Ill-prepared? Health-care service delivery in Zimbabwe - Afrobarometer
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Dispatch No. 240 | 4 October 2018
Ill-prepared? Health-care service delivery in
Zimbabwe
Afrobarometer Dispatch No. 240 | Thomas Isbell and Matthias Krönke
Summary
As Zimbabwe struggled to contain a deadly cholera outbreak in September-October 2018,
questions focused again on failures of infrastructure and leadership that continue to leave
the country vulnerable to such a preventable, “medieval” disease (Burke, 2018; Eyewitness
News, 2018). Zimbabwe has suffered repeated cholera outbreaks, including one in 2008 that
claimed more than 4,000 lives and infected more than 98,000 people (World Health
Organization, 2009).
Fueled by poor sewage and water systems, the latest outbreak is also facilitated by
inadequate health-care infrastructure and shortages of medicine, intravenous fluid, and
protective clothing (World Health Organization, 2009, 2018; News24, 2018; Sunday Times,
2018). The government has declared a state of emergency, announced budget
reallocations, and asked for international and private-sector assistance while politicians
blame their opponents and several Harare City Council employees are accused of inflating
prices on sanitary and health products (Burke, 2018; News24, 2018).
In this dispatch, we use Afrobarometer survey data collected in early 2017 to examine
Zimbabweans’ perceptions of their health-care system. Findings show that citizens have
become significantly more critical of the government’s performance on basic health care.
Many Zimbabweans, especially poor and urban residents, say it’s difficult to obtain care, and
a majority went without needed care at least once during the previous year.
Afrobarometer survey
Afrobarometer is a pan-African, non-partisan research network that conducts public attitude
surveys on democracy, governance, economic conditions, and related issues in African
countries. Six rounds of surveys were conducted in up to 37 countries between 1999 and
2015, and Round 7 surveys are being completed in 2018. Afrobarometer conducts face-to-
face interviews in the language of the respondent’s choice with nationally representative
samples.
The Afrobarometer team in Zimbabwe, led by Mass Public Opinion Institute, interviewed 1,200
adult Zimbabweans between 28 January and 10 February 2017. A sample of this size yields
country-level results with a margin of error of +/-3 percentage points at a 95% confidence
level. Previous surveys were conducted in Zimbabwe in 1999, 2004, 2005, 2009, 2010, 2012,
and 2014.
Key findings
▪ A majority (55%) of Zimbabweans say the government is doing “fairly badly” or “very
badly” at improving basic health services, more than 20 percentage points worse
than evaluations in 2009 and 2012.
Copyright ©Afrobarometer 2018 1▪ Six in 10 Zimbabweans – but only five in 10 rural residents – live in areas with a nearby
health clinic.
▪ A majority (59%) of respondents say they went without needed medicine or medical
care at least once during the year preceding the survey. The proportion going
without care decreased significantly between 2009 and 2012 but has remained
stable since then.
▪ The same proportion (59%) say it is “difficult” or “very difficult” to obtain needed
medical care. Poor respondents and urban residents are particularly likely to
encounter difficulties.
▪ Only one-fourth (25%) of Zimbabweans say their ability to get needed health care has
improved in recent years. Poor respondents and urbanites are more likely to say
things have gotten worse than wealthier citizens and rural dwellers.
Government performance on basic health care
Fewer than half (43%) of Zimbabweans say the government is doing “fairly well” or “very well”
on improving basic health services, while a majority (55%) say it is doing “fairly badly” or “very
badly.” This is similar to popular evaluations of the government’s performance on health care
going back to 1999, with the striking exception of surveys in 2009 and 2012 (Figure 1).
Public approval ranged between 33% and 45% between 1999 and 2005, a period when the
country was witnessing a decrease in primary health care services and an increase in
maternal and child mortality (UNICEF, 2010).
Approval climbed to about two-thirds (64% in 2009, 69% in 2012) during the Government of
National Unity period, when the Ministry of Health and Child Welfare was overseen by the
Movement for Democratic Change (MDC) and investments by international partners and
the Treasury supported a significant increase in the availability of essential drugs in health
facilities across the country (UNICEF, 2010).
But popular approval of the government’s performance dropped again, to current levels,
between 2012 and 2015.
