Harp Needs Assessment for the Health Sector in Zimbabwe
Humanitarian Assistance And
Recovery Programme (Harp)
Rapid Needs Assessment for the Health Sector in Zimbabwe
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HARP Rapid Health Assessment Report May 2002
Table Of Contents
Abbreviationsii
Executive summaryiii
1.0Introduction And Background1
2.0Objectives of Assessment1 2.1 Outputs Of Assessment 2
3.0Methods And Limitation2
Findings
4.0Health Stakeholder Analysis4
4.1Health Stakeholder Profile4
4.2Strengths Of Operation5
4.3Weaknesses Of Operation6
4.4Operational Problems And Constrains6
4.5Plans for the current Humanitarian Crisis7
4.6Recommendations7
5.0Disease Surveillance11
5.1Recommendations11
6.0Burden Of Disease12
6.1Epidemics13
6.1.1Epidemic Trends14
6.2Recommendations15
7.0Access To Health Care Vulnerable Groups16
7.1Staffing of Health Services16
7.2Costs of Health Care17
7.3Availability of Services to Communities18
7.3.1Availability of health facilities18
7.3.2Use of outreach services19
7.3.3Health Extension Workers Services19
7.4Recommendations20
8.0Drugs21
8.1Recommendations23
Abbreviations/Acronyms
AIDS Acquired Immune Deficiency Syndrome
ARI Acute respiratory Infection
CBD Community Based Distributor
CFR Case Fatality Rate
EHO Environmental Health Officer
EHT Environmental Technician
HARPHumanitarian Assistance and Recovery Programme
HAS Health Services Administrator
HBV Hepatitis B Vaccine
HC Health Centre
HIV Human Immune Deficiency Virus
IMCI Integrated Management of Childhood Illnesses
MOHCW Ministry of Health and Child Welfare
NANGONational Association of Non Governmental Organizations
NBTSNational Blood Transfusion Service
NGONon Governmental Organization
NNT Neonatal Tetanus
Pharm Tech Pharmaceutical Technician
PMD Provincial Medical Director
RDC Rural District Council
SM School Master
TBTuberculosis
TM Traditional Midwife
UMPUzumba –Maramba-Pfungwe
UN United Nations
UNCT United Nations County Team
UNFPAUnited Nations Population Fund
UNHCR United Nations High Commissioner for Refugees
UNICEFUnited Nations Children’s Fund
VHW Village Health Worker
WFP World Food Programme
WHOWorld Health Organisation
ZACH Zimbabwe Association of Church Related Hospitals
EXECUTIVE SUMMARY
A rapid health assessment was carried out in twenty-four (24) districts of Zimbabwe to guide the Health Sector response to the humanitarian crisis arising from economic recession and the 2001/2002 drought. The assessment entailed a desk review to determine vulnerable groups and populations after which a field assessment was carried out. The findings were:
Twelve (12) partners in provision of health services were identified. These organisations run programmes on HIV/AIDS, family planning, primary health care and emergency relief services. Problems of coordination and duplication of efforts were found among the partners.
It was found that peripheral health facilities had no capacity to analyze and use local data to control locally endemic diseases.
Trends in morbidity and mortality over the years 1997 – 2002 showed that for most diseases morbidity rates declined while mortality rates increased. However, for cholera both morbidity and mortality increased for the years 1999 to 2002. Major causes of morbidity were ARI, malaria skin diseases, diarrhoea and injuries while major causes of mortality were ARI, malnutrition, diarrhoea, TB and HIV/AIDS. Both morbidity and mortality tended to be high in specific districts. In 2001 morbidity rates in under fives were lower than in persons aged above five years.
Some 24% of all posts (in all categories of staff) on establishment in all provinces combined were vacant. Since January 2000 12%, 13%, 18% and 8% of doctors, clinical officers, pharmacists and nurses respectively have left the MOHCW. At health facilities where substantial losses occurred, this had compromised the quality and quantity of services provided. Charges levied by some health institutions have reduced access to services by women and children. The large-scale movement of people under the current humanitarian crisis has resulted in these populations not accessing health services including safe water supplies and adequate sanitation. Consequently these populations are extremely vulnerable to disease outbreaks. It is estimated that 1 million people countrywide are vulnerable due to lack of basic health services.
