Report No. 4214-ZIM Zimbabwe Population, Health and Nutrition Sector Review (In Two Volumes) Volume 11: (Annexes) June 17, 1983 Population, Health and Nutrition Department FOR OFFICIAL USE ONLY U Document of the World Bank This document has a restricted distribution and may be used by reopients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization FOR OFICIAL USE ONLY TABLE OF CONTENTS (Volume II) MAIN TEXT (See Volume I) Pan ANNEXES: 1. Note on the Demography of the African Population of Zimbabwe 1 2. Proposed Child Spacing Project Description 18 3. Mortality and Morbidity Data 20 4. Comparison of Existing and Proposed Health Service Models 25 5. Organizational Structure of Health Services 26 6. Health Facilities Utilization and Geographical Distribution 29 7. Proposed Changes in the Malaria, Schistosomiasis and Immunization Programs 33 8. Health Manpower Data 35 9. Training of Health Personnel; Basic Programs 38 10. Organizational Structure of the Unified National Health Information System 44 11. Sources of Finance for Health Expenditures 45 12. Inpatient Costs and Subsidies 56 13. Composition of MOH Budget 57 14. Health Development Plans, Cost Implications and Affordability 58 15. Nutrition 68 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ANNEX 1 Page 1 of 17 Annex 1: NOTE ON THE DEMOGRAPHY OF THE AFRICAN POPULATION OF ZIMBABWE Summary 1. Data from the 1969 census of Zimbabwe for the African population, previously analysed by early indirect techniques now gone out of use, were re-analysed by modern methods. Mortality in childhood in the late 1960's was found to be very low by African standards (though a close match to neighbouring Botswana) with infant mortality in the neighbourhood of 100, and 12-13 percent of children dying between birth and their fifth birthday. The implied expectation of life at birth ranges from 53-58, depending on the model life table chosen. The total fertility rate is estimated from reported fertility data to have been at least 8. The female stable age distribution corresponding to these levels of fertility and mortality fits the reported female age distribution of 1969 extraordinarily well, providing powerful support for the estimates given above. The rate of natural increase for the African population of Zimbabwe may have been near 4 percent in the late 1960s. The 1962-1969 intercensal rate of growth (4.2 percent for the African population and just under 4 percent for the total population) is in accord with these estimates; however the 1969-82 intercensal growth rate (2.94 percent for the total population) is not. Possible explanations include overcounting in 1969, undercounting in 1982, emigration (of both Africans and non-Africans) between 1969 and 1982, and misreporting of fertility and mortality in 1969. No resolution of the problem can be achieved until the full results of the 1982 census become available. Sources 2. There exists as yet only one reliable source of demographic data for the African population of Zimbabwe; namely, the census of 1969. This collected information on exact age for each individual, and data on the number of children ever born, still living, and already dead, as well as on the date of the last live birth, from each woman aged 15 years or over. Such a set of data allow estimation of fertility and child mortality, though regrettably no information was collected on adult mortality. 3. Two national demographic sample surveys had previously been conducted, in 1948 and 1953-55. They gathered much potentially valuable data on births and deaths during the past year, and on number of children ever born, still alive, and already dead. Unfortunately age was classified only in very broad categories, basically over and under puberty. Without precise age data none of the modern methods of analysis can be properly applied, and it is impossible to evaluate the recorded crude birth and death rates for the past year. These surveys, therefore, can be of little use. 4. The results of the 1969 census are thus exceedingly important. Unfortunately, however, they were not fully analysed at the time. In the late 1940's and early 1950's C.A.L. Myburgh (for many years a prominent statistician with the Rhodesian government) had developed empirically based equations for estimating total fertility and expectation of life at birth ANNEX 1 Page 2 of 17 from the kind of limited information available from the 1948 and 1953-55 surveys.l/ These were pioneering efforts, but have now been entirely superseded by the body of analytical techniques built up during the 1960's and 1970's, largely by W. Brass and A.J. Coale, which are based on precise age data and make much fuller use of all the information available. These newer methods, though then already in common use, were not employed in the analysis of the 1969 census (except for some consideration of the age structure by reference to stable models) and the published estimates of the total fertility rate and expectation of life at birth (7.5 and 50 respectively, yielding a crude birth rate of 52, a crude death rate of 16 and a rate of natural increase of 3.6 percent) were almost entirely derived from Myburgh's equations. 5. In these circumstances, a re-analysis of the 1969 data was indicated, and a standard analysis was accordingly performed. Mortality 6. The data on children ever born and children surviving by age of mother were analysed by the well-known Brass child survival technique (Trussell version).2/ Table 1.1 gives the reported proportions of children dead by age of women, and the resulting estimates of the proportion of children who die between birth and a given age (qx); also presented are the corresponding levels in the North, South and West3/ families of the Coale-Demeny model life-table system.4/ These model life tables encapsulate all reliable life tables from the nineteenth century up to the 1960's, and hence all accurately recorded human mortality experience; therefore the degree of internal consistency within the recorded data with respect to the models provides some test of the overall reasonableness of the data. 1/ Published in C.A.L. Myburgh: 'Estimating the Fertility and Mortality of African Populations from the total number of children ever born and the number of those still living': Population Studies, Vol. X No. 2, Nov., 1956. 2I By this method, the proportions of dead for women aged 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, and 45-49 are equated to the life-table functions ql,q2,q3,q5,q10,ql5,q2o, or the probability of surviving from birth to exact age 1,2,3,5,10,15,20, after adjustment to allow for the age pattern of fertility; the earlier childbearing begins, the older the children to women of a given age will be. The exact procedure used for adjustment varies according to the version of the technique being employed. For further details see 'A Manual of Indirect Estimation Techniques': Hill, Zlotnik and Trussell: UN, 1983 (forthcoming). 3/ East (which shows extremely heavy infant mortality and light child mortality) is omitted because it is very rarely used (never in Bank projections) and is highly unlikely to be appropriate for Africa. 4/ For each family, (which has a distinctive age pattern of mortality), life table are ranked by female expectation of life at birth from level I to level 24 with 2.5 years between each level. Level 1 is a female e° of 20 years, level 24 a female e° of 77.5 years. The male e° is lower than the female at each level, typically by about 3 to 4 years. ANNEX 1 Page 3 of 17 Tabe 1. 1: ICFa CF (lRI MO BY AGE CF W, MI'L DZW W'1r BIRTH AM A GIV3 AZ, AM C1E-MM E(UIVA1 a LIFE TAM IEVELS Proportimn Dylxg Propor- Betwom Birth & Age X Ca1e-[e2n Equwlent tate of Age of tios of (qi) Mtdel LIfe Table level Refereim Women C1ilren Age X CD NIDrth CD Soth CD Wst Nbrth Soah %wt of qic 15-19 .106 1 .111 .10B .114 13.3 16.2 14.1 1968 20-24 .125 2 .124 .129 .130 14.5 16.7 14.8 1967 25-29 .141 3 .133 .142 .140 14.9 16.7 14.8 1965 30-34 .159 5 .155 .161 .159 14.8 16.2 14.4 192 35-39 .178 10 .185 .184 .181 14.6 15.6 14.1 1960 40-44 .199 15 .204 .202 .200 14.4 15.1 13.8 1957 45-49 .218 20 .219 .218 .217 14.4 14.9 13.8 1954 It is clear that the results are highly consistent, suggesting that reporting of child survival was reasonably reliable. There are indications of some decline in childhood mortality over the past 15 years (the lower the Coale-Demeny level the higher the mortality), although the size of the decline varies according to the model pattern. It should be remembered that the older women probably underreport the proportion of dead children more than do younger women, so that any reported decline can be considered a minimum estimate of the actual fall in mortality. 