2016-.

2021
 Outline of presentation
• Health Development Fund • Maternal Health
( 2016-2021) • Child health
• Implementation – donors, • Neonatal health
service providers and
implementing partners • Nutrition
• Health Resilience Fund ( 2022- • Family planning
2025) • Vaccination
A total of EUR 126 000 000 was provided under the 11th European Development Fund (EDF) to a pooled multi-
donor Fund, the Heath Development Fund (HDF) (supported by EU, UK, IRL, Sweden and Gavi) from 2016-
2021.

Aim of the Programme

The Programme focused on three major intervention areas:

• Improved policy development and improved governance and coordination at national level.
• Integrated measures to strengthen the health systems and health service delivery nationwide (supply side
interventions).
• Sustained community engagement and participation in health (demand side interventions).

6 Thematic areas:
RMNCAH&N – including FP, GBV, SRHR, obstetric fistula, girl’s empowerment (child marriage and teenage
pregnancies), cervical cancer screening
Health financing – access
Medical products and vaccines
Research & Innovation
HRH
M&E
Health Development Fund (2016-2021)
• Lead by MOHCC
• Implemented by UNICEF and UNFPA
• Equitable access
• 92% district hospitals – emergency care, CS and blood transfusions
• Essential medicines and nutrition
• 849 PHC through RBF ( removal of user fees)
• WASH
• Solar energy
• Training of VHWs ( 4790 additional)
• Nine million people access to community based services
• Provincial health team – 8 provinces
• COVID-19 response plan
• Community engagement
• Strengthened structures in MoHCC
 Health Development Fund 2016-2021
• Supported high impact interventions to save lives • The HDF contributed to impressive
and protect the health of the most vulnerable results in maternal and child mortality
• This included strengthening primary health care over the past decade but the gains
(PHC) structures, Activities targeted district health made are threatened by ongoing
facilities in the country as the most effective
approach to maintain access to quality health
economic instability, the impact of
services, COVID-19, and the risk of a funding gap
• The HDF contributed to impressive results in for the first semester of 2022. Other
maternal and child mortality over the past decade donors to the HDF are the UK’s Foreign,
but the gains made are threatened by ongoing Commonwealth & Development Office
economic instability, the impact of COVID-19, and
the risk of a funding gap for the first semester of (FCDO), Swedish International
2022. Other donors to the HDF are the UK’s Foreign, Development Cooperation Agency
Commonwealth & Development Office (FCDO), (SIDA), Irish Aid and the Global Alliance
Swedish International Development Cooperation
Agency (SIDA), Irish Aid and the Global Alliance for
for Vaccines and Immunisation (GAVI).
Vaccines and Immunisation (GAVI).
 HDF / HRF
• Closely aligned to the • Contribute to the Sustainable
Constitution, the national Development Goals (SDGs) on
priorities set out in the the eradication of poverty
National Development Strategy (SDG-1), zero hunger (SDG-2),
(NDS-1) and the Government good health and well-being
of Zimbabwe’s National Health (SDG-3), gender equality (SDG-
Strategy 2021-2025. 5), reduced inequality (SDG-10)
and climate action (SDG-13).
Maternal and under 5 mortality
The HRF: Rationale for Equity Approach and Geographic
Targeting
Trends of Health facilities charging User Fees for Maternal
Services
started to show some health facilities charging user fees as from Q3 2022.

Trends of Health facilities charging User Fees for Maternal

Services
30.0%
20.0%
10.0%
0.0%

Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2
2014 2015 2016 2017 2018 2019 2020 2021 2022
—·— Charging ANC services —·— Charging Delivery services • Charging full maternity services

Fig 13: Trends of Health facilities charging user fees for maternal services
Neonatal Mortality
Neonatal mortality in Zimbabwe is at 32 deaths per 1000 live births and has remained
unchanged in the last 15 years (MICS 19); with notable geographical disparities within and
between provinces

Fig 16: Newborn Mortality: MICS 2019

Highest neonatal mortality rates were reported in rural provinces which
are Midlands (47) and Mashonaland East (39) against a national
average of 32 while the lowest rates were in Matabeleland North (16)
and Bulawayo. Education of the mother also contributed to the widening
disparities, as children born from mothers with pre-primary education
were more likely to die at the neonatal stage (47 per 1000 live births)
compared to those born to mothers with higher education (16 per 1000
live births) (MICS, 2019). Interventions moving forward should be
aligned with this data to guide allocation of investments in line with
needs of different regions, while strengthening community support
structures targeting the less privileged women with lower education
levels who are also poorer with less access to essential services.
 Under Five Mortality
The national under fiver mortality rate stands at 73 deaths per 1000 live births (MICS 19). Highest
rates were reported in Masvingo and Midlands (83), followed by Manicaland (85).

