Malaria Cases and Case Fatality Rate 600,000 518,030 500,000 437,496 400,000 331,722 300,000 199,864 200,000 161,357 100,000 74,221 13.30 13.10 11.6% 6.10% 8.80% 13.80% 0 2009 2010 2011 2012 2013 2014 Year Malaria Cases Malaria Case Fatality Rate Source: MOHCC, 2015 22 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Other diarrheal diseases The number of cases for diarrhoea has increased from 554,213 in 2010 to 763,136 in 2014 (Table 10). Annually, over 400 deaths from watery diarrhoea are reported. More than 50% of the deaths occur in children under the age of 5 years. Table 10: Diarrhoea and Dysentery Cases, 2008-2014 Cases 2010 2011 2012 2013 2014 Diarrhoea 554,213 701,182 779,310 817,787 763,136 Dysentery 36,121 58,154 61,195 61,869 49,373 Source: MOHCC, 2015 Rabies On average 150 animal cases of rabies are reported every year, though the condition is considered to be under-reported. In humans, cases of rabies have increased from two deaths in 2010 to sixteen in 2014. The challenge with rabies vaccination remains that of responsible pet ownership coupled with the high cost of vaccination and erratic supply of the vaccines. Anthrax Outbreaks of anthrax in livestock occur annually in Zimbabwe. The commonest form of anthrax in Zimbabwe is the cutaneous type, which is a zoonotic disease. This is due to the handling of carcasses during skinning and the consumption of infected meat against public health advice. The number of anthrax cases in humans has increased from 76 in 2010 to 135 in 2014. Hepatitis Hepatitis is a common cause of chronic liver disease in Zimbabwe but other viral infections are also important. The prevalence of viral hepatitis amongst Zimbabweans has not been systematically updated although the burden of disease is increasing. The WHO estimates that at least 1.5 million people worldwide are killed annually by this ‘silent killer’. 2.5.2 Non-communicable diseases Non-communicable diseases (NCDs), which include cardiovascular disease, cancer and diabetes mellitus, all of which are associated with the common risk factors of poor diet, insufficient physical activity, tobacco use, and alcohol abuse, caused 63% of all deaths globally in 2008 with more than 80% occurring in developing countries. Other common NCDs include injuries, eye and hearing conditions, epilepsy and mental illness. It is estimated that NCDs account for 31% of the total deaths in Zimbabwe (World Development Indicators 2012). Obesity is a major contributor to NCDs. Initiating and sustaining behavior change related to diet and physical activity is a major challenge facing health professionals, policymakers, and researchers National Health Strategy For Zimbabwe 2016-2020 23 Situation Analysis of Zimbabwe’s Health Sector worldwide in their efforts to reverse global obesity trends. Gathering insights on consumer attitudes and perceptions that affect their behavior, as well as establishing partnerships within communities to influence healthful behavior change, are critical steps. Previous strategies have disproportionately considered communicable diseases in terms of funding and implementation and neglecting most, if not all of the non-communicable diseases. However, the burden of NCDs has significantly increased over the years and requires corresponding strategies to deal with it. For most of the NCDs, the last baseline study on prevalence was last conducted in 2005, and there has not been a national multisectoral NCDs prevention and control strategy and screening guidelines. This shows the extent of the neglect of these diseases over the last decade or so. Currently there are no health policies with regards to most NCDs and related risk factors such tobacco and alcohol. Hypertension and Cardiovascular Diseases According to the 2005 study, the Zimbabwe prevalence rate for hypertension was 27%. Globally 26.4% of the adult population in 2000 had hypertension (26.6% of men and 26.1% of women) and 29.2% were projected to have this condition by 2025 (29% of men and 29.5% of women). The total number of adults with hypertension globally in 2000 was 972 million, with 639 million in developing countries. The number of adults with hypertension in 2025 was predicted to increase by 60% to a total of 1.56 billion. The Global Burden of Disease (GBD) 2010 ranked blood pressure as the leading single risk factor for GBD. It has long been recognised that hypertension is an important risk factor for cardiovascular disease and mortality. Prevention, detection, treatment and control should therefore receive high priority. According to WHO, cardiovascular diseases account for 9% of the total deaths in Zimbabwe. In 2014, new hypertension cases and follow-ups seen as outpatients amongst those aged 0-24 years were 671 and 3,905 respectively. Higher numbers were seen amongst those aged 25 years and above, with 23,605 new cases and 774,491 follow up visits in the same year. Hypertensive diseases accounted for 0.4% (1254) inpatients of all age groups in 2014. The bottleneck analysis showed that commodities (in particular essential medicines), geographic access and continuity with respect to scheduled reviews are the major bottlenecks on the management of hypertension. Diabetes Mellitus According to the 2005 study, the Zimbabwe prevalence of diabetes was 10% and WHO estimates that 1% of total deaths in Zimbabwe are due to diabetes. In 2014, the number of new cases and follow- ups seen as outpatients aged 0-24 years and 25 years plus were 769 and 1,986; and 8,658 and 102,077 respectively. A total of 4,679 cases were seen as inpatients and accounted for 24,633 patient days (MOHCC 2014). The major bottlenecks are commodities (in particular glucostrips and essential medicines), and initial utilisation of services. Proper monitoring of diabetes is crucial to mitigate the rate of complications arising from poorly controlled blood glucose levels. Is essential therefore that the strategies seek to address healthy life style and diet, improve commodities availability and screening services. Cancer Cancer is a disease that affects large numbers of people from all walks of life. It is emerging as a major public health concern in sub-Saharan Africa and is expected to double in the next twenty years. Cervical 24 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector cancer, though preventable and curable in its early stages, is the leading cause of cancer deaths in this region. In Zimbabwe, cancer is a major cause of morbidity and mortality with over 5,000 new diagnoses and over 1,500 deaths per year. According to WHO, cancers account for 10% of total deaths in Zimbabwe. The number of people developing cancer is expected to increase due to HIV and AIDS and other infections, unhealthy lifestyle choices and an ageing population. Most of the common cancers in Zimbabwe are infection associated. A total of 3,519 new cancer cases were recorded among Zimbabweans in 2009, comprising 1,427 (40.6%) males and 2,092 (59.4%) females. According to the Zimbabwe National Cancer Registry (ZNCR) 2009 annual report, the five leading causes of cancer among black Zimbabwean men were: Kaposi sarcoma (20.8%), prostate (13.7%), oesophagus (6.3%), non-Hodgkin's lymphoma (6.2%) and liver (5.7%). The five most common cancers among Zimbabwean black women were cervical cancer (33.5%), breast (11.7%), Kaposi sarcoma (8.9%), eye (6.5%) and non-Hodgkin lymphoma (4.9%). Diagnosis of cancer induces fear both in the individual and in families, and is frequently viewed as a death sentence. Its prevention, diagnosis and treatment poses great challenges particularly in resource constrained environments. There is reason for optimism however, as research indicates possibilities for major strides in its prevention and cure. There have been major improvements in the diagnosis and treatment of cancer, particularly in high income countries. However, adoption of new technologies in cancer diagnosis and treatment will place substantial and diverse pressure on the already overburdened and underfunded health delivery system, and therefore requires careful planning and resource mobilisation. Currently, over 5,000 new cancer cases are diagnosed (all types) in Zimbabwe annually. Experience has, however, shown that this is just the tip of the iceberg as many cancers are not captured by the routine National Health Information System because the patients do not present for treatment, or some deaths are not registered. Of those who do report, the majority are already at an advanced stage of disease due to limited access to screening services. The current cancer treatment and palliation services are unable to meet the existing demand. Additionally, and despite great progress in reducing HIV prevalence in recent years, Zimbabwe remains one of the countries most heavily burdened with HIV with an adult prevalence of 15%. The large number of people living with HIV results in an even higher number of people who will develop cancer in Zimbabwe. Meeting this increased demand and ensuring sufficient quality of services will require early and sustained decisions on investment, human resource planning and the re-organisation of health care services. The bottleneck analysis revealed that both access to cancer screening services and initial utilization of services are the major bottlenecks in cancer management. Cancer prevention, early detection, control, palliative care and rehabilitation requires a population-wide, integrated and cohesive approach to cancer that encompasses prevention, screening, diagnosis, treatment and support, palliative and rehabilitative care. This calls for strong political, technical, and practical leadership as well as significant investment in terms of infrastructure and equipment, human resources, technologies, medicines and vaccines. Injuries WHO estimates that 8% of the total deaths in Zimbabwe are due to injuries. The most common injuries presenting at health facilities are primarily due to road traffic accidents and assaults. This has been compounded by poor prevention strategies, increasing traffic volumes coupled with ageing road infrastructure and uncontrolled animal movement. The challenge has been the proper management of these injuries owing to lack of appropriate skills in trauma management. In addition, pre and inter National Health Strategy For Zimbabwe 2016-2020 25 Situation Analysis of Zimbabwe’s Health Sector hospital management of trauma remains a challenge particularly in rural areas. Imaging diagnosis has not been easy with secondary, tertiary and quaternary institutions lacking functional Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans. It is essential that specialists be availed to manage such cases. The general shortage of personnel at all levels is a contributory factor. Oral Health The burden of oral health problems is largely driven by lack of simple preventative measures as communities only seek care when they have specific dental problems. Whilst the school health programme has been effective in addressing oral health issues at schools, the same cannot be said of the wider communities. There still remains an unmet need for oral and dental services at all levels of the health care system. The major challenges facing oral health services include inadequate and inequitable distribution of personal (e.g. maxillo-facial surgeons); shortages of essential dental instruments and supplies especially at district level; inadequate x-ray machines; service vehicles to support supervisions and outreach activities, and the dental school infrastructure needs upgrading. Rehabilitation In Zimbabwe, effective coverage for rehabilitation is low at 30% owing to the low rehabilitation practitioner to patient ratio and Community Based Rehabilitation programme which is currently not receiving much attention. Retaining and re-attracting back rehabilitation practitioners remains a huge challenge. Focus should also be directed towards training and improving the availability of rehabilitation equipment and commodities and to strengthening mechanisms for early detection and management of injuries and disabilities. One of the root causes of poor continual utilisation is user fees, particularly when patients present for scheduled reviews. The rise of NCDs has also contributed to the increased demand for rehabilitations services. Mental Health A lot of challenges in managing mental illnesses in the community arise from long standing cultural stigmatization. This directly impacts on the health seeking behavior of the population, and support for the mentally ill from families and communities. The bottlenecks identified are inadequate commodities (40%) and low initial utilization (20%). The low initial utilization is due to the stigma and cultural barriers. The health delivery system has not adequately paid attention to the availability of commodities and specialists personnel (doctors, nurses, clinical psychologists, etc.) to be able to provide quality mental health services. 2.5.3 Reproductive, Maternal, Newborn, Child Health and Adolescents Maternal and Child Health Major achievements were made in reducing the Maternal Mortality Ratio (MMR) from 960 maternal deaths per 100,000 live births in 2010-2011 (ZDHS) to 614 in 2014 (MICS) (Figure 21). However this still remains unacceptably high in comparison with the sub-Saharan regional average of 510 (2013) and falls short of the Zimbabwean MDG target of 174. 