7. We may take the average of the levels for age groups 20-24 and 25-29 as a fair estimate of the level of childhood mortality over the 4 1/2 years before the census, i.e. the period 1964-69.5/ For any model pattern, the percentage of children dying before they reach the age of 5 is between 15 and 16 percent. The percentage dying before the age of 2 is 12-13 percent. Infant mortality varies considerably more according to the exact model chosen, but would lie between 95-105 (North - 96, South - 103, West - 105). 8. These estimates of mortality in childhood can be considered fairly firm. There are no data, however, on mortality in adulthood, and hence this and the overall level of mortality must be inferred from models. The selection of model is of some importance, since the balance between child and adult mortality varies substantially. Given very much the same overall level of childhood mortality, the North model yields an expectation of life at birth for the period 1964-1969 of 52.5, the South model 57.5, and the West model 52.9, a range therefore of 52 to 58. 5/ The estimate from the 15-19 age group is usually discarded, as it is considerably less robust than the others. It is highly sensitive to the exact shape of fertility pattern used to convert reported proportions, dead to equivalent qxs, and is also affected by the relatively high infant mortality of teenage mothers. ANNEX 1 Page 4 of 17 9. On a priori grounds, either North or South would seem the most suitable for an African population. North is distinguished by relatively low infant mortality, high child (1-4 years) mortality, high adolescent mortality, and low old age mortality; it is very commonly used for African populations, (including in our Bank projections) as well as for other developing cuntries in the tropics. South is distinguished by high infant and child mortality, low adolescent and adult mortality, and high old age mortality: it is commonly used for the population of the Middle East, North Africa and Latin America (including in our Bank projections) as well as elsewhere in the developing world. It seems likely that the estimate from North may be rather too low, since in many Eastern African populations for which adult mortality data exist, the level of mortality in adulthood appears to be relatively low compared to the childhood level.6/ Data from the 1971 census in neighbouring Botswana, for example, which did collect adult data, yielded an IMR of 97 and qs of 15.3 percent, coupled with an e° of 55.5; the age pattern of mortality was thus midway between North and South. 10. Naturally there can be no guarantee that either South or North, or indeed any available model, accurately reflects the age pattern of mortality in Zimbabwe. There is no substitute for actual data. It is probably safe to say however, that the expectation of life at birth in Zimbabwe in the late 1960's was over 50, perhaps over 55. Infant mortality was in the neighbourhood of 100, and 15 or 16 percent of the children born did not live to see their fifth birthday. These levels of mortality are very low by contemporary African, even Eastern African, standards. It is encouraging to note, however, that contemporary child mortality levels in Botswana were apparently so similar. Fertility 11. The reported fertility data, namely age-specific fertility rates for the 12 months before the census, and the mean number of live births per woman (parity) are shown below in Table 1.2 and in Figure 1. Table 1.2: AGE-SPECIFIC FERTILITY RATES AND MEAN PARITY, 1969 Age Group of Reported ASFR Reported Mean Women Parity 15-19 .076 .25 20-24 .270 1.52 25-29 .302 3.09 30-34 .262 4.48 35-39 .219 5.50 40-44 .147 6.09 45-49 .074 6.35 Total Fertility Rate 6.745 6/ See J.G. C. Blacker: "The Estimation of Adult Mortality in AFric from Data on orphanhood": Population Studies 31:1, March 1, 1977. ANNEX 1 Page 5 of 17 12. Clearly fertility, as reported in both ways, is very high; clearly also, the two sources are not quite consistent. The usual interpretation of the pattern seen in Figure 1 is that current fertility has been underreported at all ages (because of misperception of the time interval involved, or simple omission of births), while life time fertility has been increasingly underreported at older ages because of increasing memory lapses, problems with large numbers, or greater numbers of deceased children that the respondent may be reluctant to mention. A precise measure of the discrepancy between the two fertility curves can be obtained with the well-known Brass P/F ratio techniques, by shifting the cumulated current fertility measures (F) to ages that match reported parity (P)7/ (with the aid of some kind of model fertility schedule) and obtaining the P/F ratio for each age group.8/ The results are as follows: Table 1.3: PARITY TO FERTILITY RATIOS, 1669 Age Group of Women P/F Ratio 1. 15-19 1.59 2. 20-24 1.31 3. 25-29 1.16 4. 30-34 1.11 5. 35-39 1.06 6. 40-44 1.01 7. 45-49 .95 13. Underreporting of current fertility is clearly evident here. Brass has suggested that if the series of P/F ratios is reasonably consistent and plausible, then the ratio for one or more of the younger are groups (normally P2/F2 or P3/F3, or the average of P2/F2 and P3/F3 or of P2/F2, P3/F3 and P4/F4) can be used as a correction factor for the reported ASFRs. The reasoning is that the degree of underreporting should not vary 7/ Cumulated age specific fertility rates refer to the end-point of each 5-year age-group, whereas mean parities refer to the mid-point. Hence, for example, cumulated ASFRs for the age groups 15-19 and 20-24 refer to exact age 25, while the mean number of children ever born to women aged 20-24 refers to exact age 22.5 years. 8/ For further details see "A Manual of Indirect Techniques for Demographic Estimation': Hill, Zlotnik and Trussell: UN, 1983 (forthcoming). -6- ANNEX 1 Page 6 of 17 by age ( so that the age pattern of the reported ASFRs is usable); while young women are likely to report their parity fairly accurately, since the events concerned are few and recent and the level of female education is likely to be higher in recent years than further in the past. 14. This procedure is doubtful in the case of Zimbabwe. As is commonly found with Eastern African data, the P/F ratios are not consistent and the range of possible correction factors is hence very wide. Implied total fertility rates would vary from 7.9 to 8.9. Moreover, the percentages of women giving no fertility information were not negligible; the application of the standard El-Badry technique for estimating what proportion of these women were actually childless, and what proportion true not-stateds (two categories apt to be confused by interviewers) gave a very firm estimate of 6.2 percent true not-stateds in each age group..9/ These women had been previously included in the fertility calculations (which is equivalent to assuming they were all childless); their exclusion from the denominator raises the levels of both reported current fertility (to a TFR of 7.2) and reported parity (to a high of 6.8 in the 45-49 age group); hence, although the P/F ratios themselves are not affected, the corrected rates would rise even higher to a range of 8.4 - 9.4. Such very high levels, though not unprecedented in some population groups (such as the Lake provinces of Kenya and the southwestern districts of Uganda) must be considered with caution. 