Zimbabwe : from supermarket to cafeteria / by H. Anenden

the countryside by encouraging all concerned to develop multiple health services through various channels and in different forms . In a number of counties, the need was for specialised hospitals. For exam- ple, in Shanxi Province there were 329 small specialised hospitals, 80 per cent of which were at township or town level. Again to keep pace with the new situation, Conghua County in Guangdong Province has since 1984 focused its efforts on reorganising the village clinics by putting them under the dual super- vision of the township administra- tion and township health centre. There is one health clinic for each village, which is run collectively, based on a system of independent accounting, whereby the villagers assume sole responsibility for the profits and losses of their own accumulated fund. Methods such as these have suc- ceeded in strengthening health facilities at the grass roots. Since the reorganization, the health infra- structure in China's rural areas is taking various patterns. Today 52.92 per cent of village health clinics are run by the collectivity or by rural doctors on a contract basis; 10.08 per cent are run by rural doctors working jointly; 31.5 per cent are run by individuals; 3.39 per cent are run by health centres which extend their services to vil- lages, and 2.11 per cent are run in other ways. In the country as a whole, 40 per cent of rural medical workers have won the title of ru- ral doctor after passing qualifi- cation examinations. In addition, 1,680,000 part-time rural midwives and medical assistants have com- pleted training courses. All these rural doctors, midwives and medi- cal assistants are working actively in the countryside and represent reliable manpower for primary health care. Thanks to the establishment and development of the three-level medical networks, a relatively com- plete medical and health delivery system now covers the countryside and plays an active and effective role in developing primary health care. Generally speaking, most dis- eases can be prevented, treated and controlled in the peripheral health facilities, while more difficult prob- lems can usually be tackled by the medical and health institutions at county level. • W ORLD HEALTH, June 1987 Zimbabwe: from supermarket to cafeteria After independence, Zimbabwe embarked on a new health programme with energy and pragmatism. When one approach to pnmary health care proved inefficient, a better method quickly replaced it by H. Anenden ~ n many African countries, the post-independence era has seen the emergence of a new con- sciousness about the importance of health in the development of the nation. Although the basic infra- structure such as hospitals and pharmacies had been provided by the former colonial authorities, these were usually concentrated in the big towns, whereas the country- side was summarily left to its own devices. Health development in The government's policy is to set up a rural health centre not further than eight kilometres from every person in the country. Environmental sanitation is one of the responsibilities of these centres. Photo WHO/Liba Taylor post-colonial Africa therefore had to tackle simultaneously not only the training of more medical prac- titioners, an increase in the number of hospitals, dispensaries and health clinics, and the manufacture of pharmaceutical products, but also the decentralisation of health services and the devising of new approaches to meet new circumstances. Zimbabwe is one of the late- comers in the confraternity of inde- pendent nations. In the wake of the numerous political and economic problems, the country had also to face a restructuring of the health system so as to reach the more remote and indigent areas. A national survey carried out in 1984 by the Ministry of Health among 5,000 children (aged one to five) in eight provinces showed that nearly one third suffered from malnutrition, and another third had · borderline status. Even in the capi- tal, Harare, a large proportion of children showed evidence of under- nutrition and dietary deficiency of micro-nutrients. Communicable diseases are also widespread among the adult black population, with a high incidence of tuberculosis among blacks as well as malaria cases, and intestinal and urinary parasitic infestations. Many communicable diseases are due to the unhygienic conditions in which people live. 21 Zimbabwe 's polyclinics can now han- dle a much wider range of health problems than they used to. Photo WHO/H. Anenden It is obvious that Zimbabwe's · main health problems stem from its peculiar colonial history. Whereas in most former colonies the basic health infrastructures served (in part) the people of that country as well as the colonial rulers, in the Southern African countries, the existing regime set up an infrastruc- ture that served to widen and deepen the already unbridgeable gap between the black majority and the white minority. Cities with a predominant white concentration grew up, whose spectacular ap- pearance was in stark contrast with the state of poverty of blacks in the countryside. Every aspect of devel- opment was orientated towards the needs of the white minority. The state of health in present-day Zimbabwe is a consequence of the gross inequalities which pervaded society, and which now present the government with an arduous task of social renewal over and above the economic problems facing all newly-independent nations. As recently as 1979, staggering differences existed between the 22 MI<TEilNITY VISIHNG HOURS 6, QQ AM 7, 00A»; L 00 PJrt - 2 . 