26 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Figure 21 Trends in Maternal Mortality Ratio (MMR), Zimbabwe and Sub-Saharan Africa 1200 No. of Deaths per 100,000 Live Births 1000 960 Zimbabwe 800 600 614 SSA 510 400 MDG Target 174 200 2 per. Mov. Avg. (Zimbabwe) 0 1990 1995 2000 2005 2008 2010 2013 2014 2015 Years Source: World Bank 2014 Similarly, the under-five mortality rate dropped from 84 deaths per 1,000 live births in 2010/11 to 75 in 2014 but falls short of the 2015 MDG target for Zimbabwe of 25. The infant mortality rate decreased from 57 deaths per 1,000 live births in 2010/11 to 55 in 2014. According to the World Health Organization Global Health Data (2014), 2,100 maternal deaths reported in Zimbabwe in 2013 were due to causes that are known, preventable and treatable. The major direct causes of maternal deaths were haemorrhage (34%), pregnancy induced hypertension (19%), unsafe abortion (9%), sepsis (9%) and the indirect causes included AIDS defining conditions and malaria (18%), and other direct causes (11%). According to the Zimbabwe Maternal and Perinatal Mortality Study (ZMPMS 2007), the majority of maternal deaths (63%) occur in the postpartum, 24% in the antenatal, and 6.6% in the intrapartum periods. The same study also revealed that successful treatment of direct causes of maternal death could reduce maternal mortality by 46%. The 2013 HMIS data showed that 87% of the reported maternal deaths occurred at health facilities and 13% at home (although the picture could have been distorted by under-reporting of community maternal deaths). Adolescents and young people contribute significantly to maternal deaths. Zimbabwe has a youthful population, with two thirds of the population below the age of 25 years. The youth is one of the key affected population groups as most of the sexual reproductive health indicators for youth are either deteriorating or remaining high. The adolescent fertility rate in 2014 was estimated at 120 births per 1,000 women aged 15-19 years (MICS 2014). According to 2010/11 Zimbabwe Demographic Health Survey, 20.5% of women aged 20-24 years have had at least one live birth before the age of 18 years. The rural-urban differential in teenage fertility is striking, as rural girls were twice as likely to become a mother as their urban counterparts. The decline of the Maternal Mortality Ratio among women of 15-19 years at 21% is much slower than the average decline of 43% for women of 15-49 (MICS 2014). National Health Strategy For Zimbabwe 2016-2020 27 Situation Analysis of Zimbabwe’s Health Sector The major causes of death among children under one year are respiratory and perinatal conditions; for those between one and four years it is mainly nutritional deficiencies, followed by respiratory conditions. Intestinal conditions are also a major cause of death, ranking third for both age groups. Nearly half (44%) of the under-five mortality is a result of neonatal causes (MICS 2014). Pre-maturity, birth asphyxia and sepsis are the major causes of neonatal deaths (Figure 22). Figure 22: Causes of under-five mortality in Zimbabwe Malaria Other diseases 1% 19% Neonatal sepsis Measles 9% 1% Birth asphyxia Injuries Neonatal 13% 44% Congenital 5% 3% HIV/AIDS Pneumonia birth 9% 3% Preterm 14% Other neonatal Diarrhoea 2% 9% Pneumonia 12% Source: WHO/CHERG 2014 The gains in health outcomes can be attributed to the implementation of high impact interventions which have seen improvements in key coverage indicators. The number of pregnant women booking for antenatal care is 94% whilst those delivering in facilities with skilled birth attendants is 80%. Immunization coverage has improved in the past years with at least 83% of children being immunized against measles in 2014, up from 76% in 2009. According to the MICS 2014, 92% of children had received BCG vaccination. Despite the high national coverage in utilization, there is still variation in performance by provinces as indicated in Table 11 below. Table 11: Selected MNCH coverage indicators by province, 2014 Mash. Mash. Mash. Mat. Mat. Indicators National Byo Manica. Midlands Masvingo Harare Urban Rural Central East West North South ANC 1 93.7% 96.0% 91.1% 93.3% 91.2% 93.5% 98.4% 96.4% 93.0% 93.4% 93.7% 95.3% 93.0% Institutional 79.6% 94.3% 72.0% 71.0% 80.3% 73.3% 88.7% 84.2% 75.6% 75.1% 89.7% 92.7% 74.2% deliveries BCG 94.7% 96.3% 94.6% 94.6% 91.1% 92.1% 99.3% 95.3% 97.7% 92.6% 96.1% 96.8% 93.9% Measles 87.6% 90.8% 86.7% 85.2% 86.6% 87.0% 93.0% 92.2% 91.1% 78.1% 89.0% 90.3% 86.5% Source: MICS data by province 28 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Furthermore, the effective coverage indicators show notable gaps that could explain the mismatch between the high coverage and the impact indicators (e.g. women attending 4 or more ANC visits, 70% - MICS 2014, full immunization coverage, 69%, PNC 6 weeks, 55% - HMIS). Nutrition Nutrition is prioritized in Zim-Asset, under cluster one. In addition, the GOZ has endorsed a multi- sectoral Food and Nutrition Security Policy and a National Nutrition Strategy. Commitment IV of the Food and Nutrition Security Policy focuses on Food Safety and Standards, and it commits to the provision of safe and wholesome food to all through monitoring and enforcement of all locally produced and imported foods to meet national Public Health legislation and international standards for quality and safety. Adolescent and Maternal Nutrition The nutrition status of a woman before and after pregnancy plays a significant role in ensuring good maternal outcomes. Of concern is the rising trend in overweight and obesity among urban women who according to the National Micronutrient Survey of 2012, were more likely to be overweight (27 percent) and obese (17 percent) compared to their rural counterparts, 19 percent and 11 percent respectively. Infant and Young Child Nutrition Recent MICS 2014 results indicate that there is a downward trend in stunting from 35% in 2005/6, to 27.6% in 2014 with noted disparities in Zimbabwe. Stunting remains high in rural areas (30%), compared to 20% in urban areas and there are gender disparities. Of concern is that 10% of children are born already stunted and this points to a need for maternal, pre-pregnancy and adolescent nutrition interventions. Infant and Young Child Feeding Practices In Zimbabwe, the majority of babies (98%) are breastfed, but sub-optimal breastfeeding practices put them at risk. The recent MICS survey showed an improving trend in exclusive breastfeeding rates among children zero to five months, from 26% in 2009 (MIMS) to 41% in 2014 (MICS). Nutritional Status of Men The 2010 ZDHS reports that 9% of men aged 15-54 years are overweight or obese, while 15.2% are underweight (BMI <18.5) and 75% of men were found to have a normal weight. Overweight and obesity is higher in urban areas (11.4%), compared to 5.7% in rural areas. Zimbabwean men in the highest wealth quintile and those with more than secondary education and older than 30 years of age were found to have a higher prevalence of overweight and obesity. 2.5.4 Public health surveillance and disaster preparedness and response Building a resilient heath system requires an effective public health surveillance and disaster preparedness and response programme. Zimbabwe is prone to man-made and natural disasters such as floods and drought, which have major implications on the health status and survival of the National Health Strategy For Zimbabwe 2016-2020 29 Situation Analysis of Zimbabwe’s Health Sector population. The recent outbreak of Ebola in West and Central Africa and the potential threat of such epidemics to the population points to the need for a robust health surveillance and disaster prepared and response programme across sectors and at national and sub-national levels. Epidemic prone diseases that are a threat to public health in Zimbabwe include diarrhoeal diseases such as typhoid, dysentery and cholera, and zoonotic diseases such as anthrax, rabies and plague. Outbreaks of malaria particularly in areas that are not known to be malaria prone support the need for a robust surveillance to detect the spread of diseases. Between August 2008 and July 2009, Zimbabwe faced an unprecedented cholera outbreak that resulted in 98,592 cases and 4,288 deaths. The number of cholera cases reported post 2009 has declined from 1,022 in 2010 to zero in 2014. The case fatality rate of cholera has declined from 2.1% in 2010 to zero in 2014. The country remains at risk for cholera due to low safe water and sanitation coverage. The highest number of cholera cases have been reported in Chiredzi and Masvingo districts in the last five years. Environmental Health Services Environmental Health seeks to address all physical, biological, chemical, social and psychosocial factors in the environment. The theory and practice of assessing, correcting, controlling, minimizing and preventing those factors potentially affect the health of present and future generations. The environment in which people live is a key determinant to the levels of exposures, morbidity and mortality. The constitution of Zimbabwe Section 29 (3) mandates the state to take all preventive measures within its limits of resources available to it including education and public awareness programmes, against the spread of diseases. Section 73 reinforces that every person has the right to an environment that is not harmful to their health or wellbeing, and the environment protected for the benefit of present and future generations, whilst Section 77 of the same constitution gives Zimbabweans the right to safe, wholesome, potable water and sufficient food. The following sections of the constitution, Section 28 (Housing Legislation), 32 (Sporting and Recreation facilities legislation), 34 (Domestication of international instruments/conventions) all affect environmental health. The major challenge facing environmental health services is funding to support training of new and existing environmental health staff, improvement of water and sanitation infrastructure, inspections and outreach visits. Provision of protected water sources and improved sanitation remains a priority as coverage remains low and there are notable rural and urban differences. For example, 47% of households in urban areas and 30% in rural areas used improved sanitation facilities. Environmental health services by their nature require mobility to support supervision, general inspections and health education. Currently, enforcement and compliance with such legislation is limited because of limited resources 30 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector Table 12: Water and sanitation MICS Indicator Description Value Indicator Use of improved Percentage of household members using improved 4.1 MDG 7.8 76.1 drinking water sources sources of drinking water Percentage of household members in households 4.2 Water treatment using unimproved drinking water who use an 12.0 appropriate treatment method Use of improved Percentage of household members using improved 4.3 MDG 7.9 35.0 sanitation sanitation facilities which are not shared Open defecation Percentage of household members with no facility 31.7 Safe disposal of child’s Percentage of children age 0-2 years whose last 4.4 57.8 faeces stools were disposed of safely Percentage of households with a specific place for 4.5 Place of hand washing hand washing where water and soap or other 50.5 cleansing agent are present Availability of soap or Percentage of households with soap or other 4.6 55.8 other cleansing agent cleansing agent Source: MICS, 2014 2.6 Synthesis of Emerging Issues From the Analyses 2.6.1 SWOT analysis The Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis highlighted key issues for further analysis and indeed broader areas that needed to be addressed by the strategy (see SWOT synthesis report). These are summarized in Table 13 below. Available information from MICS (2014) showed that 76% of household members had access to improved sources of drinking water (Table 12). Only 35% of household members reported using improved sanitation facilities. Challenges still remain around open defaecation, low use of improved sanitation, safe disposal of faeces and hand washing in the country, which suggests that a significant number of the population is at risk from water and sanitation related diseases. Food monitoring is at 56% according to MICS (2014) (i.e. iodized salt monitoring). National Health Strategy For Zimbabwe 2016-2020 31 Situation Analysis of Zimbabwe’s Health Sector Table 13: SWOT Analysis Strategic Area Key Issues for the strategy Policy and Administration - Enhance Regulatory & Coordination Capacity w Practitioners w Health financing l Collection, Pooling, Allocation w Implementing partners - Align & synchronise policies to the National Strategy - HRH Administration, Management & Policy Capacity w Training w Recruitment l Posting & Transfer w Retention l Career progression l Supportive Supervision, Mentorship l Performance Evaluation & Remediation w Exit from service - Review of the organizational structure of the MOHCC at national and subnational levels & management capacities - Creation of an overall M&E framework - Introduction of quality management systems - Procurement and Supply Chain Management - Core Health Services Package Public Health - Specific focus on public health emergencies and preparedness including mass casualties - Capacitate environmental health and community nursing services - Government Analyst Laboratory upgrading & linkage with other strategic laboratories e.g. in Ministry of Agriculture laboratories - Enhance infection control strategies - Capacitating Port Health Service & International Health Regulations (IHR) 2005 - Need for an integrated school health care programmes - Integrated communicable and non-communicable disease programmes Primary Care - Introduce integrated community services through multi-sectoral partnerships - Coordination, capacity building of community based health workers - Decentralization of health services - Capacity building on management of health services - Need to promote and build capacity for health research Hospital Services - Institutional leadership & governance - Update procurement system guidelines - Invest, maintain, upgrade hospital infrastructure, equipment, transport and communication systems - Promote research and utilization of research findings - Strengthening referral systems 32 National Health Strategy For Zimbabwe 2016-2020 Situation Analysis of Zimbabwe’s Health Sector 2.6.2 Bottleneck analysis For a detailed understanding of the existing bottlenecks and indeed root causes to current health sector performance, a Bottleneck Analysis (BNA) was conducted for selected tracer conditions. The tracers were systematically selected to highlight specific programmatic areas that form part of the strategic pillars of this strategy (Table 14). Table 14: Selected Tracer Conditions for BNA Thematic Thematic Thematic Tracer Areas Tracer Areas Tracer Areas Interventions Interventions Interventions Health • WASH HIV and AIDS • STI Mental Health • Epilepsy promotion • Gender based • PMTCT • Substance abuse violence • Adult treatment • Life skills education/ • Paediatric treatment school health • Key populations (sex workers) Maternal and • Family Planning TB • TB treatment Disability • Accident and newborn health (Adolescent) • DR-TB and emergency • Focused ANC • Paediatric TB Rehabilitation • Prevention of • Skilled delivery disability • EmONC • Rehabilitation • PNC/Neonatal sepsis/Asphyxia HBB/Prematurity Child Health • Immunization Malaria • LLIN Elderly • Old age program • Community iCCM • IRS (Pneumonia, • ACT treatment Malaria, Diarrhoea) Adolescent • Adolescent Communicabl • Epidemic Prone Cross-cutting • e-HMIS health pregnancy – SRH e diseases Diseases health system • Policies (Community/HF) • Outbreak control issues • Adolescent HIV (Cholera, dysentery, treatment rabies) Nutrition • EBF NCDs • Hypertension General • Pre/eclampsia • Minimum (BP) Health • Severe malaria acceptable diet • Diabetes Services • Micronutrient • Cervical Cancer supplementation • Obesity (Pregnant Women • Eye health and Adolescents) • Cardiovascular • Healthy life style/ diseases obesity • Injury and • Clinical nutrition violence services • Eye and hearing • Community IYCF program • Growth monitoring • SAM National Health Strategy For Zimbabwe 2016-2020 33 Situation Analysis of Zimbabwe’s Health Sector The BNA looked at a number of related dimensions: enabling environment (policy, administration, coordination mechanism, financing etc.); commodities; human resources; access; initial utilization; continuity, and quality. As qualitatively shown in the SWOT analysis, the BNA highlighted the specific bottlenecks in relation to commodities supply and security; the human resource capacity needs; determinants of access issues, and the factors influencing first contacts and follow-up, and more importantly quality. Figure 23 shows the typical BNA results for adolescent health—HIV treatment. Figure 23: BNA results - adolescent HIV treatment 0% 0% Baseline New Target 9% 100% 96% 71% 26% 32% 30% 24% 8% 5% CommodiƟes: ProporƟon health Access: UƟlisaƟon: ConƟnuous EffecƟve ProporƟon of faciliƟes with at ProporƟon ProporƟon of UƟlisaƟon: Coverage: health faciliƟes least one health of health faciliƟes adolescents living ProporƟon of ProporƟon of with FDC TLE workers trained in providing ART with HIV aged 10 - adolescents living adolescents on ART prescripƟon iniƟaƟon services 19 years who have with HIV aged 10 - ART for 12 months and management been tested for 19 years who are that have had a HIV and know on ART viral load test their results Source: BNA, 2015 Overall, the bottleneck analysis revealed that despite the high service coverage, the quality of care at all levels remained poor or sub-optimal, there was weak programme integration resulting in missed opportunities, and there was lack of continuum of care along the life cycle (newborns, adolescents) and across service delivery levels (community level, tertiary level). Financial barriers impeded access to services, especially by vulnerable groups due to high user fees (at hospital level and in urban areas), as well as inequitable geographical distribution of health facilities especially in new settlement areas. There was significant negative influence of religious and other socio-cultural objectors on care seeking. Limited fiscal space resulted in inadequate allocation of Government resources for service delivery. The main challenge remains of how to mobilise adequate resources to sustain health services, against a national economy that has yet failed to recover and changing donor priorities. The current shortage of qualified staff with the required attitude and skills will continue to compromise quality and equity. These challenges must be addressed over the strategy period. 34 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 3 3.1 Overall Structure of the Strategy The overall strategy structure is informed by the programme based budgeting format recently assumed by the MOHCC. This structure recognizes the need to link resources to results. The vision and mission are described including the underpinning principles to this strategy. The key results areas that this strategy seeks to achieve are then summarized upfront, and this is followed by the proposed strategic responses by priority programmes: Communicable diseases; non-communicable diseases; Reproductive, Maternal, Newborn, Child Health and Adolescents) and Public health surveillance and disaster preparedness and response. The services delivery platforms or entities (Primary Care Services and Hospital Care Services) for implementing the identified strategies are then described followed by a description of the enabling environment for service delivery (Policy Planning and Coordination, Human Resources, Finance and Administration, Procurement and Supply Chain Management, Monitoring and Evaluation, Provincial Administration, Multi-sectoral Partnerships, and Research and Development). Cross-cutting issues including quality and equity, gender, and community participation are integrated across the priority programmes and service delivery platforms or entities. This strategy is informed by the situation analysis, and the need to improve quality of services and enhance equity in access and health outcomes. The strategy implementation framework that demonstrates how these strategies are linked to the desired outcomes is described followed by the estimated costs and funding options for the strategy. 3.2 Vision To have the highest possible level of health and quality of life for all Zimbabweans The Government of Zimbabwe desires to have the highest possible level of health and quality of life for all Zimbabweans. This is to be attained through the combined efforts of individuals, communities, organizations and the Government, which will allow Zimbabweans to participate fully in the development of the country. This vision will be attained through guaranteeing every Zimbabwean access to an essential health services package. The Ministry of Health and Child Care has therefore committed to the following Goals or Key Result Areas (KRAs): l Strengthening priority health programmes l Improving service delivery platforms or entities, and l Improving the enabling environment for service delivery The ultimate goal is to have a healthy population with equitable access to quality services through a strengthened health system. National Health Strategy For Zimbabwe 2016-2020 35 Strategic Direction for Health 2016-2020 3.3 Mission To provide, administer, coordinate, promote and advocate for the provision of equitable, appropriate, accessible, affordable and acceptable quality health services and care to all Zimbabweans while maximizing the use of available resources, in line with the Primary Health Care Approach 3.4 Principles and values Underpinning the Ministry of Health and Child Care’s vision and mission are the following values: l Equity in health status and health care l Gender equality l Essential quality services l Cost effectiveness l Efficiency l Appropriateness l Social solidarity l Affordability l Client and provider satisfaction l Transparency and accountability l Ownership and partnership in health, and l Continuous Monitoring and evaluation. Achieving the mission of the Ministry of Health and Child Care will be realised through: l Strengthening the Primary Care Approach as the main strategy for health development l Resource mobilization for health to ensure predictable and sustainable resources l Strengthening multi-sectoral partnerships in health services and care guided by the principle of three ones (one national plan, one coordinating mechanism and one monitoring and evaluation mechanism), and l An adaptive and reforming health sector 3.5 Key Result Areas Over the next 5 years, the Ministry of Health and Child Welfare seeks to attain clearly defined performance targets (Table 15). This National Health Strategy defines and explains strategies for attaining these goals and targets for the priority programmes; service delivery platforms or entities, and the enabling environment for service delivery. It presupposes an effective referral system that ensures continuum of care and that clients are seen at appropriate levels of care. The primary care level should be the first contact with the health care system and hence performs the key gatekeeping role and ensures appropriate referrals to higher levels of care. The strategy has three overall strategic goals and twenty objectives. 36 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Table 15: Key Result Areas Key Result Area Objective Key Indicator Baseline 2014 Target 2020 Goal 1: To strengthen priority health programmes Priority 1: 1. To reduce malaria incidence from Malaria incidence 39 5 Communicable 39/1000 in 2014 to 5/1000 in 2020 diseases and malaria deaths to near zero by 2020 Malaria deaths 654 0 % of outbreaks detected 2. To ensure timely detection and within 48 hours and 30% 100% control of epidemic prone diseases controlled within 2 weeks 3. To reduce morbidity due to Schistosomiasis and soil transmitted Prevalence of STH and 22.7% (for 10% helminthes and other NTDs by 50% SCH SCH/STH) by year 2020. 40.3% (men) 4. To prevent new HIV infections and % people who are tested 85% to reduce deaths due to HIV by 50% and know their status 56% (women) % of people on ART TBD 90% % of ART patients virally TBD 90% suppressed 5. To reduce mortality, morbidity and Mortality rate 10% < 5% transmission of tuberculosis by 90% Priority 2: 6. To reduce the incidence of selected % reduction in NCDs Non-communicable Non-Communicable Disease (NCDs) 0% 5% burden Diseases by 50 % % increase in number of 7. To improve the mental health diagnosed mentally ill to TBD 90% status of the population the expected mentally ill patients 8. To reduce disability and % patients under CBR to TBD TBD dependence by 50% total rehabilitation patients 9. To improve the quality of life of elderly persons and improve life % of older persons that TBD 100% expectancy from 61.5 to 65 years by receive geriatric care 2020 Priority 3: 10. To reduce maternal mortality ratio MMR 614 300 Reproductive, from 614 to 300 by 2020 Maternal, Newborn, Child 11. To reduce Neonatal Mortality Rate and Adolescents from 29 to 20 deaths per 1,000 live NMR 29 20 births 12. To reduce the under-five mortality rate from 75 to 50 deaths per 1,000 live <5 mortality 75 50 births 13. To reduce mortality and morbidity Proportion of children 28% 19% due to malnutrition by 50% under 5 years stunted National Health Strategy For Zimbabwe 2016-2020 37 Strategic Direction for Health 2016-2020 Key Result Area Objective Key Indicator Baseline 2014 Target 2020 Priority 4: 14. To strengthen environmental health % of outbreaks detected Public Health services, early detection of disease within 48 hours and 30% 50% surveillance and outbreaks and man-made disasters controlled within 2 weeks disaster from 30% to 50% by 2020 preparedness and response % of districts with functional coordination 50% 100% mechanism Percentage of household members using improved 35% 50% sanitation facilities which are not shared Percentage of household members using improved 76.1% TBD sources of drinking water Goal 2: To improve service delivery platforms or entities Primary Care 15. To reduce morbidity by at least Proportion of villages with 50% through the provision of community based health <60% >90% accessible, affordable, acceptable and workers effective quality health services at community and health centre level % districts implementing Essential Primary Health 0% 100% Benefits Hospital Services 16. To ensure universal access and % of hospitals with Quality TBD provision of complementary package Management Systems of hospital services including emergency and ambulatory curative % of hospitals with TBD services functional theatre services 17. To ensure universal access and % of tertiary hospitals with provision of quality tertiary specialist TBD 100% specialists curative services % of patients and families 40% 18. To promote and support provision 200,000 needing palliative care (80,000 of quality palliative care services in need who are receiving it people) Goal 3: To improve the enabling environment for service delivery Policy Planning 19. To improve health outcomes % of policies and and Coordination through facilitation and co-ordination strategies aligned to the 0 100% of an effective and efficient health NHS delivery system Human Resources Overall vacancy rate 17% 10% Finance and Number of institutions 82 TBD Administration audited against the plan cost centres Number of districts with 0 62 functional PFMS 38 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Key Result Area Objective Key Indicator Baseline 2014 Target 2020 Monitoring and Harmonised M&E policy 01 1 Evaluation framework % of actual to planned Provincial PHT reviews convened TBD 100% Administration per year Procurement and supply chain % availability of essential 42% 80% management medicines Multi-sectoral 20. To strengthen multi-sectoral A policy on public/private Partnership collaboration with local and and public/public 0 1 international partners partnerships % of functional national and subnational TBD 90% intergovernmental platforms Research and 21. To improve uptake of scientific % health research Development research evidence for decision making informed by the national TBD 70% and policy development by 70% health research priorities Number of clinical trials on Traditional Medicine TBD 2 conducted 3.6 Strategic Responses Addressing the current challenges facing the health system and indeed achieving the key result areas highlighted above requires innovation and strengthening of priority programmes and service delivery platforms or entities. The policy and administration framework must be appropriately strengthened to ensure effective policy planning and administration, regulation and compliance with national norms and standards. The health system must be strengthened to respond to the burden of communicable and non-communicable diseases; reproductive, maternal newborn child health and adolescent issues; and public health disease surveillance and disaster preparedness and response. Interventions must be evidence based and supported by robust research and development. Of fundamental importance is strengthening of the primary care system including community systems as the entry point to the health care system. Hospitals at various levels must be capacitated to handle these referrals and other complicated cases to ensure a continuum of care and better outcomes. Underpinning the proposed strategies is the need to improve quality and equity of services, mainstreaming of gender issues, and working in partnership with all other sectors that contribute to the production and maintenance of health. Each of these strategic components is discussed in turn. National Health Strategy For Zimbabwe 2016-2020 39 Strategic Direction for Health 2016-2020 Priority 1: Communicable Diseases Communicable diseases remain a major contributor of morbidity and mortality in the country. This strategy seeks to address these priority communicable diseases using proven health interventions. Goal 1: To strengthen priority health programmes Objectives Specific objectives Strategies Objective 1: 1.1.To increase access of the • Improve vector control through Indoor Residual Spraying population at risk to effective (IRS) and use of Long Lasting Insecticide Treated Nets (LLIN) To reduce malaria and appropriate malaria • Strengthen advocacy, and behaviour change and incidence from 39/1000 in prevention interventions by communication activities 2014 to 5/1000 in 2020 2020 • Strengthen demand creation for malaria prevention and and malaria deaths to near control activities zero by 2020 • Strengthen Intermittent Preventative Treatment (IPT) and prophylaxis • Strengthen larval source management and personal protection 1.2. To ensure prompt and • Strengthen case management (diagnostic, medicines, and appropriate management of supportive care) at all levels of care all malaria cases by 2020 • Improve surveillance systems, monitoring, evaluation and research 1.3 To enhance pre- • Increase the number of districts in pre-elimination phase elimination activities (increasing surveillance) Objective 2: 2.1 To strengthen