Fig17: Under 5-year-old Mortality: MICS 2019

As in the case of neonatal mortality, under five mortality was higher in mothers with pre-primary
education (121 per 1000 live births) compared to those with higher education (31 deaths per
1000 live births) against a national average of 73 per 1000 live births. Rural areas were more
affected compared to urban areas as well.
 Nutrition crisis
Nearly one out of four (23.5%) Zimbabwean children are stunted (chronic
malnutrition) and do not grow and develop to their full potential. This translates to
over half a million children who are already stunted. 3% of children under 5 years in
Zimbabwe are wasted (acute malnutrition) – translating to 20,000 children who need
life-saving treatment for severe wasting every year. Different forms of malnutrition
coexist within the same children: 1.1% of children under-five are both stunted and
wasted, and 0.5% are both stunted and overweight. Children who are both wasted
and stunted are 12.3-times more likely to die than their well-nourished counterparts.
Children under-nourished in the first 2 years of life and who rapidly gain weight
during childhood or adolescence have an increased risk of chronic disease related
to nutrition.
Malnutrition is not spread evenly across the country – there are areas with higher levels of
wasting and stunting.

Fig 20: Prevalence of stunting and wasting by Province

Trends in stunting
Progress in Family Planning Indicators
 Family Planning
While the national contraceptive prevalence rate (CPR) is around 68%, there are however, geographic
variations in CPR which is lowest in Manicaland (57%), Matebeleland South (60%) and Masvingo
(61%). The CPR is also higher in urban areas as compared to rural areas.

Fig 22 - Percentage of currently married women aged 15-49 currently using a modern contraceptive method by
provinces (ZDHS)
 Utilization of Essential Services
The 2019 MICS data revealed that 93% of pregnant women aged 15-49 years
were seen at least once by skilled health personnel during pregnancy (ANC1), and
71.4% attended four or more antenatal care visits (ANC4+), which is higher than
the 2014 MICS estimate of ANC4+ coverage (56%). Nationally only 10% of women
were able to meet the minimum 8 ANC visits required by the new guidelines,
though this analysis will still focus on inequities surrounding the four ANC visits.
Across the 4 sampled ANC package components presented below, performance is
poor in rural areas compared to urban areas. However, ANC visits seem to be
working well in rural areas compared to urban areas, albeit with lower quality, as
urban areas reported better coverage of packages.
Coverage of iron and folic acid supplementation (IFAS) for
at least 90 days during pregnancy has shown some
improvement since 2010, however remains extremely low.
ANC is a key platform for delivery of IFAS, as well as
counselling and preparation for exclusive breastfeeding
which at 42% is well below the regional average and off-
track to meet the WHA target for 2025 (of at least 50%).
Research in 6 sub-Saharan African countries has shown
that 9% of pregnant women did not attend ANC visits due
to the risk of COVID-19 transmission, 20% reduced the
frequency of their IFA supplement consumption, and 29%
had disrupted birth plans because of the Covid-19
pandemic , highlighting that the negative effects of the
pandemic are likely to be seen for some time to come.
Coverage of Iron and Folic Acid
Supplementation at ANC
Low Birth Nationally,
Weight the average proportion of children born with low
birth weight (recorded and recall) was 8.7%. The widest
disparity was among children born at home (18.9%) and
those born at health facilities (8.3%). The results also
show that young mothers less than 20 years are more
likely to have a LBW baby (10%) compared to mothers in
the age range 20-34 (8.1%). However, LBW babies begin
to rise in mothers above 35 years (9.1%). Comparatively,
India’s LBW rate of 7-8% alone is estimated as
contributing 60-80% of all neonatal deaths , therefore
Zimbabwe’s agenda on reduction of newborn deaths will
have to include interventions targeting the adolescence
and
maternal malnutrition that are underlying factors to the
LBW rates, prioritizing the most impacted sub-populations
and regions.
Intervention districts • 20
• 21
Mudzi Mash East
Kariba Mash West
• 22 Hurungwe Mash West
• 23 Mhondoro Ngezi Mash West
1 Chipinge Manicaland • 24 Makonde Mash West
2 Makoni Manicaland • 25 Chegutu Mash West
3 Mutare Manicaland • 26 Sanyati Mash West
4 Chimanimani Manicaland
• 27 Chiredzi Masvingo
5 Nyanga Manicaland
• 28 Chivi Masvingo
6 Mutasa Manicaland
7 Buhera Manicaland • 29 Hwange Mat North
8 Mount Darwin Mash Central • 30 Umguza Mat North
9 Centenary Mash Central • 31 Binga Mat North
10 Mazowe Mash Central • 32 Tsholotsho Mat North
11 Bindura Mash Central • 33 Gwanda Mat South
12 Mbire Mash Central
• 34 Umzingwane Mat South
13 Guruve Mash Central
14 Marondera Mash East
• 36
15 Mutoko Mash East • 35 Mangwe Mat South
16 Murehwa Mash East • 36 Beitbridge Mat South
17 Goromonzi Mash East • 37 Bulilima Mat South
18 Hwedza Mash East • 38 Gweru Midlands
19 UMP Mash East
• 39 Gokwe South Midlands
20 Mudzi Mash East • 40 Kwekwe Midlands
• Table 1: Prioritized Target Districts for HRF Interventions
Routine Immunization Coverage, Zimbabwe,
period 2013 to 2022
Provincial increases in first under 16 ANC
visits
First under 16 ANC visits
 HRF
• The Fund was established in Decemer 2022 between
the EU, UKaid, Ireland and Gavi. • The HRF will focus on four critical strategies:
• The HRF will focus on four critical strategies: • (i) securing the gains achieved through the
• (i) securing the gains achieved through the HDF by HDF by maintaining a focus on provision of
maintaining a focus on provision of essential health essential health services, with consideration
services, with consideration of disability and gender
inclusion; of disability and gender inclusion;
• (ii) improving accountability, good governance and • (ii) improving accountability, good
transparency in the provision of quality health care governance and transparency in the
services provision of quality health care services
• (iii) strengthening health security, including promoting
digital tools to increase efficiency and innovation • (iii) strengthening health security, including
• (iv) ensuring environmentally sustainable Primary promoting digital tools to increase efficiency
Health Care (PHC) facilities. and innovation
• (iv) ensuring environmentally sustainable
Primary Health Care (PHC) facilities.
 The problem tree below summarizes and clarifies the situation and drivers of ongoing
preventable deaths in women and children. This document is aligned to the National Health
Strategy 20212025 and its under-pinning National Development Strategy -1 (NDS-1).