Figure 1: Government performance on improving basic health services | Zimbabwe
| 1999-2017
100%
80%
67% 69%
63% 64%
53% 54% 55%
60%
40% 31%
45% 29% 46% 43%
35% 33%
20%
0%
1999 2004 2005 2009 2012 2015 2017
Very well/Fairly well Very badly/Fairly badly
Respondents were asked: How well or badly would you say the current government is handling the
following matters, or haven’t you heard enough to say: Improving basic health services?
Copyright ©Afrobarometer 2018 2Rural, older, and less-educated citizens are more satisfied with the government’s handling of
basic health care in 2017 than their urban, younger, and better-educated counterparts
(Figure 2). The biggest differences in perceptions are between the wealthy and the poor.
Only 29% of interviewees who score high on the Lived Poverty Index (measured as the
frequency with which people go without five basic necessities) say the government is doing
well in this area, compared to 79% of respondents who do not experience any lived poverty.
Figure 2: Government performance on improving basic health services | by
socio-demographic group | Zimbabwe | 2017
Rural 46% 52%
Urban 39% 59%
Women 43% 55%
Men 43% 55%
Over 56 years old 53% 44%
36-55 years old 41% 57%
18-35 years old 42% 57%
Post-secondary 35% 63%
Secondary 42% 56%
Primary 51% 47%
No formal education 46% 47%
High lived poverty 29% 70%
Moderate lived poverty 38% 60%
Low lived poverty 53% 45%
No lived poverty 79% 16%
0% 20% 40% 60% 80% 100%
Very well/Fairly well Very badly/Fairly badly
Respondents were asked: How well or badly would you say the current government is handling the
following matters, or haven’t you heard enough to say: Improving basic health services?
Among 25 African countries surveyed in 2016/2018, Zimbabwe ranks well below the average
of 53% in approval for how the government is handling basic health care, well behind
Swaziland (83%), Botswana (71%), and Namibia (67%) (Figure 3).
Copyright ©Afrobarometer 2018 3Figure 3: Government performance on improving basic health services
| 25 countries | 2016/2018
Swaziland 83% 15%
Botswana 71% 27%
Kenya 68% 30%
Burkina Faso 67% 32%
Namibia 67% 32%
Mauritius 64% 34%
Ghana 64% 29%
Mali 62% 38%
Lesotho 59% 29%
Tanzania 58% 40%
Côte d'Ivoire 58% 39%
Zambia 57% 41%
Senegal 54% 46%
25-country average 53% 45%
Nigeria 51% 48%
Benin 50% 48%
Cape Verde 47% 51%
Uganda 47% 53%
Niger 46% 54%
Madagascar 44% 55%
Zimbabwe 43% 55%
Guinea 41% 59%
Malawi 41% 58%
Togo 36% 62%
Tunisia 32% 63%
Gabon 28% 71%
0% 20% 40% 60% 80% 100%
Very well/Fairly well Very badly/Fairly badly
Respondents were asked: How well or badly would you say the current government is handling the
following matters, or haven’t you heard enough to say: Improving basic health services?
Access to health facilities
One prerequisite for providing adequate health care is infrastructure to deliver such services.
To estimate residents’ access to basic health-care facilities, Afrobarometer fieldworkers
recorded the presence or absence of health clinics in (or within walking distance of) survey
enumeration areas. Overall, 61% of respondents live in areas with a nearby health clinic.
Access is more common in cities (75%) than in rural areas (52%) (Figure 4). Over time,
Afrobarometer survey findings show access to health facilities rising rapidly between 2005
(23%) and 2009 (76%), then declining to current levels in 2012.
By province, residents of Mashonaland East (77%) and Mashonaland Central (71%) are most
likely to have ready access to a health clinic, whereas Bulawayo (32%) has the lowest
coverage. However, distance to a clinic may be an even bigger problem in a sparsely
populated province such as Matabeleland North (42%) than in urban Bulawayo.
Copyright ©Afrobarometer 2018 4Figure 4: Health clinic in enumeration area | by location and province | Zimbabwe
| 2017
Zimbabwe 61% 39%
Rural 52% 47%
Urban 75% 25%
Mashonaland East 77% 23%
Mashonaland Central 71% 29%
Harare 68% 32%
Manicaland 66% 34%
Midlands 64% 36%
Mashonaland West 58% 42%
Masvingo 48% 52%
Matabeleland South 42% 46%
Matabeleland North 42% 58%
Bulawayo 32% 68%
0% 20% 40% 60% 80% 100%
Clinic in enumeration area No clinic in enumeration area
Fieldworkers were asked to record: Are the following facilities present in the primary sampling
unit/enumeration area or in easy walking distance: Health clinic (private or public or both)?