Seventy-three percent (73%) of peripheral health facilities had severely depleted stocks of essential drugs.
Epidemic prone diseases such as cholera show an upward trend. Peripheral health facilities did not seem to have the capacity to detect and control the epidemics.
Vulnerable populations are located far from any health facilities and this compounded by lack of outreach services.
Recommendations
MOHCW in partnership with WHO/HARP should strengthen coordination mechanisms by e.g. holding regular consultative meetings with NGO partners in health with the view to operate in unison to maximize efforts directed at cushioning impact of the humanitarian crisis.
WHO/HARP to support training of peripheral health workers in order to improve disease surveillance.
WHO/HARP should provide training of peripheral workers in epidemic preparedness and control and expertise to help out control current epidemics.
Efforts directed at controlling diseases should be focused at risk groups and areas.
MOHCW should seriously look at rationalizing staff posts and improving conditions of service in order to retain the remaining staff and WHO/HARP to provide logistical support for supervision of staff at peripheral levels.
MOHCW should work with the health partners who run primary health care serves and rationalize the fee structure to ensure that vulnerable groups such as pregnant women, children and the elderly have access to free health services.
MOHCW should examine use of extension health workers to reach the vulnerable population groups and WHO/HARP to provide logistical support and support training of such cadres.
WHO/HARP mobilise funds to immediately procure vital drugs, vaccines and medical supplies for all health institutions to ensure adequate cover.
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HARP Rapid Health Assessment Report May 2002
1.0INTRODUCTION AND BACKGROUND
In the last three years (since early 2000) Zimbabwe has been going through a severe economic recession that has impacted negatively on the health of the population and operations of the health sector in Zimbabwe. The humanitarian crisis spawned by the economic recession has been exacerbated by effects of two natural phenomena viz Cyclone Eline flooding of some parts of Zimbabwe in February –March of 2000 and the drought that has been experienced country wide in 2001/2002 agricultural season. In response to the appeal of the Government of Zimbabwe the UN Country Team in Zimbabwe developed the Humanitarian Assistance and Recovery Programme (HARP) to spearhead efforts directed at averting and or cushioning the community, particularly vulnerable population groups, from the negative effects of the crisis. In this regard WHO, the lead UN agency in health, was mandated by the UN CT to coordinate the health sector emergency response to the humanitarian crisis.
Recent occurrences that have included stock-outs of essential drugs at most health facilities, severe losses of professional staff from health facilities run by MOHCW, reduced capacity of MOHCW to control epidemics and large scale movement of people into areas where basic health services and amenities are not available to sufficiently cater for these populations has led the health sector to believe that a humanitarian catastrophe that could put many lives at risk was unfolding. In order to identify and quantify health problems associated with this crisis a health needs assessment was conducted in May 2002.
2.0OBJECTIVES OF THE ASSESSMENT
The main objectiveof the assessment was to guide the WHO/HARP response through identification of the health needs of the population and vulnerable groups in particular while the specific objectives were to:
- Identify key stakeholders working with vulnerable groups in the field of health – specifically where, how and when key stakeholders are operating in Zimbabwe and share information with identified key stakeholders.
- Identify strengths and weaknesses of disease surveillance and response systems considering human, financial and logistics issues.
- Identify the top ten causes and the trends of mortality and morbidity in Zimbabwe including case fatality rates between the years of 1996 to 2002 disaggregated by age group and district.
- Identify vulnerable groups and districts in terms of health needs and access to health care using available data e.g. WFP reports, poverty indicators, mortality and morbidity figures, previous epidemic data and district and provincial administration reports, MOHCW reports. Note access to health care should consider – availability of drugs, supplies and health staff, costs of care, distance to health facilities and availability of outreach services.
- Assess the availability of vital drugs, vaccines and medical supplies at national and district level.
- Identify and assess the health system response to current epidemics.