timely • Establish functional Rapid Response Teams detection and control of all • Training in Integrated Disease Surveillance and response To ensure timely detection epidemic prone diseases (IDSR), and Rapid Response Teams (RRT) and control of epidemic • Improve surveillance systems, M&E and research prone diseases 2.2 To prevent outbreaks of • Improve sanitation, water quality and promote hygiene cholera and other diarrheal • Strengthen case management diseases, and the occurrence of such diseases Objective 3: 3.1 To reduce the prevalence • Establish the prevalence of selected priority Neglected Tropical of Schistosomiasis, STH, LF, Diseases (SCH, STH, LF, HAT and Blinding Trachoma) To reduce morbidity due to and Blinding Trachoma • Conduct Mass Drug Administration (Treatments) • Strengthen advocacy, and behaviour change and Schistosomiasis and soil communication activities transmitted helminthes and • Strengthen demand creation for NTDs prevention and other NTDs by 50% by year control activities 2020 • Strengthen case management Objective 4: 4.1 To achieve 90, 90, 90 • Improve HIV testing and treatment of those found positive • Optimize HIV prevention activities; w BCC w STI control To prevent new HIV infections and to reduce w VMMC deaths due to HIV by 50% w HTS w Condom promotion • Enhance HIV/TB collaborative activities and treatment of other opportunistic infections (OI) 4.2 To reduce MTCT to less • Implement PMTCT services than 5% • Enhance male involvement 40 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Objectives Specific objectives Strategies Objective 5: 5.1 To increase positive TB • Increase sputum based diagnosis treatment outcomes • Strengthen Directly Observed Treatment (DOTS) programme To reduce mortality, • Increase in high quality diagnoses and expand use of Gene morbidity and transmission expert tools of tuberculosis by 90% • Implement systematic screening of contacts • Provision of support to patients on treatment 5.2 To integrate TB/HIV • Enhance ART amongst TB cases services • Enhance HIV/TB collaborative activities 5.3 To effectively manage • Monitoring of high risk patients multi-drug resistant TB • Improve access to early diagnoses of DR-TB including susceptibly • Systematic screening of DR-TB • Strengthen capacity of DR-TB in patients • Strengthen cross boarder collaboration activities Priority 2: Non-communicable diseases (NCDs) Prevention and management of non-communicable diseases is critical to reducing the incidence of preventable illnesses, disability and death due to these conditions and diseases. A holistic strategic response requires multi-sectoral partnership in which sector ministries, the private sector and all of society act in concert in promoting healthy life styles. Goal 1: To strengthen priority health programmes Objectives Specific objectives Strategies Objective 6: 6.1 To promote healthy life • Strengthen health promotion activities styles To reduce the incidence of selected Non- Communicable Disease (cancer, hypertension, 6.2 To improve screening and • Promote screening and early detection diabetes, dental, diagnosis of selected NCDs ophthalmic cases, injuries and oral health) by 50% Objective 7: 7.1 To improve awareness and • Promote reduction in substance abuse through multi-sectoral reduce substance abuse approach (schools, police, churches etc.) To improve the mental health status of the 7.2 To improve management • Establishment of drug rehabilitation services population and rehabilitation of addicts 7.3 To improve management • Promote specialization in psychiatry (doctors/nurses/clinical of mental illness and epilepsy psychologists) • Promote early detection and management of mental illness and epilepsy • Promote reduction of stigma towards mental illnesses in the community National Health Strategy For Zimbabwe 2016-2020 41 Strategic Direction for Health 2016-2020 Objectives Specific objectives Strategies Objective 8: 8.1 To increase access to • Scale-up Community Based Rehabilitation programme quality medical rehabilitation • Capacitate training schools for specialised skills To reduce disability and services • Improve availability of rehabilitation equipment and dependence by 50% accessories in health facilities • Strengthen mechanisms for early detection and management of injuries and disabilities (introduce screening programmes for newborn and children in hospitals) Objective 9: 9.1 To promote the well-being • Improve quality of geriatric care at all levels of care and quality of life for the • Implement a support services package for the elderly To improve the quality of elderly. • Establish community support programmes for the elderly life of older persons and • Establish multi-sectoral linkages for improving the welfare improve life expectancy of the elderly in the communities from 61.5 to 65 by 2020 Priority 3: Reproductive, Maternal, Newborn, Child Health and Adolescents Reproductive, maternal, newborn, child health and adolescent services remain a priority programme for the country as it addresses a large part of the country’s disease burden. The proposed strategies are geared to prevent and avoid unnecessary morbidity and mortality amongst women and children of all age groups. Goal 1: To strengthen priority health programmes Objectives Specific objectives Strategies Objective 10: 10.1 To increase early and • Advocacy and Communication for maternal health services continuous utilization of ANC • Institute client feedback mechanisms To reduce the maternal services • Decentralization of services including infrastructure, health mortality ratio from 614 to posts and community and supplies 300 by 2020 • Introduce RBF- pay for service conditional to quality of service (incentivizing VHW/PCN based on referrals) • Set up focused quality improvement systems 10.2 To increase the • Strengthen on-the-job training (OJT), support and supervision consistent provision of quality and mentorship ANC services 10.3 To improve outcomes • Ensure availability of delivery kits of delivery • Strengthen quality of maternity waiting home services • Strengthen capacity of health workers in life saving skills including EmONC • Strengthen BEmONC • To strengthen CEmONC services through clinical mentorship and OJT • Strengthen on the job training, support and supervision and mentorship for PNC • Improve access to primary health care facilities 42 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Objectives Specific objectives Strategies Objective 10: • Advocacy and Communication with male involvement • Introduce payment exemption policy • Introduce RBF- pay for service conditional to quality • Establish and upgrade infrastructure (especially maternity waiting homes) • Strengthen continuous quality improvement systems • Strengthen maternal and perinatal death surveillance and response • Strengthening midwifery services • Improve the referral system at all levels • Strengthen transport and communication systems 10.4 To strengthen Adolescent • Improve availability of integrated Youth Friendly Services using Sexual Reproductive Health appropriate and evidence based inclusive models (ASRH) • Strengthen the school health programme to include comprehensive sexual health education • Implement comprehensive Sexual Education • Advocacy for legislation against child marriage • Enhance community level awareness on ASRH 10.5 To reduce pregnancy • Improve the method mix in Family Planning (LARCs including related risks amongst WCBA PPIUCDs) including adolescents through • Strengthen integration of FP services with MCH and selected strengthening Family Planning SRH and HIV & AIDS services Objective 11: 11.1 To scale up high impact • Decentralize mentorship and follow up of trainings to district child survival interventions for on management of small and sick newborns To reduce the Neonatal Mor- essential new born care • Improve programmes on Helping Babies breath (HBB), KMC, IMNCI, PMTCT (to address asphyxia, sepsis and hypothermia) tality Rate from 29 to 20 deaths per 1,000 live births Objective 12: 12.1 To scale up high impact • Strengthen EPI Outreach, maintain cold chain integrity and child survival interventions for improve transport availability To reduce the under-five under-fives • Strengthen IMNCI Immunizations, ETAT, Nutrition, and Paediatric ART mortality rate from 75 to 50 • Revise pre-service curriculum to include IMNCI, HBB etc. deaths per 1,000 live births Nutrition The proposed strategies focus on adolescent and maternal nutrition, infant and Young Child Nutrition, infant and young child feeding practices; and micronutrient supplementation, amongst other things. National Health Strategy For Zimbabwe 2016-2020 43 Strategic Direction for Health 2016-2020 Objectives Specific objectives Strategies Objective 13: 13.1 To reduce the prevalence • Promotion of family-focused behaviour change communication of stunting among children on appropriate adolescent, maternal and child care practices To reduce mortality and under 5 years of age • Multi-sectoral coordination and collaboration towards an morbidity due to integrated response to stunting malnutrition by 50% • Advocacy and resource mobilization for scale up of provision of high impact nutrition interventions throughout the lifecycle • Strengthen evidence generation and monitoring of interventions to address stunting 13.2 To increase exclusive • Promote early initiation of breastfeeding within 30 minutes of breastfeeding rates in children delivery 0-6 months • Promote exclusive breastfeeding • Strengthen advocacy and communication at community level 13.3 To increase children • Promote age appropriate complementary feeding 6-23 months receiving minimum acceptable diet 13.4 To increase children • Promote micronutrient supplementation 6-59 months receiving vitamin A supplementation 13.5 To reduce prevalence • Scale up coverage of iron and folate supplementation in of micronutrient deficiencies women 15-49 years and Vitamin A supplementation in (iron in women, Vitamin A in children 6-59 months children 6-59 months, iodine • Capacity building of laboratories and health workers for in children 5-12 years) implementation of National Food Fortification strategy • Strengthen food fortification monitoring and surveillance 13.6 To improve case • Capacity building for screening, identification and management identification and of severe acute malnutrition at community and facility levels management of severe • Strengthen data quality and reporting for severe acute acute malnutrition in children malnutrition from community to facility levels 6-59 months 13.7 To reduce prevalence • Promote social and behaviour change communication on of overweight and obesity healthy lifestyles (diversified diets -including consumption of among children, adolescents at least 5 servings of fruits and vegetables - decreased and adults consumption of sugary beverages) • Promotion of physical exercise of recommended duration using multi-media channels • Promote health screening and wellness days through hospital and community based platforms • Advocacy and collaboration with stakeholders e.g. CCZ on ensuring food standards are met 13.8 To increase household • Behaviour change and communication to improve household access to safe and nutritious hygiene, safe sanitation and waster food 44 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Priority 4: Public Health surveillance & disaster preparedness and response programme These environmental health strategies seek to address priority challenges in the management of all physical, biological, chemical, social and psychosocial factors in the environment including compliance with international legislation and conventions. Goal 1: To strengthen priority health programmes Objectives Specific objectives Strategies Objective 14: 14.1 To increase access to • Improve water and sanitation infrastructure safe water and sanitation • Promote appropriate water treatment and waste management To strengthen methods environmental health • Monitor water quality services, early detection of disease outbreaks and 14.2 To improve management • Strengthen waste management systems man-made disasters from of waste (solid, liquid, • Improve Environmental Hygiene through environmental 30% to 50% by 2020 chemical, radiation and awareness programmes noise) and reduce pollution • Increase technical guidance in land use planning • Monitor sanitation and housing standards • Scale-up the healthy villages and healthy towns concept • Enhance water quality and safety inspections 14.3 To reduce air, water and • Resource and strengthen regulating institutions terrestrial pollution by • Ensure institutional and industrial health and safety strengthening public health • Monitor environmental pollution regulations and awareness on • Regulation of planning and building projects environmental contamination • Enforce the provision of the Public Health Act and its provisions • Ensure compliance with international health laws and regulations • Monitor smoking in public places 14.4 To enhance safety of food • Review food legislation especially for import and export and Food Commodities, and regulations and natural packaged mineral water meat • Licensing and certification of premises • Ensure Food Quality Monitoring and inspections at all levels • Strengthen the capacity of the Government Analysts and Public Health Laboratory • Conduct public education on food safety, handling and storage • Conduct regular meat inspections 14.5 To improve climate • Conduct a climate change and health awareness change awareness • Training of Focal Points • Develop a Public Health Adaptation to Climate Change plan 14.6 To improve awareness • Strengthen Environmental Control Community Health clubs on clean and hygiene living and other community initiative conditions • Promote clean and hygienic conditions at home, public facilities and work places • Promote community participation and involvement in creating a healthy environment 14.7 To strengthen port health • Enforce regulatory compliance of imported and exported services foods • Conduct regular inspections of points of entry • Strengthen pest/vector control • Screen human remains • Screen travellers at points of entry • Strengthen International Health Regulations (IHR) National Health Strategy For Zimbabwe 2016-2020 45 Strategic Direction for Health 2016-2020 Service Delivery Platforms/Entities The identified strategies will be delivered through primary care and hospital services platforms. Mission and local government facilities will continue playing their traditional roles of partnering with the State in the provision of primary care services. Defining an essential primary care services package is essential to improving access and quality for the majority of the population. Given the existing resource challenges facing the health sector it might not be possible in the short to medium term to guarantee access to comprehensive services to all. Primary Care Services