00 !:: lol 6. OO •• -· 1. OOo• C!.IJOING PUBL.IC HOLIDAYS more affluent non-black people, some of whom might earn up to US $40,000 per annum, while some peasants might earn as little as $80 in the same period. The other two main bases of inequality between whites and blacks were the distri- bution of the means of production and access to education, both close- ly linked to the state of health. Within the health system itself, the difference between "whites only" and "blacks only". hospitals was almost inconceivable. The lat- ter were crude, with small beds, overcrowded wards and primitive sanitary facilities. Expenditure on food was far higher in the white hospitals than in the black ones. In rural areas, health facilities were almost non-existent. The uneven distribution of medi- cal practitioners over the country, with a ratio in Harare of one doctor per 4,000 people, in smaller towns of one per 30,000 and in the remote countryside of one per 62,000 peo- ple, has incited the government to adopt primary health care (PHC) in a big way, as the only practically and financially viable solution to the major problems it faces. The average cost of running one central hospital bed is over half that of a rural health centre serving some 10,000 people. The sophisticated hospitals thus provide health care at a much greater cost than is necess- ary and far above whatever rural people will ever be able to afford to pay. The present policy is to give priority to developing the lower levels of care in rural areas. The PHC programme was launched in the first half of 1982. Its main approach was to meet the urgent health needs of the masses, so that the higher levels of the health system could be developed as a function of their support to the priority work at the base of the system. At the outset, the pro- gramme concerned itself with train- ing Village Health Workers (VHW) who were to become the key link between the organised village com- munity and the local health service. VHWs are selected by their own communities at mass meetings, the main criteria being basic literacy and political commitment to serve the village. The role of VHWs is fundamentally promotive, educa- tive and preventive, mobilising the community and individuals on such issues as environmental and per- sonal hygiene, nutrition, immuniz- ation, mother and child health. They are also responsible for treat- ing simple conditions and explain- ing the treatment of diarrhoea through oral rehydration therapy. W ORLD HEALTH, June 1987 The aim in the first stage is to train one VHW for every 50 to 200 families. Government policy is to set up a rural health centre not further than eight kilometres from every person. So far 163 health centres have been built, and the existing 450 primary care clinics are being modified to function as health centres. These centres provide basic but com- prehensive health care, concentrat- ing on mother and child care, deliv- ery of uncomplicated births, family planning, immunization services, environmental sanitation, control of communicable diseases and gen- eral curative care. The RHCs are staffed by three trained workers, two providing specific care for out- patients and one dealing with mother and child care. About one woman out of every five of child- bearing age in Zimbabwe is receiv- ing family planning protection. Be- tween 1982 and 1983, child spacing programme adherents have in- creased by 65 per cent. An expanded programme of im- munization was launched at the end of 1982, aimed at halting the high mortality and morbidity arising from the six major childhood dis- eases, measles, tuberculosis, polio, whooping cough, diphtheria and tetanus. The number of fully im- munized children has risen from 25 per cent in 1982 to 42 per cent in 1984 and is steadily increasing. One indication of the high success rate is that the infant mortality rate W oRLD HEALTH , June 1987 has been reduced by almost 50 per cent in the past four years, bringing it down to about 60 per 1,000 live births. At the time of independence in 1980, the rate stood at 120 per 1,000 caused by such factors as low birth weight, diarrhoea, pneumonia, malnutrition, measles and tuberculosis. The water and sanitation pro- gramme encourages the protection of water supplies and the use of appropriate technology pumps (Blair pumps) in the rural areas. There is also a dynamic movement to promote rural sanitation by building pit latrines with vents. This involves training health workers in appropriate technology methods and they in turn educate the vil- lagers in the use of such techniques. The programme of health education goes hand in hand with the water and sanitation programme, and steady progress is being achieved through a sustained strategy of in- formation and dissemination at all levels. A recent reappraisal of the func- tion of rural health centres has led to some pragmatic changes. In the past, villagers who needed a par- ticular type of health care, whether immunization, family planning ad- vice, drugs or antenatal care, had to Loud objections to an ear check-up from a young patient in one of Zimbabwe's rural health centres. Photo WHO/H. Anenden go from one health worker to the other, since each was responsible for his or her particular unit. How- ever, several evaluation studies showed that this "supermarket" type of health service (that is, going from one "goods stall" to another) involved a larger number of health workers than should be necessary in each health centre. Sometimes people did not know exactly where to go for the help they needed. It was recognised that, with a little further training, covering a wider range of services, one health worker could provide all the basic health care specified in the PHC programme. The extra cost and time spent on this enlarged training would be balanced by the reduction in the number of trainees and by a re-deployment of the health work- ers over a larger area. Where, be- fore, three to four people would be working in one health centre, under the revised system they would each be in charge of a health centre, thus reaching a larger number of people. This new system has been called the "cafeteria" system, since the per- son in need of health care only has to "order the menu" from the server. There may be a longer queue outside the health agent's door, but at least there is no indeci- sion as where to go. The same person will vaccinate a child, con- duct a general check-up of its health, and advise the mother about the type of food it should be given. Everything "comes on a tray". Notwithstanding the special problem that the Zimbabwean gov- ernment had to face on its inde- pendence, it has launched its health programme with a special dynam- ism and a sense of pragmatism. Funds may not be available for immediate modernisation of the hospitals and buying modern equip- ment, but by shifting emphasis to the countryside and the concept of PHC, the groundwork has been laid for · an in-depth change in people's mentality and basic attitudes to- wards health. The most positive aspect of PHC is that it is designed for the people but also by the people. By accepting the pos- sibilities of change and adaptation, such as the switch from a "super- market" to a " cafeteria" system, the system is able to evolve and test itself on the ground, thus growing with the people rather than being imposed upon them. • 23