Going without health services
Whether because of inadequate infrastructure or insufficient personal resources, a large
proportion of Zimbabweans at times go without needed health care. A majority (59%) of
respondents say they went without medicine or medical care at least once during the year
preceding the survey (Figure 5), including 36% who say they did so “several times,” “many
times,” or “always.”
Between 2004 and 2009, at most one in five citizens said they “never” went without needed
medicines or medical treatment. This number increased to four in 10 (39%) in 2012, then
stabilized at this level (43% in 2015 and 41% in 2017). This improvement in service delivery may
be attributable in part to the investment of more than $600 million in the health sector
between 2009 and 2013, which among other things facilitated the reopening of closed
hospitals to improve basic service delivery (Mail & Guardian, 2013).
Women and men are about equally likely to say they went without needed medical care, as
are rural and urban residents (Figure 6). The wealthiest respondents are most likely to have
“never” gone without health care (100% and 68%, respectively. among those with no or low
lived poverty, compared to just 6% of the poorest individuals).
Copyright ©Afrobarometer 2018 5Figure 5: How often went without medical care | Zimbabwe | 1999-2017
100%
87% 84%
80%
80%
61% 59%
57%
60%
40%
43% 40%
39%
20%
20%
13% 15%
0%
2004 2005 2009 2012 2015 2017
Never Just once or twice/Several times/Many times/Always
Respondents were asked: Over the past year, how often, if ever, have you or anyone in your family:
Gone without medicines or medical treatment?
Figure 6: How often went without medical care | by socio-demographic group
| Zimbabwe | 2017
Rural 40% 59%
Urban 40% 58%
Women 39% 59%
Men 41% 58%
56+ years 40% 59%
36-55 years 33% 66%
18-35 years 45% 54%
Post-secondary 46% 53%
Secondary 37% 62%
Primary 44% 56%
No formal education 44% 53%
High lived poverty 6% 94%
Moderate lived poverty 26% 74%
Low lived poverty 68% 32%
No lived poverty 100%
0% 20% 40% 60% 80% 100%
Never Just once or twice/Several times/Many times/Always
Respondents were asked: Over the past year, how often, if ever, have you or anyone in your family:
Gone without medicines or medical treatment?
Copyright ©Afrobarometer 2018 6Provinces also vary widely on this indicator. In Masvingo (62%) and Mashonaland Central
(52%), more than half of residents never went without medical care, while this was the case
for fewer than one-third of residents in Manicaland (26%) and Matabeleland North (31%)
(Figure 7).
Figure 7: How often went without medical care | by province | Zimbabwe | 2017
Masvingo 62% 38%
Mashonaland Central 52% 48%
Mashonaland East 48% 50%
Midlands 40% 59%
Mashonaland West 36% 64%
Matabeleland South 36% 64%
Harare 35% 62%
Bulawayo 35% 64%
Matabeleland North 31% 68%
Manicaland 26% 74%
0% 20% 40% 60% 80% 100%
Never Just once or twice/Several times/Many times/Always
Respondents were asked: Over the past year, how often, if ever, have you or anyone in your family:
Gone without medicines or medical treatment?
Experiences with health services
Of course, living close to a clinic and being able to afford care do not guarantee that
residents will be able to get the medical attention they need. It may also depend on
whether qualified staff, functioning equipment, and sufficient drugs are available.
Afrobarometer asked respondents how easy or difficult they had found it to obtain needed
medical care. Of the 59% who had contact with a public hospital or clinic during the year
preceding the survey, 54% say it was “easy” or “very easy,” while 46% describe it as “difficult”
or “very difficult” (Figure 8).
Figure 8: Easy or difficult to obtain medical treatment | Zimbabwe | 2017
46% Easy/Very easy
54% Difficult/Very difficult
Respondents were asked: In the past 12 months, have you had contact with a public clinic or hospital?