15. The weight of the evidence from fertility data, however, seems to point to a total fertility rate of at least around 8. This can be checked by analysis of the age distribution. The male age structure shows some sign of disturbance by past migration; the overall sex ratio of the population is 101, with sex ratios above 100 in every age group except 0-5 and 15-29, and the proportion under 15 is (untypically) lower for males than for females. We therefore examine only the female age distribution, which may be fairly confidently assumed to be approximately stable (i.e. no appreciable migration, constant fertility and at most only a gradual decline in mortality) and hence both unchanging and determined solely by the given mortality and fertility rates in force. We compare the stable female age distribution resulting from a gross reproduction rate of 4 (i.e. a total fertility rate of 8.1 or 8.2) and the rough level of 9/ By this method, age-specific proportions of women reported as childless are plotted against age-specific proportions of women with not-stated fertility. If a reasonable relationship appears, it is concluded that incterviewers have linear entered some childless women as not-stated. A line is then fitted to the plotted data points from which the time proportions childless and not-stated can be obtained. For further details see 'A Manual on Indirect Techniques for Demographic Estimates': Hill, Zlotnik and Trussell, UN, 1983 (forthcoming). -7- ANNEX 1 Page 7 of 17 mortality indicated by child survival data, (i.e. a South model level of 17 or a North model level of 14) with the reported female age distribution of Zimbabwe in 1969.10/ 16. The results are shown in Table 1.4 and Figures 2 and 3. Table 1.4: COMPARISON OF REPORTED FEMALE AGE DISTRIBUTION ACCORDING TO THE 1969 CENSUS WITH STABLE FEMALE AGE DISTRIBUTION IMPLIED BY A GROSS REPRODUCTION RATE OF FOUR Reported Female Coale-Demeny Age Cumulated Age Distribution Stable Population: GRR = 4.0 to Age (Percent) North Level 14 South Level 17 5 21.2 21.4 21.3 10 38.0 37.9 37.9 15 51.1 51.1 51.1 20 60.9 61.8 61.8 25 69.1 70.4 70.3 30 77.0 77.2 77.2 35 82.4 82.7 82.6 40 87.7 87.1 87.0 45 91.0 90.5 90.3 50 94.2 93.2 93.0 55 96.3 95.3 95.1 60 97.8 96.9 96.8 65 98.3 98.1 98.0 70 99.1 99.0 98.9 75 99.4 99.5 99.5 75+ 100.0 100.0 100.0 10/ This age distribution is a corrected version of that given in the 1969 census report. Age was tabulated not as number of years lived but as date of birth, and the authors of the report took those born in 1969, 1968, 1967, 1966 and 1965 as equivalent to those aged less than 5 years. However, the census was held in April, 1969, so that only a third of the true numbers aged less than one year were included. As a rough adjustment for this, all those born in 1964 were also counted as under 5 years here, those born during the previous 5 years as aged 5-9, and during the 5 years before that are aged 10-14. Earlier groupings were not altered; it is highly probable that in most cases of adults (if not also children) enumerators estimated age in years (by eye, by historical calendar, etc.) and then subtracted from 1969 to get date of births, a procedure which would not be affected significantly by the dating of the census. This adjustment produces a somewhat younger age distribution than that given in the census report: however implied fertility with the report's distribution is still very high, as can be seen from the estimated TFR of 7.5 derived partly from that age distribution. ANNEX 1 Page 8 of 17 17. The fit in both cases (particularly at the younger ages) is astonishingly good, given the likely errors in age determination. There can be little doubt that an estimate of around 8 is appropriate for the total fertility rate of the late 1960's of the African population of Zimbabwe. The general level of mortality shown by child survival data also seems to be acceptable. 18. It is of some interest to consider the vital rates of the matching stable population. These should approximate well the vital rates of the African female population at least, though the male and consequently total population rates will be somewhat disturbed by distortions in the male age structures caused by migration. 19. The stable female birth rate lies between 53 and 54, depending on the exact model chosen (among North, levels 14 and 15; South, levels 16 and 17). The stable female death rate varies from 11 to 14, according to model level. The rate of natural increase consequently falls between 3.9 and 4.2. Normally one would expect the male population to show a very similar rate of natural increase (though as the product of somewhat higher birth and death rates) and hence the female rate of natural increase would provide a good approximation to the natural increase of the total population. However, the male population of Zimbabwe appears to have experienced some net immigration, visible as a male surplus overall and at older adult age groups. This would act to reduce the crude birth rate of the total population, and probably to increase the crude death rate. Hence the rate of natural increase for the African population of Zimbabwe in the late 1960's may have been slightly lower than the range of 3.9 - 4.2 percent given above. Precise determination would require choice of a life table and age specific fertility schedule and some smoothing of the age distribution. It is probably safe, however, to put the African rate of natural increase for that period as not far below 4 percent. 20. The rate of natural increase for the total population would undoubtedly be somewhat below this level, since non-African natural increase will have been lower; if it were one or two percent, the national rate would be a point or two lower--say 3.8 or 3.9 percent. 21. These new estimates for the late 1960's differ slightly from those arrived at in the 1969 census report. Fertility is higher (a TFR of about 8 versus 7.5), mortality lower (eO of 53-58 versus 50), and hence natural increase higher (about 4 percent versus 3.6 percent, for the African population). However, both agree in showing fertility levels that are among the highest n the world, mortality levels that are low by African standards of the period, and natural increase also among the highest in the world. 22. How do these estimates of fertility, mortality and natural increase fit in with recorded population growth? Table 1.5 below shows intercensal/intersurvey population growth rates from 1901 to 1982. -- ANNEX 1 Page 9 of 17 Tab1e 1.5: INERCNSINR SURVEY ERJIXD 1/ Average 1901 Aimal Cim/ Growth Tax - 1948 1948- 1954 1954 1961/62 1961/62-1969 1969- 1982 Rate(%) RegLster Survey Survey Survey Survey "us Census Ceuis Cenus CeUsm African Pop. 2.8 4.0 5.9 4.2 Total POP. - - - 3.98 2.94 1/ 7fe 1901-1948 period is taken as 47 years: 1948 - 1953/55 as 6 yeF: 1953/55-1962 as 7.6 years: 1961/62-1969 as 7.5 anld 7 years: 1969-1982 as 13.3 years. 23. The 1901-48 growth rate need not be taken too seriously but does indicate very high growth. So does the 1954-1961/62 rate, although no doubt heavily biased upwards by the greater coverage of a census than a survey grant. The 1948-1954 and 1961/62-69 rates, both between comparable types of data collection, fit in well with the natural increase estimates given above, allowing for some net immigration and improvement in completeness of enumeration over time. The 1969-82 growth rate, however, is quite inconsistent and requires explanation.ll/ 24. There are several possible causes which could contribute to this inconsistency. It is known that the non-African population left in large numbers during the 1970's, although this could account for only a small part of the discrepancy. Possibly also some of the foreign African immigrants may have left. Although all the Zimbabwean refugees are thought to have returned by the time of the 1982 census , it is still possible that some remained abroad. The 1982 census was held at rather short notice on a very tight schedule, and it is possible that the level of undercount was higher than that of 1969; returning exiles and refugees might have been particularly likely to be overlooked, and many parts of Zimbabwe must still have been in confusion and disorganization from the war and the resettlement of returnees. Alternatively, the 1969 census could have been an overcount, for unknown reasons (though this seems very improbable) or the mortality fertility and age data may have been consistently misleading because of misreporting of age, births and deaths. Another possibility is that natural increase actually fell during the 1970s because of either/or reduced fertility (from war disruption or just conceivably the spread of 11/ Note that the historical series of growth rates published in the World Bank's annual World Development Indicators reflect this discontinuity in recorded growth since it is based largely on the recorded intercensal growth, following the usual UN system. -10- ANNEX 1 Page 10 of 17 birth control) or increased mortality (from the direct and indirect effects of the war). 