Equity in Health: Zimbabwe Nine Years On.
This paper summarises Zimbabwe's legacy in both health (or disease) and health services. It then examines the changes in the economic environment which have taken place in Zimbabwe since independence in April 1980, concentrating on those which are relevant toilealth. It also describes the post independence restructuring of the health sector itself. Access to health care and some aspects of the functioning of the referral system are also briefly dealt with. The questions of community participation in health and accountability of health workers, both central to the Primary Health Care (pHC) approach, are addressed by a brief discussion of the Village Health Worker (VHW) programme. The relevance of this example for the health sector as a whole is briefly examined. Finally, the paper considers some changes which have taken place in health status since independence and attempts to analyse the sources of these. Introduction This paper will look at the broad context of health and health services in Zimbabwe. It was originally conceived as a background paper for a Journal of Social Development in Africa workshop, and was intended to inform discussion on the role of health manpower in relation to equity in and access to health services in Zimbabwe. It is generally accepted that the health of a nation is a sensitive expression of the prevailing socioeconomic conditions, and that disparities in disease experience reflect differences in both living conditions and ac~ss to health care. This paper will, therefore, address both the social and economic context of disease in Zimbabwe, as well as the measures taken by the health sector to deal with it Background Much of this and the next section is drawn from Sanders and Davies (1988). In colonial Zimbabwe, as in other under-developedcountries, the greatest burden of death and disease fell on infants (under one), young children, and women in the child-bearing *
A revised version of a paper presented to the Workshop 011 Health Manpower Issues in Relation to Equity in and Access to Health Services in 2'ID1babwe, June 819 1989, Harare,2'ID1babwe. Lecturer, Dept of Community Medicine, Medical School, University of2'ID1babwe, POBox A178, A vondsle, Harare
period. In addition, mortality varied substantially by geographical area, race and class. In 1980 there was a 1:3:5: 10 ratio in infant mortality rate (IMR) between whites, urban blacks, and rural blacks, corresponding to a 39:5:1 ratio in incomes (Ministry of Health, 1984a). While the IMR of 17 per 1 000 for the white population appn»limated that of industrialised countries, for the majority black population it was estimated to be 120 per 1 000. While the better off showed the disease pattern seen in industrialised countries, the majority of the population suffered nutritional deficiencies, communicable diseases and problems associated with pregnancy. Maternal under-nutrition contributes to low birth weight in 10-20% of all births. This, and protein-energy malnutrition, were the commonest forms of childhood malnutrition, predisposing the victims to more severe and often fatal infections. The most important of these were measles, pneumonia, tuberculosis and diarrhoeal diseases, which, together with meningitis, neonatal tetanus and other infections of the newborn, accounted for most infant and young child mortality. Of the occupational diseases, industrial lung diseases such as asbestosis, silicosis (and tuberculosis) and coalminer' s lung; stress-related disorders such as high blood pressure; and plantation-related problems such as schistosomiasis, malaria and the toxic effects of pesticides and herbicides, were all (and are increasingly) visible but undoubtedly under-reported. Mental illhealth and alcoholrelated problems were also common, the latter being reflected in liver disease and indirect! y in