2.1 Outputs of Assessment
The main expected output of the assessment was to provide a full report on the health needs of vulnerable groups and make recommendations for WHO/HARP inputs while specific outputs were to:
Stakeholders (operating in the health field) serving vulnerable groups identified and relevant documentation from these stakeholders collected.
Recommendations for co-ordination mechanisms between the various stakeholders made.
Strengths and weakness of the disease surveillance system identified and recommendations for inputs from the WHO/HARP indicated.
Morbidity and mortality trends (disaggregated by district, age and sex). Among vulnerable districts and groups described.
Availability of drugs, vaccines and supplies at national, provincial and district (including selected rural health centres) indicated.
A summary of recent (2002) epidemics and the health system’s response provided with recommendations indicating inputs for the WHO/HARP support.
Additional funding required mitigate excess morbidity and mortality caused by the drought and current economic climate in Zimbabwe indicated.
3.0 METHODS OF THE ASSESSMENT
The following methods were used to carryout the assessment:
(a)Desk review: A review of documentation from various institutions and organizations (MOHCW, WHO, WFP, FAO, UNICEF, UNHCR, NANGO) on the current crisis was carried out. This effort was mostly used as a platform to develop the various approaches/strategies and focus on field aspect of the study.
(b)Field assessment:
The assessment was carried out in all the eight (8) rural provinces of Zimbabwe namely Masvingo, Matabeleland North, Matabeleland South, Manicaland, Mashonaland East, Mashonaland West, Mashonaland Central and Midlands. From each province, 3 districts were selected for study and thus all in all 24 districts listed in Annex 1 where included in the study.
The districts selected for study were defined by the UNCT, which selected them on the basis of various criteria (e.g. levels of poverty, history of population vulnerability etc). From each district three (3) health facilities were selected for study namely the district hospital, a mission hospital and a rural health centre. A total 72 health facilities were included in the study. Health personnel were interviewed at provincial, district, and health facility (including mission hospitals) levels. In the community, 20 heads of households per district (10 from a traditional communal land and 10 from newly resettled area) were interviewed and thus some 480 households from some 48 villages were included in the study.
Information on stakeholders (partner institutions that provide health services other than the MOHCW) was collected through interviews of their in-charges in Harare who were also asked to provide documentation or literature (annual reports, mission statements, plans) on the operations of their organizations.
Information on operations of stakeholders was sought from provincial and district health offices, and from heads of households interviewed in the community.
A set of data collection instruments for use at provincial, district and
community levels were developed, and criteria for selection of facilities and communities to be assessed were determined. Prior to the assessment teams that included health personnel from MOHCW (provincial staff) and WHO were selected and trained.
Data was entered and analyzed in EPI-INFO Version 6.1 and Microsoft Excel statistical packages.
Limitations of the Assessment
- The effort was constrained for time on account of the urgency of the assessment. On account of this the development of the data collection instruments was hurried and they were not pre-tested in the field.
- Selection of districts for the study was predetermined on the basis of criteria that met interest of the MOHCW and various UN agencies included on the HARP effort.
- Districts selected for study were far flung this meant that supervision of data collection was difficult on account of travel time etc.
FINDINGS
4.0HEALTH STAKEHOLDER ANALYSIS
Source of information: during interviews with the NGO’s, we collected literature materials such as reports including annual reports, country profiles, mission statements and strategic plans. From the WHO library we were able to look at (a) Country Report on NGO’s Working in the Health Sector Vol II (1997) (b) the NANGO Zimbabwe NGO Directory
4.1Stakeholders Profile
Several NGOs, UN agencies and church organizations that operate in the districts and provide a wide range of health related services have their main offices in Harare. During the field survey communities were able to indicate some 16 of these organizations operate among them (see Annex 2). Other than the MOHCW, two major partners that provide curative and preventive health services in the rural areas are the church related missions and rural district councils.