25. It seems a priori most likely, since all the data prior to the 1982 census are in broad agreement on very high growth and natural increase, since the liberation war, being short and sharp, probably had only a limited effect on fertility and mortality, and since the 1982 census was held hurriedly and in less than ideal conditions, that undercounting in 1982 is the main cause of these inconsistencies. However no final conclusions can be reached until the full results of the 1982 census, including mortality, fertility and migration data, have been released and analysed. -11- ANNEX 1 FIGURE 1 Page 11 of 17 ZIMBABWE 1969 CENSUS DATA REPORTED FERTILITY DATA Reported Mean Parity 1969 Cumulated Reported A4*-- Specific Fertility Rates Live 1968-1969 Births Per Women 7.0 6.0 0 / 5.0 25 A5o ~ ~ ~ ~ ~ ~ ~~g Gru of Woe ~~~/ ' //~~ 4,.0 // * /y/~~~ 15 00 /S3 S4 55 Ag/ru o oe -13- FIGURE 2 ANNEX 1 Page 12 of 17 ZIMBABWE 1969 CENSUS DATA FEMALES COMPARED WITH COALE-DEMENY STABLE Cumulated POPULATION SOUTH MODEL, LEVEL 17 Percent of Model Age Distribution Total - Reported Age Distribution Population 100 90 80 70 60 50 40 30 20 10 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 +75 Age Group of Females -14- FIGURE 3 ANNEX 1 Page 14 of 17 ZIMBABWE 1969 CENSUS DATA FEMALES COMPARED WITH COALE-DEMENY STABLE POPULATION NORTH MODEL, LEVEL 14 Cumulated Model Age Distribution Percent of - Reported Age Distribution Total Population 100 90 80 70 60 50 40 30 20 10 0 0 5 le 15 20 25 30 35 40 45 50 55 60 65 70 75 +75 -15- ANNEX 1 Page 15 of 17 Table 1.7: POPLU[C( (F ZIMAE BY LN CTRSIP, RA(C AND E:STY: 1969 a(t te Population` Total Area (km2) -A rican-- -Nm-African- -Total- Demrit Category N iers % Nunmers Z Numbers % Numbers European Aral/ 181,900 47 1,758,830 36 248,907 99 2,007,740 39 U Africa Area1/ 181,900 47 3,082,950 64 3,050 1 3,086,000 61 17 Areal/ 26,780 7 2,340 - 199 - 2,540 - 0.1 Total2! 390,580 100 4,846,930 100 252,414 100 5,099,344 100 13 - = less than e perent. Figures my not add exactly to totals, due to roundirg. Souce: Central Statistical Office: 1969 Popiuation Censts (Interim Report) Volume II; nve African Population: Salishgry, RhDdesia, 1971 I/ Te European area inclue s tie categories Geeral land, Specially Designated Land, Forest Land and Parks and Wild Life Land. Tle latter twv, hidch have denities of 3 ard below 1 respectively, mabe up 14 percent of tie total European Area. Ihe African area Includes Camnal lard (er-Tribal Trust lId), African Purchase land, Specally Designated land, Forest land and Parks, ard Wild life lard: the latter tO, agin vwth simlar lw dernities, make up 2% of the total African Area. The National Area is also described as Ihreserved lad. 2/ Totals include 3,070 railway travellers (2,810 Africars, 239 Europeare, 5 Asiar and 14 Coloured) wko are not included in any Ilad category. Figues do not ncessarily add to totals, becase the Africm figure have been rounded. -16- ANNEX 1 Page 16 of f7 Table 1.8: IER EA DISIRIBU1ION CF lE AFRICAN KIVE-BCRN popULAT= CF ZIBA3 BY IAN2aE AMD PR)VDUI OF BIRH: 1969 CENS Nlebele anil/ Slva2/ Other Idiius3/ NDn-Tndigencs4/ Total Provinoe of Birth Allied LInuaes languags Lanlaws Langaaes Manicalaid 1 94 3 2 100 Masonaland NDrth 83 4 12 100 MaSlDflaJAnlS(xlth 1 90 2 8 100 d tabelelaid North 68 12 14 5 100 Matabelelani South 65 18 15 1 100 Midlands 16 79 2 2 100 Victorla 7 92 - - 100 Total Born in Zibabe (Percent) 17 74 4 4 100 (Number) 740,080 3,329,050 194,550 185,850 4,477,470 - = less than 1 person Soures: 1969 Poplation Ceosus (Interim Report) Vol. II: The African Population; Central Statistical Office, Salisbiry, Rhxdesia, 1971 1/ Includes Ngni, 1ebele and Shagana. 2/ Tj.udes Shona, Kalanga, Kararga, Korekore, Mayika, Ndau, Zezuru and other Shona. 2bte that 41 prcnr-t of those born in Manicalwd Province reported Manyika as their La.guaga. 3/ Includes Sena-Ch d, Sotho-Tswna, Tonnga-fr, Tonga, %rda and other lrIdin wsaguages. 4/ ludes Benba, lozi, Ngid, Nyanja, Senga, hsa, Yao and other N-Irnlgous laguages. 5/ Total includes 27,940 "Not stateds"; percentages wiUl not necessarily sun to 100 for this reason and because of rouding. -17- ANNEX 1 Page 17 of 17 Table 1.9: AFRICAN POPULATION OF ZIMBABWE BY COUNTRY OF BIRTH: 1969 CENSUS Country of Males Females Total Males Females Total Sex Birth (Numbers) (Percent) Ratio Zimbabwe 2,187,440 2,296,650 4,484,090 89.6 95.4 92.5 95 Malawi 123,310 40,130 163,440 5.1 1.7 3.4 307 Mozambique 77,440 31,670 109,110 3.2 1.3 2.2 245 Zambia 29,700 14,810 44,510 1.2 .6 .9 201 Other 8,710 12,070 20,780 .4 .5 .4 72 Not Stated 13,580 11,420 25,000 .6 .5 .5 119 Total 2,440,180 2,406,750 4,846,930 100.0 100.0 100.0 101 Figures may not add exactly to totals, due to rounding Source: 1969 Population Census (Interim Report): Vol. II: The African Population: Central Statistical Office, Salisbury, Rhodesia, 1971. -18- ANNEX 2 Page 1 of 2 Annex 2: ZIMBABWE PROPOSED USAID-ASSISTED CHILD-SPACING PROJECT 1982-86 The project would consist of the following components: (a) An increase in the cadre of CSFA's field educators/distributors from 308 presently to 668 by FY85/86, and a corresponding increase of their supervisors (group leaders) from 34 to 70. In addition, the CSFA will train up to 216 field educators/distributors from other organizations (e.g., the Community Development and Women's Affairs Ministry, the MOH, etc.). The mobility of the field staff will be assured through the provision of bicycles and motorcycles; (b) An expansion of the staff of the CSFA's Youth Advisory Service from three persons at present to 33 persons by FY84/85. This will permit the CSFA to provide population education and elementary child-spacing information to 650 schools and to an estimated 100,000 students and teachers annually by FY85/86, up from about 200 schools and 33,000 youth presently. A number of similar courses on family life education will be offered to other interested groups, such as Church organizations. The CSFA will also launch a new program for individual child spacing counselling of youth, starting in the two main cities of Harare and Bulawayo; (c) The addition of two physicians and four nurses to the clinical services staff at the CSFA's main clinic (the Spilhaus Clinic in Harare), to strengthen contraceptive referral services, surgical sterilization capability, and infertility services; (d) The recruitment and training of 60 Medical Assistants to provide child spacing counselling and services, including IUD insertion, at 60 MOH rural health facilities; (e) The strengthening of the natural child spacing methods element of the CSFA program through expansion of the curricula used in the child spacing training of field educators/distributors and their supervisors, medical assistants, and nursing personnel, and through the production of appropriate printed materials; (f) The development of an information, education and communications (IEC) program at the CSFA through the establishment of an IEC department with a full-time IEC specialist and support staff, the development of IEC materials, and the provision of equipment for their use in the field. The IEC program is expected to reach one million families over the project period; -19- ANNEX 2 Page 2 of 2 (g) The establishment of a Research and Evaluation Department at CSFA; (h) The strengthening of CSFA's training program through the provision of technical assistance to improve teaching methods and through the development of training materials; and (i) The strengthening of CSFA's management capability at headquarters level through increasing management staff, the provision of technical assistance in financial management, the establishment of a computer-assisted management information system, and the feedback of research and evaluation results into the management process. -20- ANNEX 3 Page 1 of 5 Annex 3: MORTALITY AND MORBIDITY DATA Table 3.1: ZIMBABWE--MORTALITY BY AGE AND CAUSE, CITY OF HARARE, 1979 Age African Non-African Under One Prematurity 228 10 Intrapartum asphyxia 56 2 Congenital anomalies 55 3 Pneumonia 125 5 Tetanus 26 0 Neonatorum - - Gastroenteritis 70 0 Other 84 9 Total Under One 646 29 One to Five Congenital anomalies 20 1 Pneumonia 50 1 Gastroenteritis 89 Malnutrition 76 Measles 70 Misadventure 14 Other 40 1 Total One to Five 359 3 Fifteen to Twenty-four Road Accidents 25 9 Assault/Homicide 26 0 Rheumatic Heart Disease 17 0 Complications of Pregnancy 17 0 Renal Failure 13 0 Misadventure 11 3 Other 84 9 Total Fifteen to Twenty-four 193 21 Twenty-five to Fourty-four Suicide 20 12 Road accident 53 11 Homicide 42 2 Misadventure 31 2 Hypertension 39 3 Cancer 55 8 Complications of Pregnancy 34 0 Other 140 12 Total Twenty-five to Fourty-four 414 50 -21-- ANNEX 3 Page 2 of 5 Age African Non-African Fourty-five to Sixty-four C.A.D. 7 71 Cancer 115 98 Hypertension 50 10 Other Cardiovascular 94 21 Respiratory illness 31 17 Alcohol 50 15 Pulmonary TB 13 Castroentritis 9 Other 21 Total Fourty-five to Sixty-five 390 232 Sixty-five and Above C.A.D. 1 115 Hypertension 27 105 Lung cancer 6 25 Other cancer 42 80 Accident/suicide 10 24 Other 145 156 Total Sixty-five and Above 231 505 Source: Annual Report of the Medical Officer of Health, City of Harare, 1979 Table 3.2: EPIDEMICJIGICAL PATEN BY TYTE (F FAIMS AND FRE YJENC CF OM(E Mbarch 1982 ---- 2Mashona - -Victoria-- Age and Sex Cm_ercial African OLned Co_mmnal comual Under 5 years % of Total 52 34 51 57 % femle 50 60 51 32 Rank Order of Occurrae All lIE/Cough (Malaria, Scabies URTI/Cough Diarrhea/Dysntery Diarrhea/Dysentery ( Diarrhea/Dysentery Diarrhea/Dysentery Malaria, Scabies Boys URtE/Cough Malaria URII/Cough Diarrhea/Dysentery Diarrhea/Dysentery Scabies