[If yes:] How easy or difficult was it to obtain the medical care you needed? (Note: Respondents who
say they had no contact with a public hospital or clinic are excluded.)
Copyright ©Afrobarometer 2018 7Perhaps surprisingly, more rural (58%) than urban (45%) respondents say it was easy to access
health services, and those with no formal education (67%) are more likely than their more-
educated counterparts to find it easy to obtain care. Poor Zimbabweans struggle
significantly more to obtain medical care than wealthier citizens (Figure 9).
In line with the urban disadvantage seen above, residents in Bulawayo (58%) and Harare
(59%), the country’s two biggest urban centers, are about twice as likely to find it difficult to
obtain needed care as their counterparts in Mashonaland Central (30%) (Figure 10).
Figure 9: Easy to obtain medical treatment | by socio-demographic group
| Zimbabwe | 2017
Rural 58%
Urban 45%
Women 54%
Men 53%
56+ years old 62%
36-55 years old 49%
18-35 years old 54%
Post-secondary 59%
Secondary 50%
Primary 57%
No formal education 67%
High lived poverty 36%
Moderate lived poverty 45%
Low lived poverty 73%
No lived poverty 81%
0% 20% 40% 60% 80% 100%
Respondents were asked: In the past 12 months, have you had contact with a public clinic or hospital?
[If yes:] How easy or difficult was it to obtain the medical care you needed? (Note: Respondents who
say they had no contact with a public hospital or clinic are excluded.)
Figure 10: Easy or difficult to obtain medical treatment | by province | Zimbabwe
| 2017
Mashonaland Central 70% 30%
Mashonaland East 65% 35%
Masvingo 65% 35%
Manicaland 58% 42%
Matabeleland South 56% 41%
Mashonaland West 52% 48%
Midlands 49% 51%
Matabeleland North 46% 54%
Bulawayo 42% 58%
Harare 41% 59%
0% 20% 40% 60% 80% 100%
Easy/Very easy Difficult/Very difficult
Respondents were asked: In the past 12 months, have you had contact with a public clinic or hospital?
[If yes:] How easy or difficult was it to obtain the medical care you needed? (Note: Respondents who
say they had no contact with a public hospital or clinic are excluded.)
Copyright ©Afrobarometer 2018 8In addition to difficulties in obtaining care, many Zimbabweans complain of long waiting
times. Only one in five respondents (19%) say they were assisted “right away,” while one-third
(34%) say they received care “after a short time.” But almost half say that they either “never”
(11%) received care or had to wait “a long time” (36%) (Figure 11) – a problem even under
normal circumstances, and likely to worsen during a health crisis such as a cholera outbreak.
Figure 11: Time taken to receive medical care | Zimbabwe | 2017
11%
19%
Right away
After a short time
After a long time
36%
Never
34%
Respondents who say they had contact with a public hospital or clinic were asked: How long did it take
you to receive the medical care that you needed? Was it right away, after a short time, after a long
time, or never? (Note: Respondents who say they had no contact with a public hospital or clinic are
excluded.)
Despite these difficulties, only 4% of respondents who had contact with a public hospital or
clinic say they had to pay a bribe, give a gift, or do a favour to obtain medical care (Figure
12).
Figure 12: Paid bribe to obtain medical care | Zimbabwe | 2017
4%
Never
Once or twice/A few
times/Often
96%
Respondents who say they had contact with a public hospital or clinic were asked: How often, if ever,
did you have to pay a bribe, give a gift, or do a favour for a health worker or clinic or hospital staff in
order to get the medical care you needed? (Note: Respondents who say they had no contact with a
public hospital or clinic are excluded.)
Copyright ©Afrobarometer 2018 9Better or worse over time?
In line with declining popular approval of the government’s performance on health care,
most Zimbabweans see little overall improvement in recent years in their ability to get
needed health care. While one-fourth (25%) of respondents say their ability to get medical
care when they need it has gotten “better” or “much better” over the past few years, three-
quarters say it has deteriorated (37%) or remained unchanged (37%) (Figure 13).
Figure 13: Better or worse: Ability to get needed care? | Zimbabwe | 2017
100%
80%
60%
40% 37% 37%
25%
20%
2%
0%
Better/Much Same Worse/Much Don´t know
better worse
Respondents were asked: Please tell me if the following things are worse or better now than they were
a few years ago, or are they about the same: Your ability to get medical care when you need it?