Primary care is the basis of the health system in Zimbabwe and will be the major delivery vehicle for implementing the identified strategies. However, the primary care level needs to be strengthened to ensure equitable access to essential health services. To facilitate this process an Essential Primary Care package that focuses on provision of comprehensive preventive and basic diagnostic and treatment services at health center and community level is to be developed, costed and implemented. In addition, the focus will not only be on nurses and VHW but also other community based cadres and professionals working as multidisciplinary teams at this first line level. To enhance the performance of VHW, use of performance based funding needs to be explored to improve coverage, and the levels of household services provided at the community level. The proposed strategies address both the community and the health centre level components of primary care services. Community level services Community level services relate to those services provided in the community and at sub-district and even at village or household level as part of community participation in co-production of needed services closer to the families or households. Goal 2: To improve service delivery platforms or entities Objectives Specific objectives Strategies Objective 15: 15.1 To Strengthen • Strengthen community participation Community Systems • Increase Community Based Workers: To reduce morbidity by at w Coverage least 50% through the w Package of services provision of accessible, w Household health services affordable, acceptable and w Support / PBF effective quality health • Strengthen accountability at a) Community level, and services at community and b) MOHCC local facility level health centre level • Improve number of functional Health centre Committees • Enhance inter-sectoral collaboration at community level 15.2 To decentralize health • Introduce Health Posts in communities care services and increasing • Strengthen PBF at sub-district level autonomy of sub-district level • Strengthen referral systems between community and primary health care levels • Implement an essential health benefits package at primary care throughout the country 15.3 To strengthen quality of • Introduce Quality Management System services (both technical and • Improve supportive supervision and mentorship perceived) • Reinforce client feedback mechanisms • Capacitate health care providers on work ethics, ethical practice and public relations • Enhance local monitoring and evaluation 46 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Health Centre Level services Primary Health Care (PHC) was adopted in Zimbabwe in 1980 to deliver health care to the majority of the population through increased community access to health services. PHC was launched primarily to improve maternal, neonatal and child health (MNCH), and included high impact and cost effective interventions, such as comprehensive antenatal and postnatal care, an expanded programme of immunization (EPI) as well as community level health promotion, child monitoring and surveillance through Village Health Workers (VHWs). By 1990, about 85% of the population had access to basic health services. During the same period, child immunization coverage increased from 25% to 80%, and together with increased coverage of other child health interventions, resulted in an under five mortality rate which dropped by more than 20%, from 104 per 1,000 live births to 81 per 1,000 live births. (UN Inter-agency Group for Child Mortality Estimation, 2010). The ongoing economic decline has led to diminishing budgets available for health care, resulting in reduced provision at all levels. This system breakdown was characterized by a shortage of skilled professionals, eroded infrastructure, and lack of essential drugs and commodities. Concurrently, demand for services has been undermined by the non-standardised application of user fees. Loss of human resources in the health sector has had a detrimental impact on the availability of services, particularly in rural areas. Vacancy levels are as high as 89% for midwives, 64% for government medical officers and 49% for nursing tutors. Although demand for midwifery training is high, only 13 of the country's 20 midwifery schools are currently functioning, with plans and funding now in place to revive all 20 schools. In an effort to address high vacancy levels, MOHCC has trained over 4000 Primary Care Nurses (PCNs) since 2004. PCNs are deployed to rural health centers following one-year training. A donor-funded Health Retention Scheme has assisted in retaining some staff, but a long-term solution for retaining qualified health staff is urgently required. To compensate for staff shortages, the Government has also introduced 'task sharing,' allowing health workers to perform new tasks. For example, Primary Counsellors were recently approved to provide HIV testing and counseling, and MOHCC is advocating for nurses to initiate antiretroviral treatment (ART). Currently every district has at least 2 doctors, every primary health care center has at least 2 qualified nurses, 59% of administrative wards are serviced by an Environmental Health Technician and 60% of Villages have access to a village health worker. However, coverage in new settlement areas is lagging and remains a critical gap. Worth noting is that the staff complements described are based on a human resource establishment that has not been reviewed based on current service delivery needs. In terms of the health information system data capturing at community and PHC levels remains paper based which results in poor data quality. There is no clear definition of disease burden by catchment area and data is not disaggregated by catchment area resulting in low utilization of data for program planning and prioritization. There remains an opportunity for decentralization of the DHIS2 to primary health care center level. The Service availability and readiness assessment findings show that health facility density in Zimbabwe is less than two primary health facilities per 10,000 population in all provinces, except Bulawayo. Zimbabwe targets 23 health workers per 10,000 population but this target is not being met in all provinces except Bulawayo. Most provinces have less than 10 health workers per 10,000 population which means the majority of primary health care centers are understaffed. In the surveyed areas, outpatient utilization is 0.35 outpatient’s visits per person per year, which also falls below the target of 5 outpatient visits per person per year in all provinces (ZSARA 2015). National Health Strategy For Zimbabwe 2016-2020 47 Strategic Direction for Health 2016-2020 Despite prioritization of establishment of community health councils in the previous health strategy, there remains a gap at district level. Country wide, first level referral facilities do not have community health councils to support oversight of hospital administration. According to ZSARA 2015, 96% of facilities have access to emergency transport and communication. The NHS performance reports that 67% of the population lives in rural areas, while 33% are in urban areas. Zimbabwe has 1,700 administrative wards covered by 1,630 health facilities. Through funding from the Health Transition Fund, there has been significant improvement in human resources, equipment and medicines. The Results Based Financing approach has supported some improvements in quality of service delivery. However, this improvement has not fully extended to the district hospital and community health worker levels. Currently all urban facilities are under administration of the local government and usually underfunded to support basic primary health services. The current primary health care package and incentives schemes are skewed towards rural facilities. In addition, peri-urban settlements are growing faster than the health system can cope with provision of primary health services to these areas. Given the funding situation and the inequities across geographic areas and urban and rural areas, the Ministry seeks to develop and implement an essential health benefits package of services. The notion of promising entitlements to comprehensive services to all Zimbabweans is unattainable in the short to medium term. The Essential Health Benefits package defines the core services that need to be provided at a minimum to all Zimbabweans at primary level. This essential package of services will be continuously reviewed as the fiscal space and hence budget allocations for health services improve over time. Goal 2: To improve service delivery platforms or entities Objectives Specific objectives Strategies Objective 15: 15.4 To implement an • Reorganise service delivery platforms including community essential health benefits levels for Essential Health Benefits package To reduce morbidity by package at primary care at least 50% through the throughout the country provision of accessible, 15.5 To strengthen leadership, • Improve integrated coordination and management structures affordable, acceptable governance and management at community level and effective quality health of primary health care • Capacitate Health Centre Committees on governance of health services at community centre activities and health centre level • Delineate roles and responsibilities of the DHE and hospital executives to improve oversight roles 15.6 To improve • Upgrade power sources at facilities to have sustainable and infrastructure development predictable power supply 15.7 To strengthen the • Adopt appropriate IT technologies for collection, collation of collection and utilization of health information and medical records including monitoring health information for of HR, commodities, etc decision making • Adopt technologies that facilitate real time monitoring of commodities, equipment, human resources availability at all levels 15.8 To strengthen Health • Strengthen RBF/PBF including urban primary care facilities Financing at the Primary and and accredited private health providers first referral level • Adopt innovative mechanisms of addressing user fees as a barrier to access, e.g. vouchers, prepayments/insurance schemes 48 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Hospital Services Zimbabwe’s health referral system is a four-tiered pyramidal system with the lower level primary health facilities (clinics), secondary level (district hospitals), tertiary level (provincial hospitals) and quaternary level (central hospitals). There are six national (central) referral hospitals. Each of the eight administrative provinces has a tertiary (provincial) hospital that acts as a referral centre for other hospitals in that province. There is a district hospital or designated hospital in each of the districts. Mission hospitals contribute a significant number of beds mostly at secondary and primary care level with some being run as designated district hospitals. Hospitals are managed by policy prescribed boards and executives. For some time now, hospitals have been requesting for autonomy, to be run by statutory independent boards set up by the Minister of Health. To date, hospitals boards have been appointed at central hospital level with none at provincial and district level. Such Boards are "corporate" bodies capable of contracting, owning and disposing of assets, acquiring and disposing of land and buildings, borrowing money for capital investment and retaining fee revenue, among other things. This is different from the Hospital Advisory Boards (HAB) members, who are appointed by the Minister of Health from the local community, whose role is limited to community involvement in the general wellbeing of the hospital. A typical hospital executive consists of a medical superintendent or Chief Executive Officer for central hospitals, clinical director (for central hospitals), a matron, an administrator, a pharmacist and a chief nursing tutor. Hospitals are an important part of a health care system as they provide essential curative, rehabilitative and supportive services to primary care facilities. However, they consume significant and disproportionate amounts of resources compared to non-curative services. In the financial year 2014, central hospitals accounted for more than 30% of total health expenditure (PER, 2015). Despite this skewed expenditure pattern, problems of hospital cost escalation continue unabated. Claims that public hospitals are under-funded, with very little disbursements from Treasury remain. For example by September 2015, Harare Central Hospital had only received $560,000 out of a budget application of $17,500,000. This means that hospitals are primarily operating at very poor cash flow positions funded by charging patients for services and overstretching creditors thereby increasing debts. This also contributes to the inefficiency of hospital services delivery and the low quality of services produced. It is advisable to establish a cost per bed per capita for each diagnostic group by hospital level to determine the real health financing gap for hospitals and better mobilise resources. Over the last decade patients have been presenting at most hospital out patients department with simple ailments that can easily be managed at primary care level, further straining the available infrastructure, financial, human and other resources. Enforcement of the referral system based on the primary health care approach and patient education are key to ensuring that hospital services are only limited to those who really need them. The supply chain management of health commodities for hospitals is poor with donor medicines largely skewed to primary health care facilities where availability is over 80%. The average medicine availability in hospitals is at 42% with theatre commodities solely funded by HSF and patients. Most of the hospitals have pharmaceutical manufacturing units for simple compounding of simple formulations such as Glycerine/Ichthammol, Gentian Violet and Silver Sulfadiazine Cream. These are “low hanging fruits” which can further reduce costs at the same time increasing product availability. National Health Strategy For Zimbabwe 2016-2020 49 Strategic Direction for Health 2016-2020 However there should be investment in the manufacturing equipment and units layout as these have been idle for a long time. The hospital information systems need to be harmonised and fully computerised with all departments, equipment and patient flow properly linked electronically. The availability of equipment and ambulances/service vehicles is at 52% and 33% respectively. The vacancy rate for specialists at hospitals is at 65% with significant disparities in institutional or geographical distribution and poor skills mix. For example, 95% of general surgeons are based in Harare whilst there are very few anaesthetists and paediatricians. To address these challenges, it is imperative