Diarrhea./ysentery Cmnjunctivitis/Scabies Girls URl/cugh Diarrhea/bysentery Diarrhea/Dysentery Malaria, pRieiDra Diarrhea/Dysentery Scabies URII/Cough Diarrhea/Dysentery e 5 and over Z of Total 48 66 49 43 % female 60 48 54 63 Rank Order of Cocurrence An Injury Malaria Malaria Malaria Backachel/ (Vaginal Discharge Headache Venereal Disease (Conjunctivitis Men Injury Malaria Headache Venereal Disease Bwacachel/ Venereal Disease Malaria Malaria Wcmen Abdoninal Pain Mlaria Abdominal Pain Malaria ( Backachel/ Vaginal Discharge (Malaria Pelvic Infection m (Injury (Pelvic Infection i 0 URI = Upper Respiratory Tract Infection F 1/ The tenm 'hackache" sometimes appears in clinical records as an euphemism for venereal disease. Source: Health Facility Survey, World Bank Health Sector Mission, 1982 ANNEX 3 Page 4 of 5 Table 3.3: LEADING DISEASES TREATED AT HARARE CENTRAL HOSPITAL: 1981 Disease/Injury Number of Cases % of Total Infective & Parasitic Disease 3,993 10.4 Diarrhea 1,360 Malaria 623 TB 437 Measles 137 Dysentery 100 Neoplasms 2,239 5.8 Malignant 1,569 Benign 670 Endocrine, Nutritional & Metabolic 1,732 4.5 A. Malnutrition 935 --Kwashiorkor (358) --Nutritional marasmus (313) --Marasmus Kashiorkor (112) --Malnutrition NOS (152) B. Diabetes mellitus 294 C. Dehydration 168 Disease of Blood 621 1.6 Anaemia, unspecified 278 Mental Disorder 1,502 3.9 Schizophrenia 617 Nervous System & Sense Organs 2,229 5.8 Cataracts 536 Meningitis 323 Circulatory System 1,943 5.0 Congestive Cardiac Failure 445 Hypertension 369 Respiratory System 3,300 8.6 Bronchopneumonia 1,149 Other pneumonia 514 URTI 217 Digestive System 1,690 4.4 Cirrhosis of Liver 93 Genitourinary System 2,856 7.4 Pelvic Inflammatory Disease 779 -24- ANNEX 3 Page 5 of 5 Disease/Injury Number of Cases % of Total Complications of Pregnancy, Child- 3,634 9.4 birth & Palaperium Spontaneous Abortion w/o Complications 2,086 Other Abortions 340 Puerperal Sepsis 243 Skin & Subcutaneous Tissue 581 1.5 Cellulitis 350 Musculoskeletal 834 2.2 Osteomyelitis 329 Congenital Anomalies 626 1.6 Unspecified anomalies of heart 51 Club foot 50 Spina Bifida 37 Conditions of Perinatal Pd. 333 0.9 Neonatal tetanus 128 Ill Defined Conditions 1.181 3.1 Convulsions 178 Pyrexia of unknown origin 132 Abdominal pain 131 Failure to thrive 107 Injury & Poisoning 5,112 13.3 Fractures 1,772 Injury & Wounds 1,614 Concussions/Traumas 506 Adverse Drug Reactions 418 Burns 407 Supplementary Factors Influencing Health 248 0.6 Suicides 40 Maternal deaths 36 Procedure not carried out 49 Supervision of normal pregn. 31 Lodger 25 Supplementary Expernal Cause of Injury 3,764 9.8 RR Train & Motor Vehicle acc. 806 Unarmed fight or brawl 517 Other assault 333 Accidental poisoning 191 Total 38,418 100.0% Source: Harare Central Hospital Medical Records, 1982 -25- hrex 4: A CCWAISN tF ESTMG AND PLANED REITH ANNEX 4 Dmy slE IN Z A (M M 9Bm ) -FItiD4Systes---lmd~iwry Syse- Level Facility.sad Service No. Staff lael Faility and Services NO. Staff Nbtiol ontra HOSpLtal-oodera loptal 4 Doctors, Mib, Nati.l N)tical Referral 4 Doctors, services ~MS; asn ater cain r 4 -sti am, me, wort staff ceiral hieptals other staff Prtiaca Garal WmpitstaIsdern thspital 11 Doctor, Sis, Proinia Pro iil 11 Doctors, service but s BiAli servi e my As, aKI other HoepLtal-adatiz s5l, Was, not be avilable suort staff geral hspitals aml other sufWort staff District District Hospitals-iepital services 29 Vais but District District 55 3 Doctors, bit -ray I diad 3oAtic filities inils HspLtal-hisptal 21 SMR, 50 my not be awilable, oaer cf beds Doctors, 9Ns, services, 140 bes, MIs, sK var frc. 40 to 160 HAs KI ctber disA tin sd otber pport staff X-ray filiti supportiz staff Rural Arm a. 1rl Hospitala-outpatiet and 56 MAs wK pvral Ward Rural Health sbott 2 Nas, at beld inpstient services but mi dctor help Leve1/ or Cmire-aipt entt 76(0/ let c District about serices, with ieel b. local MihDrity about MAs, er 10,00D obsrvation bes, 2 mternity clinics - auptiest services, other 414 varyig fraon 1 PoPAt- mteruity bs, axl traini,1 srvices wry bur my ide to 3 am of ion full oaze cf ME HA, sK 1 oberntim bods, maternity beds, them with serces imlHiD4 murse aide i.dxation, dcild spain services _ternity dild spqcig, phs anteaztal are d ddild elfu training, sivirmztal clini numm-aids, snitatimi asd gerira biep health edtutio c. Lasimon Hospital aid Clinics-vary about varying from greatly fros cinic type servce to 88 clinic level District Hospital level services staffig to District _tal I1 stdfiq A 4op Vl-pert tim tai 1 MU of tarar offering 8000 50 to eivirOKCl 20O 1/ sanitati, health futiles education, awatiw sevices for mn a,Ilits, referral for other diseases, and rerral for ddld opecing Urim 1u5cipol cinics-aitstint 42 Urban lmicipal 42 Arie serTvices, aternity sKd observtion Areas clinics-existirs bed, imzztin, child spacing uicijal clinic services, aneotal a are e+ d1A velfre clinics / Pattern cf srvic delivery for arcial fam are h not yet bom defined. 2/ Tle larr -fssion hq Ltas wil be upgraded to dstrict lnpitals, ile tle mlaer siim faclities will fumetic a REs. A similAr tformtion.is plamel for nra hospitals. 0 II U, '-4 I :1 S ii fi - - -l N w ii ii I U 1 0N N ' I N U, NU, I! 0 -' Km 'I U, .u, I j I & -27- ANNEX 5 Page 2 of 3 A%\ LA~~~~~~~~~~i EI I 'U\\\ 4 g ~ ~~ . lt 1i -28- ANNEX 5 Page 3 of 3 Table 5.3: DIAGRAMATIC REPRESENTATION OF THE PROPOSED HEALTH SERVICES ORGANIZATIONAL STRUCTURE AT THE VARIOUS LEVELS OF SOCIO-POLITICAL ORGANIZATION LEVEL OF EXECUTIVE SOCIO-POLITICAL CARE BODY ORGANIZATION |Ministry of k- Other l /t Health Ministries National Referral ) Centers TERTIARY ) LEVEL ) 3 Provincial Health Provincial Health Provincial .Services Authority Committee Authority SECONDARY District Health District Health LEVEL Services Authority Committee uncil Health Centers Health Center I- r Committee| 3 ~~~~~~~~~CommitteeI PRIMARY ) LEVEL ) )X ) Village Health Workers and the Village Community Source: MOH Document Annex 6: HEALTH FACILITIES UlTLIZATION AND GEOGRAPHICAL DISTRIBUTION Table 6.1: BED OCCUPANCY RATES PoR HO6YITA1S, 1979 --General Beds - ma ternity Beds Total Bed-- Adais- Bed- Occup- Admis- Bed- Occup- Admis- Bed- ocup- sions days a:y sions days aey aione days iey Institution No. Beds 1,000 1,000 rate Z Beds 1,000 1,000 rate Z Beds 1,000 1,000 rate Z Central Ho4pitals 4 2,574 85.7 796.7 84 458 37.6 146.6 87 3,032 123.3 943.3 85 General Hospitals n 1,758 63.5 562.7 87 146 10.5 51.0 95 1,904 74.0 613.7 88 District Hospitals 29 2,094 68.7 663.8 86 300 17.7 99.7 91 2,394 86.4 763.5 87 Special Hospitals (TB) 2 - - - - - - - - 300 1.4 112.0 102 Special Hospitals (Psychia. Serv.) 4 _ _ _ _ _ _ _ _ 1,320 6.6 442.5 91 Missions 59 2,396 52.2 563.6 64 547 11.7 73.7 37 2,943 63.9 637.3 59 Industry and Mines Hospitals 29 - - - - - - - - 1,417 46.3 - 79 Rural Hospitals 56 1,757 47.6 353.0 55 263 11.7 67.1 69 2,020 59.3 420.1 57 Total 193 10,579 317.7 2,939.8 76 1,714 89.2 438.1 70 15,330 461.2 3,932.4 78 1/ Number of beds in table 6.3 differ from those in this table because the WHO reported inventory of facilities used In preparing table 6.3 may not be accurate. As missions are reopening their facilities, estimates of number of beds in mission facilities may also not be accurate. Source: Secretary of Health Report 1979 Ma! Approved List of Institutions 1981 WHO Country Profile 1980 0 ANNEX 6 -30- Page 2 of 4 Table 6.2: NUB3 CF HEALTH UNITS BY TYPE CF KM hAL 19AS 19 Populatim No. of Persons per Area per Area sq. ba. in Population Deity Health Halth Unit Health Unit Type of Area thmmands in thmuaids Perscs/sq.