According to this survey, the situation worsened more for urbanites (45%) than rural dwellers
(32%), and more for the better-educated (42% of those with post-secondary qualifications)
than for the less-educated (28% of those with no formal education). Again, the poorest
members of society seem to carry a disproportionate share of the burden. Among those
experiencing high lived poverty, 50% say their ability to obtain needed care has gotten
“worse” or “much worse,” compared to only 13% of the wealthiest respondents (Figure 14).
While differences according to lived-poverty level are the most consistent and pronounced
throughout this analysis, differences by province remain substantial as well. In Manicaland,
57% of respondents say that their ability to obtain needed medical care has worsened,
followed by Bulawayo (47%) (Figure 15). In contrast, in Masvingo – the province with the
highest percentage of people who “never” went without needed medical care (see Figure
7) – 59% of respondents say their ability to get care has not changed,
Bulawayo is at the other end of the spectrum: It is the province with the lowest percentage of
enumeration areas with clinics, one of the largest proportions of the population who say that
obtaining medical care is difficult, and the smallest proportion of the population (18%) who
say that things have improved.
Copyright ©Afrobarometer 2018 10Figure 14: Better or worse: Ability to get needed care? | by socio-demographic
group | Zimbabwe | 2017
Rural 25% 41% 32%
Urban 24% 29% 45%
Women 26% 35% 38%
Men 24% 38% 36%
56+ years old 33% 33% 31%
36-55 years old 22% 31% 44%
18-35 years old 24% 41% 34%
Post-secondary 25% 32% 42%
Secondary 22% 38% 39%
Primary 31% 37% 30%
No formal education 28% 36% 28%
High lived poverty 17% 32% 50%
Moderate lived poverty 21% 33% 43%
Low lived poverty 31% 42% 26%
No lived poverty 48% 39% 13%
0% 20% 40% 60% 80% 100%
Better/Much better Same Worse/Much worse
Respondents were asked: Please tell me if the following things are worse or better now than they were
a few years ago, or are they about the same: Your ability to get medical care when you need it?
Figure 15: Better or worse: Ability to get needed care? | by province | Zimbabwe
| 2017
Harare 34% 21% 43%
Mashonaland Central 31% 48% 20%
Matabeleland North 29% 23% 42%
Mashonaland East 24% 39% 33%
Masvingo 23% 59% 17%
Midlands 21% 33% 44%
Manicaland 21% 21% 57%
Mashonaland West 20% 56% 24%
Matabeleland South 18% 45% 37%
Bulawayo 18% 32% 47%
0% 20% 40% 60% 80% 100%
Better/Much better Same Worse/Much worse
Respondents were asked: Please tell me if the following things are worse or better now than they were
a few years ago, or are they about the same: Your ability to get medical care when you need it?
Copyright ©Afrobarometer 2018 11Higher taxes/fees for increased health spending?
Given Zimbabwe’s budgetary constraints, can the new government count on citizens to help
foot the bill for improvements in the health-care sector? In response to a question in
Afrobarometer’s 2015 survey, almost half (45%) of Zimbabweans said they would “somewhat
support” or “strongly support” paying higher taxes or user fees if the additional funds would
be spent on public health care. Urban, younger, and more educated citizens were more
likely to support such a proposal (Figure 16).
The idea found the least resistance in Manicaland (28% somewhat/strongly opposed), the
province with the greatest proportion of citizens who went without medical care in the year
prior to the 2017 survey.
Figure 16: Willingness to pay higher taxes/fees to increase health spending
| by socio-demographic group | Zimbabwe | 2015
Zimbabwe 45% 42%
Rural 40% 45%
Urban 53% 37%
Women 44% 42%
Men 47% 42%
56+ years old 40% 43%
36-55 years old 47% 41%
18-35 years old 46% 42%
Post-secondary 47% 42%
Secondary 49% 40%
Primary 39% 44%
No formal education 33% 46%
High lived poverty 44% 44%
Moderate lived poverty 44% 44%
Low lived poverty 47% 40%
No lived poverty 41% 40%
Manicaland 57% 28%
Harare 57% 37%
Bulawayo 56% 36%
Mashonaland West 54% 36%
Mashonaland East 50% 34%
Mashonaland Central 42% 51%
Matebeleland North 37% 38%
Masvingo 32% 49%
Matebeleland South 25% 63%
Midlands 23% 59%
0% 20% 40% 60% 80% 100%
Somewhat support/Strongly support Somewhat oppose/Strongly oppose
Respondents were asked: If the government decided to make people pay more taxes or user fees in
order to increase spending on public health care, would you support this decision or oppose it?