that performance based standards be set for specialists to train others and that their distribution be equitable. Patients are currently experiencing long waiting periods for surgeries. For example urology and orthopaedic surgery patients have to wait on average six months with some as long as twelve months. It is therefore important not only to increase the number of specialists but also to capacitate the hospital theatres and health commodities for better hospital service delivery. Goal 2: To improve service delivery platforms or entities Objectives Specific objectives Strategies Objective 16: 16.1 To ensure efficient and • Strengthen oversight on hospital boards according to effective leadership and corporate governance principles To ensure universal corporate governance in • Establish Quality Management System access and provision of hospitals complementary package of hospital services 16.2 To improve generation, • Ensure efficient equitable allocation of available resources including emergency mobilization and allocation • Ensure efficient collection of funds owed and ambulatory curative of resources at hospitals • Improve resource mobilization at hospital level services 16.3 To improve service • Implement Quality Management System and improve patient delivery efficiency flow • Capacitate and improve hospitals theatre services • Improve availability of diagnostic services (laboratory/radiology) 16.4 To improve hospital • Increase availability of functional fixed mechanical equipment, patient management medical equipment and technologies. • Establish patient and staff safety programs • Hospital Infrastructure refurbishment and increased availability of functional hospital vehicles 16.5 To promote hospital • Capacitate management on utilization of IMMIS and DHIS2 based research for improved • Establish and capacitate hospital research committees patient outcomes Objective 17: 17.1 To increase the • Set performance based standards for hospital specialists to availability of specialists and train others To ensure universal access targeted skills • Address disparities in geographical and institutional and provision of quality distribution of specialists tertiary specialist curative services 17.2 To improve hospital • Increase the number of functional ICU and HDU at provincial patient management and central hospitals • Improve availability of specialist diagnostic services (laboratory/radiology) 50 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Goal 2: To improve service delivery platforms or entities Objectives Specific objectives Strategies Objective 18: 18.1 To ensure availability of • Provide training, mentorship and supervision in palliative care essential palliative care for health professionals and non-health professionals To promote and support medicines, training and nationally to develop the necessary skills, knowledge and provision of quality evidence based research attitudes critical in providing quality palliative care. palliative care services • To collaborate with other key palliative care stakeholders such as HOSPAZ (Hospice and Palliative Care Association of Zimbabwe) and Island Hospice Service. • Monitoring and Evaluation of all palliative care service provision. • Promote evidence base palliative care research • Make palliative care essential medicines available and accessible to patients. 18.2 To link palliative care to • Utilise palliative care, hospice programmes (including all prevention and treatment levels of health care facilities, HBC, NAC, palliative care organisations) to identify and refer patients and families to appropriate services for early identification and provision of holistic care. Enabling Environment for Service Delivery In order to successfully implement priority programme strategies, an enabling service delivery environment needs to be created. Therefore, investments have to be made in strengthening this environment and the relevant issues and strategies for doing so are explained in turn. Policy and Administration Policy, Planning and Coordination Policy and administration creates an enabling environment for good governance in the provision of health services. The WHO health systems blocks highlight the importance amongst others of leadership and governance, human resources, health information, procurement and supply of commodities and equipment, infrastructure and financing as critical to the provision of quality health services. During the period under review, the MOHCC had approximately 103 policy and guiding documents, which have to some degree, guided the implementation of health services. However, there was poor synchronization of these strategic documents with the NHS and access to these documents was also limited. This made coordination within the Ministry, inter-ministerial and with other partners a major challenge. Despite the many policy documents, there are still gaps in the guiding documents necessary for creating an enabling environment such as the Health Financing Policy. It was also noted that some of the available policy documents are now outdated and require revision especially the National Health Policy of 1994. Human Resources for Health Zimbabwe has improved over the last the last 5 years on its human resources retention with an overall in-post rate standing at 81% as of July 2015 (MOHCC Staff returns, 2015). However, this is based on an outdated staff establishment that was last holistically reviewed in 1996. There are also major National Health Strategy For Zimbabwe 2016-2020 51 Strategic Direction for Health 2016-2020 challenges in the equitable distribution of this workforce by region as well as by cadres. According to the Public Expenditure Review, Bulawayo had 18 nurses per 10,000 population while Manicaland had 6 nurses per 10,000 population (World Bank PER, 2012). The working conditions for most of the health workers, as compared to regional conditions including salaries, have remained low creating low motivation resulting in brain drain and failure to re-attract those who left back into the country. Finance and Administration The country has failed to meet the Abuja Declaration commitments (spending 15% total government expenditure on health) from the time it was signed up but the GOZ has been making efforts to ensure that health remains a priority Ministry, as it always received the third biggest allocation when compared to other ministries. However, 80% of this has been absorbed mainly by salaries and has fallen short of the WHO recommendation of $86 per capita. The essential health benefits package estimated required an estimated minimum budget per capita of $56.84 (Vaughan 2014). Partner support has sustained most of the programmes work with 98% of medicines being procured by partners (NatPharm, 2015). It has been noted that pooled funding gave the advantage of allocative efficiencies, for example, the HTF. Fragmentation and verticalization of program activities has, however, resulted in limited cross- subsidisation and limited value for money. Procurement and supply chain management The health sector has seen fragmentation in the procurement of health products as these were largely procured through donor funding. Consequently, there have been inequitable commodities supply and security across referral levels particularly at hospital level. There is therefore need to consolidate and integrate supply chain systems and also introduce electronic systems to improve supply chain visibility, data consolidation and quality. Furthermore, increasing transparency in procurement at all levels is equally important in improving value for money and reducing opportunities of system abuse. Monitoring and Evaluation There is currently no harmonized M&E framework policy to ensure that progress is tracked in an integrated fashion. The M&E framework for this strategy is shown in Annex I. Provincial Administration Lack of coordination of national and provincial structures largely due to absence of clearly defined roles remians a challenge that is affecting supportive supervision, and effective implementation of programmes and strategies at ground level. 52 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Goal 3: To improve the enabling environment for service delivery Objectives Specific objectives Strategies Objective 19: 19.1 To create an enabling • Strengthen the governance structures at all levels of the health environment through system To improve health improved planning and • Create regulatory authority for Health Insurers outcomes through monitoring of health service • Strengthen hospital management boards facilitation and delivery • Develop health financing policy coordination of an effective • Revise National Health policy and efficient health delivery • Streamlining roles and responsibilities between Ministry and system HSB • Review organizational structure of the Ministry • Develop a policy framework for Health worker voluntary services. • Align programmatic strategies to the NHS • Harmonise health-related policies and strategies • Gender mainstreaming in all policies • Strengthen quality assurance and improvement across programmes • Re-enforce Risk management processes of resources for health (e.g. performance audits) • Create safety nets through NHI • Develop a traditional medicine policy implementation strategy • Strengthen the protection of Intellectual Property Rights(IPR) of traditional medicine and indigenous knowledge Systems 19.2 To ensure an efficient • Develop an HRH Strategy in response to the needs of the NHS - and effective health workforce to include the following: w Strengthen HR planning and management w Revise staff establishment w Introduce performance based management w Scale up HRIS database at the district level w Create an integrated annual training plan for in-service training in place and development strategy (to address pre-service and in-service training) w Clarify Roles and responsibility for training schools, eg School of nursing (SON) and others. w Strengthen work ethics and practices amongst health workers w Develop an induction manual 19.3 To implement • Ensure alignment of MOHCC financial management system to accountable, effective and the PFM Act and its regulations transparent management • Strengthen coordination of development partner funding systems at all levels of the • Introduce PBB across districts health sector • Safeguard and ensure optimum use of resources through audits • Introduce a resource allocation formula • Introduce compulsory maintenance plans and budgets for equipment and infrastructure • Conduct National Health Account studies • Continuous resource mobilization for the health sector 19.4 To improve procurement • Strengthen procurement entities at all levels. practices across all levels • Develop clear guidelines for procurement activities including pooled procurement • Advocate for increased funding for medicines and medical sundries National Health Strategy For Zimbabwe 2016-2020 53 Strategic Direction for Health 2016-2020 Objectives Specific objectives Strategies Objective 19: 19.5 To improve supply chain • Integrate and harmonise supply chain systems visibility • Employ technology in logistics and supply chain management to increase visibility and commodity security • Integrate and maintain cold chain supply chain systems 19.6 To enhance performance • Develop a harmonized M&E Policy Framework for the and accountability MOHCC. 19.7 To ensure effective policy • Strengthen coordination between National and provincial level implementation at provincial • Clearly define roles and activities between provincial and level national supervision teams • Ensure integrated supportive supervisions per district • Strengthen provincial health team review meetings • Strengthen monitoring and evaluation of RBM Multi-Sectoral Partnerships Attaining the highest possible level of health and quality of life for all Zimbabweans cannot be achieved by MOHCC interventions alone. This vision can only be achieved in partnership with other stakeholders – government and non-governmental organizations. Multi-sectoral partnerships entail involving all sectors of society – government, business, civil society organisations and communities. These partnerships are particularly important for effective regulation; improved service delivery, quality, reach and effectiveness; coordination and efficiency in resource use; building ownership and a sense of involvement and participation by all. Global evidence has shown that countries that have effective structures and institutions for partner coordination have realized improved health sector performance and indeed better health outcomes. Both the National Health Strategy 2009-2013 and its extension 2014-15 strategy, recognized the need for partnerships in health with particular emphasis on partnerships with other government departments and agencies, private sector (both funders and providers), international partners who either fund and or contribute to the delivery of health producing services, and communities. Partnerships with the private sector The private sector in Zimbabwe plays an important role in both funding and providing health services, and this role needs to be enhanced. Seizing opportunities within the private sector for public purposes requires an understanding that it is not a homogenous sector. It has, on the one hand, the private-for- profit sub-sector which includes independent providers such as clinics and hospitals, and pharmaceutical, devices and equipment industries, for example. On the other hand, it has the private not-for-profit subsector that includes mission facilities, non-governmental organisations and other charitable organisations, and medical aid societies involved in funding of health care particularly for the middle class. With regards to partnerships in service provision, missions have a long history of being part of the national health care system; however, over the years support to missions through government grants has been declining in real terms. Furthermore, there has been limited monitoring of the disbursed grants to these institutions because of lack of formal service contracts that define what is expected in 54 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 some cases and or limited capacity by the MOHCC to effectively monitor and manage these grants. Some provinces have established these formal management mechanisms and similar actions are necessary country-wide. In some cases mission facilities are designated as district hospitals for instance to support the referral system, however, challenges sometimes exist in the management and coordination functions of such districts due to the dual governance structure of missions—the government and the church. Local government, like missions, traditionally fund and provide health services in their areas. Recently, local councils have been experiencing funding problems particularly for health services. Their health