- Units in thouaads in sq .la cfn Lart Manicalad 14.9 623.8 41.8 108 5.8 138.1 NshxiBalad 42.4 1,153.3 27.2 151 7.6 280.7 Matabeleland 55.7 811.1 14.6 91 8.9 611.6 Midlad 26.5 741.0 27.9 107 6.9 247.9 Victoria 23.1 872.8 37.8 54 16.2 428.0 Total Ccmu.zal Lend 162.6 4,2D2.0 25.8 511 8.2 318.2 Caearal Farm land 166.0 1,500.0 9.0 76 19.7 2,185.5 Total Rural 328.6 5,702.0 17.4 587 9.7 559.8 Source: A Spatial Planmirg Systan for Zimabwe - IUDP/UWHS, ZIM/80/008 ME list of Health Fscilities by Central Statistical Office Powlati estimtes as of December 31, 1979 ANNEX 6 -31- Page 3 of 4 Table 6.3:: N?UIER (F EDS BY PKDVE AND TYPE CF DlT=IUlCN, 1980 - - - - - - - - - - - Provie-- - - - - - - - - - Prcent f Type of Insttution Manicalar 1 Mashonaland Matabelelarl Midland Victoria Total total beis ME Facilties Central Hospital 0 1,792 1,106 0 0 2,898 15.9 Genral Hospital 350 791 0 318 323 1,782 9.8 Maternity Hospital 17 34 0 44 29 124 0.7 District Hospital 336 747 773 396 142 2,394 13.2 Rural Hospital 223 631 431 331 475 2,091 11.5 Special TB Hospital 0 180 120 0 0 300 1.7 Special Psychiatric Services 0 90 898 0 332 1,320 7.3 Total LHE Facilities 926 4,265 3,328 1,089 1,301 10,909 60.1 Other Facilities Mission General Beds 1,030 1,337 977 857 1,014 5,215 28.7 Mission TB Beds 120 180 0 340 0 640 3.5 Irdx try and Mines 0 436 320 342 305 1,403 7.7 Total Other Facilities 1,150 1,953 1,297 1,539 1,319 7,258 39.9 TEAuL 2,076 6,218 4,625 2,628 2,620 18,167 100.0 Population (1,000's) 1,110 2,780 1,400 1,040 1,030 7,360 Person per Bed 535 447 303 396 393 405 Note: The beds In local coancil clinics, tbon and rural council clinics, and nuircipal clinics are not included. Source: HEI docu.ments -32- AiNNEX 6 Page 4 of 4 Table 6.4: NUMMR CF HEALIH INSTITUTICNS BY PROVINKE AND TYPE (F IunTrTU NI, 1980 - - - - - - -- - Province- - - - - - - - Type of Institution Mashonaland Manicaland MidlaInd Victoria Matabeleland Total Lccal Ccnmunal Clinics 106 73 76 26 57 3381/ Tomn and Rural Council Clinics (including mobile) 44 6 11 4 11 762/ Rural Hospitals 17 9 9 9 12 56 District Hospitals 10 3 5 1 10 29 Mission Facilities 18 23 17 18 12 883/ Total Rural 195 114 118 58 102 587 Rural Population in thousands 2,010 1,046 876 1,005 994 5,931 Persons per Health Unit in Rural Areas 10,30B 9,180 7,420 17,327 975 10,103 Mmnicipal Clinics 20 3 8 2' 9 42 Gensral Hospitals 4 2 3 2 0 11 Cntral Hospitals 2 0 0 0 2 4 Industry and Mines 14 1 5 6 4 30 Total for the Country 235 120 134 68 117 644 Total Population in thousands 2,780 1,110 1,040 1,030 1,400 7,360 Area kn2 in thousands 112 35 56 56 131 391 Population Density Persons/km2 24.8 31.7 18.6 15.1 10.7 18.8 Average Number of Persons per Health Unit 11,800 9,250 7,760 15,147 11,965 11,428 Average Area in sq. km per Health Unit 476 291 418 824 1,120 607 1/ Some new facilities may have been added since 1981. 2/ Rural Council Clinics include about 26 mobile and about 50 static clinies. 3/ Additional mission facilities may have Opened since 1981. Source: MM3 Approved List of Facilities, Central Statistical Office Monthly Digest of Statistics, February 1982. ANNEX 7 Page I of 2 Annex 7: PROPOSED CHANGES IN THE MALARIA, SCHISTOSOMIASIS, AND EXPANDED IMMUNIZATION PROGRAMS MALARIA: Changes in the malaria eradication program are plannedl/. These include: a. Countrywide insecticide spraying campaign in all endemic areas. Currently the Blair Research Laboratory organizes and directs all the national anti-malarial spraying campaigns in all provinces. It is the intention of the MOH to decentralize the organization and implementation of the anti malarial spraying effort, in such a way that each province,and ultimately each district, will be in charge of its anti malarial spraying campaign. This will ensure better population coverage, and greatly facilitate the monitoring of the anti malarial program, which will be done at comaunity level, rather than at central level as it is done now. To this end, the MOH intends to train health personnel in the methodologies and techniques of anti malarial spraying which will provide them with skills to direct and carry out sucessfully spraying campaigns in their respective provinces and districts. b. Mass Chemotherapy. Where and when outbreak of malaria occur, spraying and mass chemotherapy will be used to control the disease. In areas of seasonal epidemics, it may be possible using chemoprophylaxis and spraying to reduce the parasite reservoir, and therefore control the disease. The possibility of utilizing these two methods in conjunction to control the disease is being reviewed in more detail. c. Environmental Methods. All water and irrigation projects are to be amnitored very closely to ensure that they do not become malaria hazards. Larvicides will be promoted in urban areas as the most economic form of malaria control Drainage of all marshes near dwelling places as well as clearing of vegetation, where this is seen to be promoting the transmission of malaria, will be instituted very rigidly through local authorities. In addition, the health education department will spend a great deal of time in the teaching of prevention of malaria as this disease is one of the major public health problems. SCHISTOSOMIASIS Four methods will be used singly or in combination to control this disease. The combination of methods used will depend on disease epidemiology in the area and resources available. a. Chemotherapy. In areas of high intense transmission and high egg excretion rates, this will be the method of choice, as it will cure many diseased patients and therefore reduce 1/ From MOH documents provided to the mission. -34- ANNEX 7 Page 2 of 2 morbidity and mortality. However, used in isolation it does not assure early control of the disease. b. Mollusciciding. Where large water bodies are grossly infected (for example, dams on farms) mollusciciding will be used to reduce the snail host parasite reservoir. Used in conjunction with mass chemotherapy, control of Schistosomiasis in the short term in selected areas will be greatly facilitated. c. Environmental Methods. Environmental methods, such as clearing of marshy vegetation, which creates an environment where snails cannot survive, hold one of the greatest hopes for snail control in rural areas, especially if accompanied by sound health education. Education on environmental methods to destroy snails will be greatly emphasized in efforts to control Schistosomiasis. d. Provision of Safe Water Supplies. In providing enough safe water, the need for the person at risk to get in contact with contaminated water is obviated. The government hopes to provide safe water for all by the year 1990. This method of Schistosomiasis control has the added advantage that if instituted, it also has an impact in reducing many other water related diseases, for example, diarrhoeas, trachoma, etc. ZIMBABWE EXPANDED PROGRAM OF IMMUNIZATION Recognizing the problems of immunization coverage in the past the Ministry of Health plans to carry out a survey of those children immunized in order to get some information on immunization levels in target groups. The results of this survey are not available yet. Following the survey the Zimbabwe Expanded Program of Immunization will be implemented. Targets for immunization coverage are as follows.2/ 1982 45% of target group 1983 55% of target group 1984 65% of target group 1985 75% of target group 1986 80% of target group 1987 85% of target group 1988 90% of target group 1989 95% of target group 1990 100% of target group The strategy is to emphasize the fixed facility approach. Immunizations will be offered at fixed facilities with or without outreach capability by developing the cold chain and training staff to do immunizations. Mobile services will be phased out except to remote areas. The program will be expanded as cold chain equipment are put into place and the staff trained. 2/ Target group = children under five, pregnant women and nursing women. -35- ANNEX 8 Page 1 of 3 Anex 8: HEALTH MANX = Table 8.1: HEALIE PERSCNL RlISTERED WIM IE MEDICAL CLUCIL CF ZIMB13E (1965-81) 1965 1970 1975 1976 1977 1978 1979 1980 1981 Medical Practioners 861 833 890 919 855 885 1,016 1,189 1,283 Dental Surgeons 124 126 144 152 135 131 143 166 178 Pharmacetical aCeists 329 310 299 304 271 304 332 364 373 Opticians 42 35 32 31 33 27 32 36 37 Dispensing Opticians - 15 25 26 26 25 27 31 36 Clinical Psydhologists - 2 24 26 21 20 22 32 38 Physiotherapists 41 46 110 115 117 124 144 160 175 Speec Therapists - - 3 7 7 7 8 9 9 Radiographers 6 4 109 124 136 154 184 217 239 Occupational Therapists - 2 12 13 12 12 15 19 20 Prosthetists and Orthotists - 2 7 6 7 8 7 9 10 Medical lab. Technologists 29 48 118 124 96 121 143 163 177 Health Inspectors 95 77 85 80 84 77 93 97 101 Meat and Other Food Inspectors 90 1 1 1 1 - - - - 1&at Inspectors - 3 28 26 34 23 29 42 45 Dental Technicians - 15 38 37 37 28 29 31 33 Dental Hygienists - 1 10 11 12 7 29 13 14 Electroence phalagraphic TechnicianB - - 2 5 7 6 9 10 10 State Registered Nurses 3,208 3,742 4,688 4,761 4,818 4,882 4,642 4,895 5,220 State Registered Midwives 1,295 1,552 1,869 2,083 2,155 2,321 2,150 2,468 2,638 Maternity Nurses - 158 172 128 173 175 142 141 142 Madical Assistants 229 1,153 2,401 2,581 2,781 3,294 2,555 3,593 4,239 African Orderlies who have not been transferred to the Medical Assistants Register 1,063 771 321 328 318 307 267 NA NA Health Assistants 57 195 334 358 387 402 358 400 417 African Hygiem demmw- strators uht have not been transferred to the Health Assistants Register 162 108 54 52 50 50 31 Nk NA Nursing Assistants - 163 789 810 736 746 662 NA NA Maternity Assistants - 209 1,762 1,943 2,035 2,166 1,935 Nk NA Source: Secretary for Health Amnml Reports 1965-79. Medical Comcil of Zinbabwe for 1980 anrl 1981. -36- ANNEX 8 Page 2 of 3 Table 8.2: DISTRIBUTION OF KEY CATEGORIES OF STAFF BY TYPE OF INSTITUTION Type of