Copyright ©Afrobarometer 2018 12Conclusion
While our data were collected in early 2017, they reflect shortcomings highlighted by
Zimbabwe’s ongoing cholera crisis. Findings point to increasing public dissatisfaction with the
government’s performance on improving basic health-care services. Access to health care is
particularly difficult in urban areas, the epicenter of the current cholera outbreak. Strong
regional disparities in access also emerge, as do clear indications that the poor find
obtaining services most difficult.
Do your own analysis of Afrobarometer data – on any question,
for any country and survey round. It’s easy and free at
www.afrobarometer.org/online-data-analysis.
Copyright ©Afrobarometer 2018 13References Burke, J. (2018). ’Medieval’ cholera outbreak exposes huge challenges in Zimbabwe. 20 September. Guardian. https://www.theguardian.com/global-development/2018/sep/20/medieval-cholera- outbreak-exposes-zimbabwe-problems. Eyewitness News. (2018). Zimbabwe death toll from cholera has now risen to 28 – report. https://ewn.co.za/2018/09/15/zimbabwe-death-toll-from-cholera-has-now-risen-to-28-report. Mail & Guardian. (2013). Parirenyatwa has another go at it. 20 September. https://mg.co.za/article/2013-09-20-00-parirenyatwa-has-another-go-at-it. News24. (2018). Raw sewage in streets: Cholera is Zimbabwe's latest crisis. 22 September. https://www.news24.com/Africa/Zimbabwe/raw-sewage-in-streets-cholera-is-zimbabwes-latest- crisis-20180922. Sunday Times. (2018). Zimbabwe cholera deaths at 24, first-line drugs not working: WHO. 13 September. https://www.timeslive.co.za/news/africa/2018-09-13-zimbabwe-cholera-deaths-at- 24-first-line-drugs-not-working-who/. UNICEF. (2010). Zimbabwe, 8 October 2010: Country needs massive investment in health to save lives. https://www.unicef.org/esaro/5440_investment_in_health.html. World Health Organization. (2009). Cholera country profile: Zimbabwe. Global Task Force on Cholera Control. World Health Organization. (2018). WHO is scaling up response to a fast-moving cholera outbreak in Zimbabwe’s capital. 13 September. World Health Organization Zimbabwe. http://afro.who.int/news/who-scaling-response-fast-moving-cholera-outbreak-zimbabwes- capital-0. Copyright ©Afrobarometer 2018 14
Thomas Isbell is a PhD student at the University of Cape Town in South Africa. Email:
tisbell@afrobarometer.org.
Matthias Krönke is a PhD student at the University of Cape Town in South Africa. Email:
mkroenke@afrobarometer.org.
Afrobarometer is produced collaboratively by social scientists from more than 30 African
countries. Coordination is provided by the Center for Democratic Development (CDD) in
Ghana, the Institute for Justice and Reconciliation (IJR) in South Africa, the Institute for
Development Studies (IDS) at the University of Nairobi in Kenya, and the Institute for Empirical
Research in Political Economy (IREEP) in Benin. Michigan State University (MSU) and the
University of Cape Town (UCT) provide technical support to the network.
Financial support for Afrobarometer Round 7 has been provided by the Swedish International
Development Cooperation Agency (SIDA), the Mo Ibrahim Foundation, the Open Society
Foundations, the Bill & Melinda Gates Foundation, the William and Flora Hewlett Foundation,
the U.S. State Department, the U.S. Agency for International Development via the U.S.
Institute of Peace, the National Endowment for Democracy, and Transparency International.
Donations help the Afrobarometer Project give voice to African citizens. Please consider
making a contribution (at www.afrobarometer.org) or contact Felix Biga
(felixbiga@afrobarometer.org) to discuss institutional funding.
For more information, please visit www.afrobarometer.org.
/Afrobarometer @Afrobarometer
Afrobarometer Dispatch No. 240 | 4 October 2018
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