The Zimbabwean Experience with Primary Healthcare in the Period 1981-2000: Which Factors Shaped this Success Story?

Author(s):

B. Criel*1, P. Bossyns2, T. Hoeree1, J. Macq3, B. Vander Plaetse4, A. Van Geldermalsen5, E. Mabiza6, G. Mhlanga6, C. Tshuma7, A. Chimusoro8

Affiliation(s):

1Department of Public Health, Institute of Tropical Medicine, Antwerp, 2Medical Department, Belgian Technical Cooperation, 3School of Public Health, Free University of Brussels, Brussels, Belgium, 4Health Section, Alafa project, Maseru, Lesotho, 5Health Services Support Programme, 6Department of Public Health, Ministry of Health & Child Welfare, Harare, 7Provincial Medical Office, Ministry of Health & Child Welfare, Bindura, 8Provincial Medical Office, Ministry of Health & Child Welfare, Gweru, Zimbabwe

Keywords: Primary healthcare, district health systems, strengthening health systems, Zimbabwe
Background:

Zimbabwe succeeded, after its independence in 1981, in dramatically transforming its health system. During the 80s and 90s, the Zimbabwean health services gradually evolved into one of the best performing systems of Sub-Saharan Africa.

Summary/Objectives:

We believe that the Zimbabwe experience constitutes a major learning opportunity for our understanding of how to organize Primary Health Care (PHC). We analyse the factors, both internal and external to the health system, which contributed to the success at the time. The current crisis in the health sector does not necessarily invalidate lessons from the past.

Results:

We distinguish between factors internal and external to the health system.

Internal factors:

1 – A clear operational model on how to organize PHC based on the development of integrated district health systems with networks of decentralized health centres staffed by small teams of versatile health workers, supported by district hospitals acting as back-up facilities for patients in need of more specialized nursing and medical care. Specific disease-control activities were largely integrated in the district health care delivery system.
2 – Multidisciplinary district health teams (doctors, nurses, health administrators, environmental workers, pharmacists) heading the district health services system and operating in a managerial environment with room for local decision-making and resource allocation.
3 – Significant support from provincial health teams for the district teams. The availability of true specialized care at the level of provincial hospitals and the existence of functional referral systems enhanced the health system’s overall credibility.
4 – Well-trained frontline health workers operating in a culture of rationalization of diagnostic and therapeutic behaviour and quality control.

External factors: 1 – Strong national political (and financial) commitment towards social sectors in general, and the health sector in particular. The rights-based approach of the Alma Ata philosophy found fertile soil in the postrevolution period.
2 – Support from the international donor community, including the provision of expatriate health workers integrated in the Zimbabwean public service system.
3 – Good basic transport and communication infrastructure inherited from the Rhodesia regime.
4 – Presence of economic development (commercial farming, tourism) in the 80s and early 90s.
5 – A bureaucratic but functional State apparatus: fulfilment of its normative role, payments of decent salaries to civil servants, punitive action in case of professional misconduct of health workers, etc.
Lessons learned:

In the case of Zimbabwe, in the period 1981-2000, a conjunction of elements, both internal and external to the health sector, led to an environment conducive to the development of equitable and effective PHC systems. With the increased attention for the strengthening of low-income countries’ health systems, the Zimbabwe experience provides a valuable source of inspiration.

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