Institution Doctors SRN MA HA Central and General Hospitals 292 1,575 923 0 District Hospitals 16 ) 348 Rural Hospitals 0 ) 210 233 Clinics 0 ) 296 Provincial Offices 12 ) - 269 Municipal Clinics 14 148 4721/ 74 Mission Hospitals 40 85 281 NA2/ Industry and Mines 27 72 NA2/ NA2/ Total 401 2,090 2,553 343 Private or not accounted for 882 3,130 1,686 74 Total Registered 1,283 5,220 4,239 417 1/ 1979 data. 2/ Not available but may not be large. Source: A variety of sources--MOH officials, Health Secrtary's Report of 1979, WHO Health Profile 1980, and Mission Data--have been used to compile this table. The data is, therefore, not accurate but may suffice for discussion of distribution of manpower. -37- ANN 8 Page 3 of 3 Table 8.3: AUrdIRIZED MCH ESTABLISHIENT Pharmacists, Radiographers Adminis- and Other Nursirg trative & Doctors Technicians SRN MA HA Aids Trainees General Total ML Head Officel/ 569 Central Hospitals 294 211 1,414 536 0 417 813 2,748 6,433 Genral Hospitals 43 34 359 499 0 21 0 757 1,713 District Hospitals 24 12 63 433 0 5 0 455 992 Rural Hospitals 0 0 0 287 0 0 0 180 467 Special Hospitals 8 3 177 81 0 63 0 414 746 PMUH Ofices 18 53 87 22 313 4 0 274 771 Laboratories 2/ 12 150 3 1 0 0 0 252 418 Leave Relief 86 5 64 38 28 0 0 181 402 Additional Posts for Medics 857 857 Miscellaneous 2 7 5 14 Total 487 468 2,167 2,761 341 510 813 5,266 13,382 1/ The head office staff are not specified in terms of different categories. 2/ Irwludes Blair Research Laboratory. Source: MMH Establishment Information -38- ANNEX 9 Page 1 of 6 Annex 9: TRAINING OF HEALTH PERSONNEL 1. The establishment for training of health care personnel consists of the following: School of Medicine and Pharmacy at the University of Zimbabwe, two centers for training of radiographers, four centers for SRNs, two centers for training of midwives, about eight mission and two government centers for training of MAs, about 7 mission and 1 government center for training of maternity assistants, a center for training of HAs, and a center in each district to train VHWs. The specialist training in physiotherapy, occupational therapy and dentistry is not available within the country. The following shows the role of various categories of personnel and the annual intake for training: No. of Training Annual Category Role Institutions Intake Doctor Serve in central, general and 1 80 district hospitals, private practice Pharmacists Pharmacist services at hospitals, 1 20 and private sector Radiographers Serve in hospitals, and private 2 25 sector SRN Nursing services at central, 4 300 general and district hospitals, other hospitals, and private sector Specialized Specialized nursing services at several small Nursing hospitals MA Serve as paramedicals in hospitals, 10 110 provide curative services in clinics and rural hospitals Maternity Maternity services in addition 8 90 Assistant to serving as MA HA Serve in PMOH offices, mainly for 1 25 the provision of preventive services 2. The Faculty of Medicine, University of Zimbabwe, has been granting its own medical degrees since 1977. Earlier, since 1968, the Medical School operated under the sponsorship of Birmingham University. The entry is after requisite grades in the "A" level examination. The course is of five years duration, two pre-clinical years and three clinical years. It is followed by a year of internship. The academic standards are high and the degree is also recognized by the Medical Council of South Africa and of the United Kingdom. The number of doctors estimated to graduate are 48, 57 and ANNEX 9 Page 2 of 6 60 in 1982, 1983 and 1984 respectively. In 1981, the intake was increased and about 80 doctors are likely to graduate each year from 1985 onwards. There are no postgraduate examinations; only some clinical training is carried out in Zimbabwe so that the students may appear in examinations overseas. 3. In 1981, there were about 100 established posts for professors and lecturers at the Medical School, of which about 37 were vacant. The faculty strength may have to be increased to cater to increased intake. 4. The training of doctors has been largely oriented towards clinical practice and most of the graduates in the past have either taken up private practice or worked in large urban hospitals. Recently some have questioned the suitability of the curriculum to meet the needs of the revised orientation of the health system. A consultant provided by WHO has reviewed the curriculum and training program for physicians. A better understanding of the socio-economic context of illness and health care needs of rural areas, and exposure to practice in rural areas by visits and placements, may be necessary for a reorientation of the graduates. But the 'what' and 'how' of such changes are still being discussed. 5. About 20 pharmacists are trained each year by the School of Pharmacy at the University of Zimbabwe in a 2-year course. But many of the graduates are absorbed by private industry. Two polytechnics also produce a small number of pharmaceutical technical assistants through a 2-year part-time course. There is a shortage of personnel in pharmaceutical services of MOH and the government would need to sponsor more candidates to these courses than in the past. Two central hospitals train about 25 radiographers each year in a 3-year course after 'A' level of training. But it is difficult to recruit even such small numbers for this course and most candidates who graduate take up jobs in other fields. In view of about 35 vacancies, the service conditions for this category of staff need to be reviewed. There are no training facilities for physiotherapists and dentistry in the country and the Ministry of Education needs to make scholarships available for study abroad in these areas. 6. On an average about 280 SRNs are estimated to graduate each year with a diploma in general nursing from the schools at four central hospitals. The entry level requirement is five "O" level of education. The training of three-year duration is based on a block system which alternates between blocks of about 4 weeks of training and about 28 weeks of fieldwork. The standard of nursing education is high and the qualifying examination is arranged by the Medical Council. The education is oriented towards work in hospitals. In the PHC system, they will also be engaged in preventive work. Several possible changes in the training are being discussed to orient SRNs to rural areas. One idea is to have a course of State Certificated Nurses, After entry at the same level as that of SRNs and two years of nursing training, these students would be expected to work in rural clinics for a period of about two years. After this service experience in rural areas, they could continue for SRN training which -40- ANNEX 9 Page 3 of 6 might take about 18 months. The overall duration of the course would, therefore, increase to five and a half years from three years and it is not clear how many students would opt for such a program. 7. After the diploma in nursing, various other specialized courses of nursing including midwifery, community health, psychiatric nursing and nursing administration are available. Two centers in central hospitals offer one year midwifery training for SRNs with one year experience after graduation. A total of about 120 students graduate each year. Table 9.1 below shows the courses and institutions for various nursing specialties. The number of students in each course other than midwifery is small, ranging from 3 to 13. Table 9.1: SPECIALTIES IN NURSING Course Duration School No. of Students Midwifery 1 yr. Two Central Hospitals 90-120 Diploma in Nursing Univ. of Zimbabwe Education 2 yrs. and Mins. of Health 6-12 Diploma in Community 1 yr. Ministry of Health 13-18 Health Nursing Harare Diploma in Nursing 1 yr. Ministry of Health, 7-10 Administration Harare Advanced Clinical 2 yrs. Mpilo Central 6-10 Nurses Diploma Hospital Diploma in 18 mos. Ingutsheni Hospital 11-18 Psychiatric Nursing Intensive Care 1 yr. Parirenyatwa 5 5-6 Diploma Harare Central 0 Mpilo 0 Anesthetic Nurse 1 yr. Harare Central Diploma Mpilo Operating Theatre 1 yr. Parirenyatwa 5 5-6 Diploma Harare 0 Mpilo 0 Diploma in 1 yr. Univ. of Zimbabwe 3-10 Health Education and Mins. of Health Psychiatric 1 yr. Ingutsheni Hospital 6-15 Certificate-Medical Assistants ANNEX 9 Page 4 of 6 8. The MA was first trained as an auxiliary to SRNs but is now more widely used. They have been trained by missions since 1950s with government grants. Several of the 15 missions offering this training were closed during the war, but about 8 are reported to have started again and others are likely to start soon. Two government schools, at Marandellas and Que Que, also provide this training. The three-year course consists of 246 hours of lectures which include human biology, hygiene, practice of nursing, general principles of medical and surgical conditions, community health and preventive medicine, family planning and laboratory work. About 72 weeks are spent on practical work including surgical, medical and pediatric nursing, operating theatre and casualty. About 110 MAs graduate each year. 9. MAs, most of them women, serve at all levels of health care institutions but are mainly in charge of rural hospitals and clinics. Therefore, they are among the major categories of service providers in rural areas. The training capacity for MAs needs to be sharply increased. MAs will continue to be in charge of RHCs in the new PHC model and therefore, will need to receive additional training in management of comprehensive services of health centers. 