infrastructure and equipment has deteriorated, health work workers benefits and numbers have shrunk and this has created more inequities in access to essential health services particularly in rural areas. Harmonisation of local government health services and service standards especially primary health care with that of the MOHCC is necessary. Suggestions were made during consultations that the MOHCC takes over local government facilities. The private for-profit sector presents opportunities for widening access to quality services beyond the middle class but a key challenge is the absence of a defined public-private partnership framework within which to cooperate. The Public Health Act and the Medical Services Act, amongst others, provide the legislative framework for governing the private sector, however there is need to strengthen and develop appropriate institutions to regulate the sector in addition to the current self-regulation that exists, particularly amongst professional groups and independent providers. Wider participation of private providers is likely to be enhanced with the introduction of new forms of health financing such as national health insurance. Medical Aid Societies and health insurance companies present opportunities for complementary funding to the health sector by tapping into the growing middle class. However, such opportunities depend on the economic prospects and growth in employment levels. With appropriate regulations and governance arrangements such agencies can potentially assist the state in meeting its health objectives of widening access to quality services. Regulatory function The MOHCC is the custodian of the principal acts or laws that govern what happens in the health sector. Regulating the health sector is a complex but necessary function to achieve public health objectives. Partnerships are necessary between Medical Aid Societies, Health Insurance companies, and other funding agencies for health for better regulatory compliance. Recent experiences with governance challenges in the medical insurance sector demonstrate the need for effective regulation to ensure that those covered by such schemes get fair health benefits, and that multiple pools are properly managed. Equally important are partnerships in regulating various health service providers within government including local government, private providers (for-profit and not-for-profit), civil society and communities. In addition, the pharmaceutical industry and other private agencies involved in the production and or procurement of medicines, commodities and equipment necessary for providing health services require regulations to ensure that the appropriate technologies are produced and distributed to where they are needed the most without creating barriers of access. Decisions on which technologies to use and not to use in the health sector need to be based on some form of health technology assessment including economic evaluation. National Health Strategy For Zimbabwe 2016-2020 55 Strategic Direction for Health 2016-2020 At the professional level, partnerships with professional bodies for ensuring ethical conduct and processes in the delivery of services is an essential part of ensuring that quality services are provided by both public and private providers and facilities. Creation of norms and standards and institutions that enforce these standards presents another layer of partnership that is not only punitive but also developmental. Partnerships with other ministries and sectors The role of other ministries, for example education, agriculture, local government and others, in producing health cannot be minimized. However, such partnerships tend to work well in contexts in which there is not only a single vision but also appropriate governance arrangements to oversee such partnerships. At the national level, the cluster system established under the ZimAsset, provides opportunities for the development of coherent policies that consider health and health related issues (health in all policies). This is particularly important in facilitating a coherent approach to funding and implementing health and health related programmes across sectors. At the sub-national levels, existing structures such as Provincial Councils, Provincial Development Committees and District Development committees present opportunities for effective inter-sectoral partnership. However, such structures have not been fully functional and need to be revitalized through more funding and capacity building. Partnerships with development partners Over the last few years, local and international partners have variously supported the health sector. Depending on which areas have received most support (e.g. HIV and AIDS, malaria, TB and MNCH), health sector performance has been variable and that situation presents challenges. The challenges relate to allocation of resources to priority areas and coordination of activities at all levels to avoid unnecessary duplication and waste, and indeed inequities across programmes and geographically. Global trends have shown that in countries where resources have been channeled through direct budget support, health care systems have performed better and demonstrated resilience even the context of disruptions. Existing partnership forums such as the bi-annual Ministry and partners meetings (e.g. Development Partners Forum, Country Coordinating Mechanism, HTF steering committee, ZimASSET clusters etc.), various technical cooperation agreements and Memoranda Of Uunderstanding (MOUs) all present opportunities for better coordination. However, as identified in the previous strategy there is still need to review and establish effective coordinating structures. Such structures will not only enhance transparency and accountability but also allow for better targeting of resources and support to where it is needed most. Partnerships with communities Communities need not be seen only as beneficiaries of health services but also as co-producers of those services. Their ability to participate in the funding and provision of services depends on the opportunities afforded to them to participate in such activities. Community participation or involvement is the cornerstone of building strong community systems for health. The Constitution defines health care as a right that must be enjoyed by all, and that right requires that the population receives appropriate, acceptable and affordable services. It also means that the health care system must be responsive to their needs and be accountable to them. 56 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 Structures for community participation exist at the local levels such as the Village Development Committees (VIDCOs) and Ward Development Committee (WARDCO), and at facility levels through Health Centre Committees (HCC) and Hospital Advisory Boards. However, the challenge has been that these structures are not always functional. Opportunities exist now to use existing PCNs together with the Village Health Workers and Environmental Technicians to improve community engagement activities at the primary care level. The involvement of other community cadres and traditional leadership will enhance demand for services, and also community and individual responsibility for their health status. Empowering communities to participate in health services planning and providing multiple forums and channels at various levels for community participation is important in building a sense of community ownership and responsibility. The Patient Charter needs to be revived in this regard. Community consultations showed that communities are concerned about accessing quality services whenever they need them. They raised issues of health worker shortages and attitudes, availability of medicines and equipment, patient transport, inpatient facilities such as beds, food and ablution facilities, amongst other things. The strategy is meant to address these issues. Systems and structures of accountability across all levels have been reported to be operating sub- optimally. These structures (e.g. Health Advisory Board) need to be empowered to function effectively and establishing a social compact with the community presents opportunities for people to know what to expect from the health care system and more importantly to know what to do in cases of none or poor delivery of services. Coordination of the multiple partners operating at community level is critical to ensure that the various partners, that is, other government agencies and non-governmental agencies work in harmony towards agreed goals in these communities. Ensuring that health is considered an integral part of other sector programmes will go a long way in addressing the coordination challenges. Goal 3: To improve the enabling environment for service delivery Objectives Specific objectives Strategies Objective 20: 20.1 To strengthen • Support existing national and sub-national structures for intergovernmental inter-governmental interactions To strengthen multi- collaboration • Create a framework for funding health and health related sectoral collaboration activities across ministries with local and international • Mainstream “health-in-all” policies across sector ministries partners • Harmonise of health services at local government level • Improve funding for local government health services 20.2 To improve public- • Develop a policy on public/private and public/public private sector collaborations partnerships in funding and provision of • Develop appropriate regulations to facilitate private sector health services involvement in providing services for public purpose 20.3 To enhance • Strengthen existing platforms for donor coordination collaboration with • Develop guidelines for partner involvement in health development partners development National Health Strategy For Zimbabwe 2016-2020 57 Strategic Direction for Health 2016-2020 Objectives Specific objectives Strategies Objective 20: 20.4 To strengthen • Develop a policy and strategy for community participation community participation and involvement • Develop a policy and strategy for community participation and involvement • Empower health workers with tools for effective community engagement • Strengthen existing local structures for community involvement • Empower communities through implementation of Patient Charter • Create multi-channels and opportunities for community participation at all levels Research and Development Research and development plays a major role in the delivery of quality health services. Research creates opportunities to identify cost-effective interventions to improve results; it makes best or promising practices available or to be better known; it informs policy and programme choices; it allows service provision without waste and duplication, and it facilitates setting of performance standards and facilitate use of performance audits, amongst other things. Research of different types should be seen as an integral part of service delivery at all levels of the health system. Although funding for health research has remained limited at 2-3% of MOHCC expenditure (PER 2015), over the last few years various agencies in Zimbabwe have conducted several research activities to support various programmes in the MOHCC and associated sectors. Evidence from such studies has largely been generated as part of reviewing programmatic progress, and to inform policymakers and programme managers of the successes and failures of programmes and more importantly attempting to understand the underlying root causes that warrant attention. In some instances such scientific evidence has not actually been used to inform policy and practice because once published the reports are displaced elsewhere. Whilst it is important to conduct robust studies to generate new knowledge and inform policy and practice, it is equally important to make sure that such evidence is widely shared, and translated into digestible forms for use by the general public, practitioners and indeed policy makers. Translating research evidence into policy, practice and product is critical to the adaptive nature of the health systems, health services and to the changing socio- economic environment that affects service providers and user behaviours. Such research will also include exploring the therapeutic value of traditional medicine. The National Institute for Health Research (NIHR) is an important agency not only in conducting relevant national health research but in also building capacity for health research at all levels and building partnerships. The institute is largely underfunded to employ and retain competent researchers, to upgrade its laboratories, improve its research infrastructure for diseases surveillance (malaria, schistosomiasis, water borne diseases, etc.), training activities, research communication and knowledge 58 National Health Strategy For Zimbabwe 2016-2020 Strategic Direction for Health 2016-2020 management generally. The Institute is a strategic asset for coordinating and collaborating with other national and international academic and research institutions in conducting essential national health research that addresses priority issues. However, the challenge is that there is no revised national health research agenda so that various agencies can contribute to its implementation. This strategy seeks to address this by updating the essential national health research agenda that clearly defines national research priorities, suggest possible approaches to addressing those research priorities, strategic research partnerships and how the evidence generated can be utilized at all levels. For instance, all indicators around adolescent health have been consistently poor over the years despite significant investments in targeted interventions. Therefore, finding appropriate solutions to adolescent health requires analysis of existing evidence and testing of new innovative interventions. Traditional medicine continues to play a role in providing services to the public but challenges remain in ensuring use of approved and registered medicines, and promoting evidence based practices. Within the health sector, there is the challenge of widespread limited use of routinely generated information by practitioners and managers at various operational levels to make informed operational and management decisions. Part of the reason for limited data use is the high workloads, and part because of limited capacity to analyse the collated data that is routinely submitted to higher levels. In order to improve coverage and quality of services provided at all levels of the health delivery system, it is critical that data use and research is mainstreamed down to the community level. The culture of asking questions, collecting data and analyzing it for informed decision making needs to be re-cultivated over the strategy period. Goal 3: To improve the enabling environment for