Unacceptably high preventable deaths

MMR-462/100,000 (MICS 2019), while IMMR rose from 92 in 2019 to 122 in 2021; 80% occur in hospital
NMR has remained unchanged for >10yrs - 32/1000 (MICS 2019)
Reduction in stunting is too slow - 24% of under-5 children; Worsening since 2019

Harmful cultural practices & Insufficient fiscal space with sub-optimal sector efficiencies Incomplete
Multi-hazard context exacerbates
norms, GBV, child rights implementation of QI/QA systems.
service coverage gaps, nutrition
violations, etc. Under investment in maintenance/replacement of medical equipment.
insecurity, rights violations, risky
CONTEXTUAL Sub-optimal knowledge levels. Procurement Supply Chain weaknesses.
behaviors
FACTORS Insufficiently implemented Protracted HRH crisis, with high attrition and demotivation.
community support structures Weak policies, e.g., reporting newborn deaths, community pneumonia
treatment.
UNDERLYING
CAUSES
Top causes in women are bleeding pre/post birth (28%), complicated high BP (18%) & severe infection (8%)
Top causes in newborns are prematurity (42%) and asphyxia (40%)
Top causes in children HIV/AIDS (21%), Pneumonia (13%) injuries (10%), and Diarrhoea (9%)

Sub-optimal & insufficient timely utilization. High loss-to- Maternal/childhood micro-nutrient deficiency.
Systemic gaps in quality of care,
follow up (ANC/PMTCT, ART, PNC, EPI & nutrition High and rising adolescent pregnancy. including weak referral systems.
services. Increase of child rights violations Low access to essential drugs.
Poorly managed co-morbidities, e.g., high BP