Table 4.1 shows the activities of health sector NGOs that were consulted on this study. They included Red Cross Zimbabwe, which is providing health and social services, an AIDS control programme and providing water and sanitation to over 100,000 people in all the 8 provinces. Lutheran World Federation operates at national level and in Beitbridge, Zvishavane, Mberengwa, Chivi, Mwenezi and Gwanda districts where they provide HIV/AIDS awareness water supply and provision of nutrition. World Vision International provides health education, water development and food security in Chivi, UMP, Insiza, Gokwe, Mt. Darwin, Chipinge, Mudzi, Chiredzi, Beitbridge, Bulilimamagwe, Mberengwa and Hurungwe districts. In the districts of Kwekwe, Mutare, Chipinge, Mutasa, Chiredzi, Tsholotsho and Mutoko, Plan International caters for some 580,000 people and runs programmes that include an STI’s/HIV/AIDS prevention, malaria control and support for
Orphans.
Care Zimbabwe is involved in women’s health, supporting AIDS affected people, providing nutrition support and delivering relief in emergencies through their sub-offices in Gweru, Mutare, Masvingo and Zvishavane. Their operations cover over 704,500 people. They run a supplementary feeding programme that caters for over 125,000 children who are either under fives or elementary school-going children. The Zimbabwe Association of Church Related Hospitals (ZACH) is responsible for coordinating the activities of church related hospitals. Most districts have church hospitals, which run
patient care services and other primary health care activities. Some facilities that are run by members of ZACH such as Mutambara (Chimanimani district), Murambinda (Buhera district) and Munene mission (Mberengwa district) are designated district hospitals. ZACH also provides other activities such as development of AIDS education, family planning and reproductive health, MCH, strengthening health information and IEC, home based care and clinical reproductive health services and research.
Other NGOs include Christian Care whose activities include projects for water and sanitation and supplying food to rural health centres (clinics) in Beitbridge, Mutare, Insiza, Hurungwe, Chipinge Guruve, Mwenezi, Chiredzi and Muzarabani districts. In Binga and Kariba districts, Save the Children UK is providing HIV/AIDS awareness and prevention, home based care training and equipping and covers over 200,000 people. REDD BANA (a Norwegian organization) is in the process of putting up a comprehensive nation-wide programme on HIV/AIDS which will have a nationwide coverage.
The UN agencies with programmes at the national provincial and district
levels include UNICEF, which operates in 26 districts countrywide.
The districts are selected based on PASS survey which is based on 4 top priorities i.e., lack of basic social services. Their services range from EPI, IMCI, safe motherhood, reproductive health, water and sanitation, nutrition and health education. UNFPA works through the PMD’s to access the districts nationwide and their activities include services in family planning, integrating HIV/STI, supporting areas with high levels of maternal/infant morbidity and mortality through upgrading quality of essential and basic emergence obstetric care. Another UN organization providing health programmes among refugees is the UNHCR.
In the field of funding, the European Commission (Zimbabwe) donated 57 million EU to cover the following activities for the period 2000 to 2006: assist MoHCW to develop a sustainable health system, provision of essential drugs and supplies, institutional strengthening of NATPHAM, enhance planning for HIV/AIDS pandemic, support increased access to district health services, support preservation of human capital in the face of HIV/AIDS and provide equipment, supplies, technical assistance and building works for the national blood transfusion services (NBTS).
4.2Strengths Of The Operations
Strengths of NGOs and other partners were identified as:
(a)ability to carry out rapid health needs assessment – most organizations indicated that they regularly carry out needs assessments to determine at risk populations and communities needing assistance.
(b)funding available for execution of tasks including prompt delivery of logistical support and manpower (experts) during emergencies and disasters.
(c)ability to meet among themselves, communicate with MOHCW and other GOZ departments and hold consultations with various administrators at provincial, district, health facility and community levels.
(d)Ability to cover large populations including operating at grassroots levels.
4.3Weaknesses Of The Operations
Information outlined under this section was obtained by asking various people at provincial, district, health facility and community levels on how they viewed the operations of the NGO’s and several problem areas were identified:
Some districts such as Chimanimani, Rushinga, Makonde, Mazowe,
Murewa and Hwedza are not covered by any NGO or partners in health
at all.