service delivery Objectives Specific objectives Strategies Objective 21: 21.1 To develop an essential • Develop a national health research policy national health research • Conduct consultative process for reviewing the national health To improve uptake of policy and establish an research agenda scientific research evidence essential national health for decision making and research agenda for the policy development by 70% country 21.2 To develop human • Build capacity of health research and development (human, capacity for health research material and financial capacity) at all levels (national, development provincial, district and community levels) 21.3 To promote translation • Establish a Technical Working Group for health research and of research into policy, development that will push the health research agenda and use practice and product of research results for evidence based decision making and policy development • Convene results sharing fora or mechanisms at various levels National Health Strategy For Zimbabwe 2016-2020 59 Strategic Direction for Health 2016-2020 Objectives Specific objectives Strategies Objective 21: 21.4 To conduct research • Ensure research approval system informed by national health (including surveys) on priorities priority health issues • Encourage collaborative projects with other institutions and investigators including practitioners • Promote research excellence (NIHR, MRCZ, RCZ, ZIPHA, etc.) • Conduct a hepatitis survey that will inform intervention strategies 21.5 To strengthen research • Conduct research on TM to inform practices framework for traditional • Promote evidence based practices medicine 60 National Health Strategy For Zimbabwe 2016-2020 Overall Context for the National Health Strategy 2016-2020 4 4.1 Implementation Framework Attaining the vision and mission of the NHS 2016-2020 needs enhanced service delivery platforms or entities and an enabling environment in which policy and administration is effectively implemented and coordinated (Figure 24). Underlying all this is the need for a sustainable funding mechanism for health in which people access and use quality services without hardship and are therefore unlikely to fall into financial hardship because of it. Achieving equitable access to health services means that the health system must provide adequate services (essential health package) to all and do so with limited direct costs (including OOP). Introducing an essential services package will facilitate this process and allow appropriate funding mechanisms to be established to deliver it over the next five years. As the fiscal space changes so will the package of essential services with the desire to continuously improve it over time. Significant investments in health system strengthening are necessary for the health facilities and other service delivery and coordination platforms to function optimally. This is achievable if the health workforce, medicines and other commodities, health information system, transport and infrastructure, and ultimately leadership and governance are strengthened and transformed accordingly. Business as usual will not lead to the desired twin outcomes of equity in access to services, and improved quality of services and indeed to “the highest possible level of health and quality of life for all Zimbabweans”. To date, inequities in access to quality services remain a challenge for the health sector and this strategy seeks to address that by improving efficiencies in the system at all levels, resourcing priority areas, focusing on quality and equity in each programmatic area, and leveraging on mutli-sectoral actions - that is, “all of government and all of society” in implementing health programmes and activities. This means that public-private partnerships for public purposes are an essential strand of this strategy so that government and all its partners work collaboratively at all levels of the health system. As innovative programmes such as RBF and others are scaled up, it important that current gains are sustained and improved, and new innovative programmes such as e-health are implemented to enhance and not to disrupt what has been working so far. National Health Strategy For Zimbabwe 2016-2020 61 Implementation of National Health Strategy 2016-2020 Figure 24: Organizational and Implementation Framework Health workforce Priority Program 1 Communicable Diseases) Medicines, vaccines and othe health products Primary Care Services Priority Program 2 Transport Equity in access Noncommunicable diseases Improved Health & Quality of life for ALL Public Health Zimbabweans HEALTH FINANCING Services Health InformaƟon Improved quality of services Priority Program 3 RMNCHA Hospital Services Infrastructure Policy and Priority Program 4 AdministraƟon Public Health Surveillance & disaster preparedness MulƟ-sectoral partnerships Research & Development The national level (Head Quarters) needs to respond to this strategy by aligning its organizational structure to achieve the desired results over the next five years. Enhanced and new coordination mechanisms at the national level must cascade to the provincial, district and even the sub-district level so that there is service integration and effective oversight. District management teams need to be strengthened and supported to facilitate more supportive supervisions and engagement with communities, particularly the vulnerable and hard to reach populations. Creation of sub-district level structures that leverage on existing ones is critical to the strengthening of community systems and improving the interface between the health system and communities. Gender mainstreaming is an inherent and important part of the strategy of addressing inequities in access and health outcomes as women and men face different health risks, experience different responses from health systems, and their health-seeking behaviour, and health outcomes differ because of social (gender) and biological (sex) differences. Implementation of the various strands of this strategy should therefore target women by improving their access to information, prevention and treatment services, and more so services to sexual abuse and violence victims. The Ministry will also facilitate enforcement of appropriate laws on sexual abuse and violence particularly of women. Community participation is viewed holistically as involving appropriate, responsive and accountable utilization of health services. Whilst people must understand their rights to health care, they must also understand their responsibilities to the health system so that the system benefits the greatest number of people. Individuals must also take responsibility for their health status by choosing appropriate lifestyles. 62 National Health Strategy For Zimbabwe 2016-2020 Implementation of National Health Strategy 2016-2020 Quality improvement and assurance is essential across service delivery platforms and policy coordination and implementation at national and provincial level. The Quality Strategy as aligned to this strategy will drive the provision of both curative and preventative services. Its focus is holistic in that its basic principles are cross-cutting: a) preventing adverse outcomes for clients (patient harm) through infection control, reducing medical errors, and costs; b) reducing unnecessary or avoidable waste through economic evaluation studies, assessments of duplication, addressing waiting times and unnecessary referrals and treatments; and c) exploring opportunities to foster innovation in how care is delivered, to include coordination between services, reducing overuse of some services, and avoiding underutilization of technology. Overall, the health system must be patient-centred and responsive to their needs. Introduction of quality standards and an institutional arrangement to ensure enforcement of these standards is necessary over the strategy period. 4.2 Costing scenarios and key assumptions Zimbabwe National Health strategy (NHS) costs estimation was facilitated by the UN OneHealth tool, a unified costing template that estimates the cost of health services and system inputs required to achieve desired health outcomes and impacts. Further details on the tool and costing process are available (MOHCC 2016). The costing exercise aimed to estimate all costs related to delivering the package of health interventions identified in the NHS for the period 2016 to 2020. Health programs costed include: Reproductive Health Maternal Newborn and Child Health; Immunization; Malaria; TB; HIV/AIDS; Nutrition; Environmental Health and WASH; Non-communicable diseases; Mental Health and Other Communicable Disease (such as Rabies, Anthrax, Other Diarrhoeal Disease). Costs related to health system investments include: Human Resource, Infrastructure, Governance, Health Information System, and Logistics. Three scenarios were defined to assess how cost and impact differ for alternative scenarios of packages, targets and activities. This allows examining alternative scenarios for reaching targets to make informed decisions and select the policy option scenario and targets to incorporate for final estimation of activities and budgets. The draft NHS provided an ambitious plan that could not be sustained by current or anticipated financial resources. This ambitious plan corresponds to the NHS3 costing scenario or “Optimal” scenario. The prioritization exercise enabled development of a robust, concise yet feasible NHS within reasonable anticipated resource envelope: this is the NHS2 costing scenario or “High Impact interventions” scenario. The policy direction informing the prioritization centered on the need to address the overarching bottlenecks identified through the bottleneck analysis conducted during the development of the NHS. The thrust was to embrace the primary health care approach (though equally addressing the referral bottlenecks), with a focus on harnessing the principal gains envisaged in preventative programming. Finally, NHS1 costing scenario reflects what it would cost to maintain current coverage level for health interventions: this is the “baseline” scenario (Figure 25). National Health Strategy For Zimbabwe 2016-2020 63 Implementation of National Health Strategy 2016-2020 Figure 25: Objectives and keys assumptions for the three costing scenarios •No change in health service and health system coverage NHS 1: "Baseline" •No change in investments Maintain 2015 coverage levels for •Flat-lined coverage of health services all health intervenƟons •No capital investments (e.g. construcƟon of addiƟonal health faciliƟes NHS 2: "High Impact •Scale-up of RMNCH, Malaria, HIV, NutriƟon and NCDs intervenƟons" intervenƟons with emphasis on lower levels of care •ShiŌ provision of prevenƟve services at the primary health level Reduce mortality associated with •Infrastructure improvements at the primary level only the 20 established leading causes •Investments to improve availability and security of medicines within limits of the proposed and supplies financial space •CapacitaƟon of skilled Human Resources •Health service and health system investments implemented NHS 3: "OpƟmal scenario" as planned •All proposed Infrastructure (construcƟon and renovaƟon of Scale up opƟmally most health health faciliƟes at all the levels) incorporated service intervenƟons •All planned HR improvements factored into this model (faciliƟes and admin staff recruitments and training) The entire plan would cost $6.7bn, $7.4bn and $8.3bn for NHS 1, 2 and 3 respectively (Table 16). At the end of the period, the per capita cost would be $73, $91 and $97 for NHS 1, 2 and 3 respectively. Table 16: Total cost for the three scenarios (million USD) Scenarios 2015 2016 2017 2018 2019 2020 Total NHS 1 926.12 1,137.54 1,192.01 1,150.43 1,125.50 1,115.62 6,647.23 NHS 2 926.12 1,187.45 1,302.72 1,316.45 1,348.63 1,364.53 7,445.90 NHS 3 926.12 1,262.98 1,516.87 1,580.66 1,577.39 1,460.60 8,324.63 The preferred scenario (NHS 2), which is expected to have a mean cost per capita of $88 over the entire period, would have the following impact in 2020: Decline in infant mortality from 45 per 1000 (2015) to 36 per 1000 live births in 2020; Decline in child mortality from 70 per 1000 (2015) to 60 per 1000 live births in 2020; Decline in maternal mortality ratio from 614 (2015) to 514 per 100,000 live births in 2020; and 101,984 life years gained by ART and PMTCT interventions by 2020. 64 National Health Strategy For Zimbabwe 2016-2020 References R CORDAID (2015) RBF Client Satisfaction Survey Results, unpublished Euro Health Group (2014) Comprehensive assessment of the supply chain for health commodities in the public sector in Zimbabwe, final report Food and Agriculture Organization of the United Nations Food Balance Sheets (FAOFBS), 2009 Global Fund (2013) Concept Note Malaria Global Fund (2013) Concept Note HIV Global Fund (2013) Concept Note TB MOHCC (2011) Health Transition Fund, A Multi-donor Pooled Transition Fund for Health in Zimbabwe, Supporting National Health Strategy to improve access to quality health care in Zimbabwe MOHCC (2015) Zimbabwe National and Sub-national HIV and AIDS estimates, 2014 Vaughan K (2014) Costing Zimbabwe’s Health Benefit: Costing Findings, Royal Institute of Amsterdam (KIT), Amsterdam MOHCC (2015) Draft Health Sector Performance review Report MOHCC Staff returns, 2015 MOHCC (2012 Formative Research on Barriers and facilitators to optimal IYCF. MOHCC (2016) Report on the costing of the Zimbabwe National Health Sector Strategic Plan 2016-2020 National Food Fortification Strategy, 2014-18 National Health Strategy, Bottleneck Analysis (2015) National Health Strategy, SWOT analysis report, (2015) National Micronutrient Survey (NMNS) (2012) National Health Strategy For Zimbabwe 2016-2020 65 References National Medicines Survey, 2013 Public Sector National Medicines Survey, 2013 Private Sector Vital Medicines and Heath Service Availability Survey, 2015, Round 23, Health Transition Fund World Bank (2015), Health Expenditure Review, Zimbabwe. World Bank Group, Report No.97175 Zimbabwe National Statistics Agency (ZimStat). 2014. Multiple Indicator Cluster Survey 2014, Key Findings, Harare, Zimbabwe, ZIMSTAT. Zimbabwe National Statistics Agency (ZimStat). 2011. United Nations Children’s Fund (UNICEF) and Collaborating Centre for Operational Research and Evaluation (CCORE) , 2013. National Baseline Survey on Life Expectancies of Adolescents Report. Zimbabwe Services Availability and Readiness Survey (2015) Constitution of Zimbabwe Amendment (No. 20) Act 2013 Zimbabwe Demographic Health Survey 2005 Zimbabwe Demographic Health Survey 2010 Zimbabwe National Cancer Registry 2009 Zimbabwe Perinatal Mortality Study, 2007 Government of Zimbabwe, Zimbabwe Agenda for Sustainable Socio-Economic Transformation (ZimAsset), “Towards an Empowered Society and a Growing Economy”, October 2013- December 2018 66 National Health Strategy For Zimbabwe 2016-2020