Fig 14: The Problem Tree – Rationale for HRF Intervention

 Lessons Learnt
I. The HDF reflects work done in coordinated and cohesive manner, through its main conduit i.e., the “Steering Committee”.
II. The model/approach merits continuation however with improvements around composition and operations.
III. The contextual volatility did pose challenges and warranted adaptive programming. The future programme should factor
in contextual risk assessments / flexibility around re-programming at design and implementation levels, including donors
contracting.
IV. The HDF has done well by investing in MoHCC's existing structures (instead of creating parallel structures) thus
achieving efficiencies and enabling GoZ (with improved capacities) to sustain / interventions. The approach is suited to all
large-scale public sector led programmes.
V. The Programme successfully leveraged internal synergies where UNICEF and UNFPA collaborated with results and
activities split according to organizational mandates and technical expertise. This approach is likely to work well across
contexts where problem to be addressed is multidimensional.
VI. The HDF driven support (both monetary and non-monetary) for Village Health Workers contributed to lift the motivation,
retention and performance. VHWs proved to be invaluable during emergencies. This multidimensional support to VHWs
has emerged as a good practice and merits replication.
VII. The HDF encouraged greater use of innovative solutions (technologies) to improve performance (mHealth mobile
application, Mobile Incentive Calculator m-IC, Rapid-Pro Nutrition Information tool etc). The results warrant continued
investments and encouragement towards innovative solutions.
 A.Programmatic Recommendations

A-1: The Programme merits continued focus on bringing improvements in the RMNCAH-N services with
suggested improvements in Programme design to meet higher-level results and better achieve the expected
outcomes of the Programme

A-2: The HDF supported system-wide strengthening approach (with wider focus on seven thematic areas as well
as ad-hoc emergency response) merits continuity. The Programme design must not only continue to factor in Risk
Management measures but also take following measures to be able to respond more effectively to contextual
vulnerabilities particularly around economic downturn and natural calamities.

A-3: The HDF Partners and the GoZ should work collaboratively to formulate (and initiate actions where possible)
an Exit Strategy, underlining strategies and actions to enable the GoZ to sustain critical interventions (e.g., RBF,
HRH Retention etc.), and same may guide the follow-up Programme design..

A-4: Programme’s MER system merits a considered re-assessment to help improve recording, reporting and
analytical capabilities in the system to capture comprehensive and usable monitoring data to inform management
decision making.
 B. Systemic Recommendations

B-1: The system merits an overhaul of the HRH management policy and practice to address issues such as high
staff turnover, burn-out, poor remuneration, slow replacement rates, low staff morale particularly nurses and
midwives.

B-2: The Programme has visibly improved systemic capacities for supply chain management, however the system
did see disruptions which call for sustained support to improve systems and structures to avoid future disruptions.

B-3: RBF approach helped improve Programme performance in multiple aspects and merits continuity and further
improvements around disbursements, access of funds, quality supervision, verifications, and RBF guidelines.
 C. Programme Oversight and Coordination:

C-1: The HDF is well guided by the Steering Committee (SC), which as a management and
oversight model merits continuity.
However, this model could benefit further if the issues related to over-saturation (of stakeholders)
could be addressed.
 Introduce 'theme-based sub-committees' to assist the Steering Committee in dispensing the
oversight and management functions by offering a considered focus to each theme separately.
 Introduce a SC led grievance management system to have community feedback to address gaps.
 Health Resilience Fund (HRF)
• Ending preventable deaths
• Global Health Security
• Health Systems Strengthening
• PMU
• Launch – 23 Jan 2022
Health Resilience Fund ( 2022- 2025)
Thematic Area Outcomes
No.1: Ending Preventable Deaths (EPD): 1.1 Increased equitable timely access to quality integrated RMNCAH service including
Preventable deaths in mothers, adolescents, new­borns, and children in Zimbabwe are on track to meet 2030 SDG nutrition and GBV
targets, with full consideration of specific gender needs

1.2. Women, children, adolescents, and young people are empowered and able to
demand services and act on their health needs

No.2: Global Health Security (GHS): 2.1 Strengthened performance of public health emergency coordination, surveillance, and
Zimbabwe’s health system can effectively prevent, detect, and respond to health threats and support continuity of response
essential health delivery

2.2 Increased risk perception and adoption of protective practices among communities at
risk

2.3 Sustained performance of essential service delivery in all emergencies

No.3: Health Systems Strengthening: 3.1 Zimbabwe’s health system is more accountable and responsive and can better utilize
Zimbabwe’s health system is more accountable and responsive and can better utilize available resources to available resources for EPD and GHS
support essential services for women and girls and reduce reliance on donor support