10. Maternity Assistants are medical assistants who have received an additional year of training in midwifery. About seven mission schools and one government school train about 90 maternity assistants a year. In the PHC system the RHCs will be staffed by two MAs, at least one of whom would also be a maternity assistant. 11. In the past, HAs were posted only at PMOH offices and, therefore, only one school, at Domboshawa, trains about 25 HAs each year. This school has 4 tutors and 8 health training officers. The entry level requirement is the "O" level certificate (see Table 9.2 below) and the three-year curriculum includes public health and preventive medicine, health education and administration, and building and sanitation. In the PHC system, one HA will be posted at each RHC, and will be in charge of preventive work in the surrounding rural area, and of supervising VHWs in the area. A large increase in training capacity of HAs will be required to staff RHCs, and modifications will be required in the curriculum so that they are able to perform their new role. Table 9.2: STRUCTURE OF TRAINING FOR MAIN CATEGORIES OF HEALTH MANPOWER "O" LEVEL "A" LEVEL CERTIFICATE CERTIFICATE PRIMARY SECONDARY E7j-FJ14jfl-$j 11 {12 J Doctors Pharmacist - C - SRN Midwifery Certificate Specialized Nursing- .-HAs Certificate -C ---Medical Assistants Mate nity Assistants -43- ANNEX 9 Page 6 of 6 12. Some consideration is being given to reducing the duration of training for MAs and HAs from three years to two years. Although the need for increased manpower in the short-term can be partially met by this measure, it is not likely to alleviate the problem significantly. The curriculae should be redesigned in view of their new roles rather than based on considerations of short-term needs. For a long time in the future, they will be the key personnel providing health services in rural areas and, once posted in the field, it will become difficult to upgrade their skills. 13. Prior to 1979, the VHWs were trained for 6 months in hospitals under the overall coordination of PMOH offices. In all, about 190 VHWs were trained. These VHWs performed largely curative work in protected villages during the war. In the PHC system, the VHW will work part-time and will be the most peripheral worker. He/She will be a part of the community and will offer services of envi-ronmental sanitation and health education, curative services for minor ailments, and referral of patients for more serious diseases and child spacing. The VHW is also expected to keep simple records of births and deaths and of causes of communal increases in morbidity and mortality. The VHWs are selected by district councils, using their own criteria. But all candidates are expected to have basic literacy skills to be able to perform the deisgnated tasks. 14. The VHWs are now trained in each district by a team of one MA and one HA at the clinic or rural hospital in the area. The duration of training is 12 weeks; about 8 weeks are spent at the training center and the remaining 4 weeks of supervised field work complete the training. The curriculum for VHWs includes hygiene, illnesses and diseases due to unclean surroundings, care of the new-born and infant, common illnesses of the childhood, referral for child spacing, first-aid procedures, common adult illnesses and a description of the PHC system. At a time about 6 to 10 VHWs are trained and a very modest residential accommodation is provided for the t-rainees at the designated training place in the district. The first batch of about 300 VHWs was trained by December 1981 and has been working since then. Three batches consisting of a total of 900 VHWs are expected to be trained each year. 15. The MOH carried out an evaluation of the first batch of VHWs in February 1982 by interviewing 66 VHWs and 121 community members. The only problems in training cited by VHWs were lack of proper accommodation, stationery, and cooking facilities. Most of the VHWs felt that their training environment was similar to the environment in which they work. Health education was considered a strong part of the training by 65 percent; water and sanitation, child care and nutrition, and diagnosis and treatment were each considered strong by about 25 percent, and leadership was considered strong by 14 percent of the respondents. A small number of respondents indicated that the deficits in the course were in the areas of midwifery and diagnosis and treatment. Thus the evaluation indicates that, by and large, training may have achieved its purpose. Although continuing training to maintain the skill level of VHWs is envisaged by the government, specific plans for such training have not been developed. -44- ANNEX 10 Annex 10: UNiFIED NATIONAL HEALTH INORMATIoN SYSTE( INFORMATTON FLO' MID TERACTION SCHD( MINSTCRmENTR) ERMNENT f+_ 4TtONALLNTERMNI3TEIAL t secRETARr | Y COMMirTEE FOR HEALIH sTAmsTICS DEPDMIOLO o|CENTRAL HEALT4 it MINISTRY OF HOME AFFAIRS HEIA THSTATISTICS L SNOMIST REGISTRAR GE4ERAL D* OEATms_ _ BJRTHS AND DEATHS OTHER I MEDRECOFf a MED. RECORD DEPARTMENTS w rrsTS OF UNIV. TRAJNNC3 I ANI CENTRAL 'UNIT / I/ kPTALS MINISTRY OF ECONOMIC IPLANNING AND DEVELOPMENT - - - } - - -~~~~~czrrp-AL smnsTics FFIC. / . / I I ~~~~~compurER U NIT PROVINCIANL UICIAL E . Of FICER P__ _C. AL "3 ~ ~ PROVNC GXNIALA*4 I HEALI OTHER HOSPTA I. Wl1 I~STAT(ICS AN fW(MTERNITES TIOFF5IC I STAnincs OTHER MINISTT,IES L_PICULTURz,MINES, DEFENSE) AND OTHER INSTITUTIONS ______________T_LEVEL(PRISo0NS) DISTRICT MEDICAL| L - - - i DISTRICT HEAlTH DISTRICT GENERAL "srATwsTics OFFICE' AND OHERf- HOSPITALS RECOW.DS AND 5TA;r11 CS R E (DATA CCd4LCflON) VI-{WI f LLOCAL AUTHORITIES, jjQE5S OTHER HOSPITALS - C4-GOVERNM ENTAL(MISSIQNS,MININC, INDUSTRIALET) VHW =VIULAGE HEALTH WORKEIR 4 - DI?RECMON OF Th4 INFOWMATION FLOW UPROVSIONALJ Source: Jaravaza V.S., et al, "Unified National Health information System" The Central African Journal of Medicine, pp 28, Vol 28 No. 2 Feb. 1982. -45- ANNEX 11 Page 1 of 11 Annex 11: SOURCES OF FINANCE FOR HEALTH EXPENDITURES 1. This annex contains a detailed explanation of the procedures and assumptions used in the process of derivation of the figures in Table 6 in the main text. All figures refer to FY80/81. Operating and Maintenance Expenditures 2. In 1980/81, operating and maintenance health expenditures were incurred in connection with services provided by the Ministry of Health, other ministries, parastatals, district and rural councils, municipalities, missions, industrial and mining health facilities, voluntary organizations, and other private providers of health goods and services (private medical practitioners, both modern and traditional, pharmacies, etc.). Sources of finance of these expenditures included the Ministry of Health, other ministries, parastatals, municipalities, missions, industrial and mining enterprises, voluntary organizations other than missions, foreign donors, insurance schemes, and private individuals. Table 11.1 below summarizes 1980/81 operating and maintenance expenditures by type of service provider and by source of finance. A more detailed explanation of the amounts shown in the table for each source of finance then follows. able 11.1: TOTAL aMMAXIl AND KfINrh?W E)TWflRES Ct HEf CARE 1980/81 - of Finaxne Irlustry Ministry of Otber Munici- arl Vol. Foreign Ins. Private TItal Service Pruviders Health Ministries Parastatals pallties Missions mies Org. Asst. Schms lIividuals Ibtal X Mindstry of Health 57,600 500 1,900 1,700 61,700 43.5 Otber Ministries 6,000 6,000 4.2 Parastatals 1,300 4,200 5,500 3.9 District/rural councils 2,700 2,700 1.9 Nkodcipalities 6,500 2,000 8,500 6.0 Missions 2,900 500 3,400 2.4 Indstry/mi6m 900 4,000 4,900 3.5 Volntary organizations 200 1,500 1,700 1.2 Private sector 500 24,400 22,400 47,300 33.4 Total 72,600 6,000 4,200 2,000 500 4,000 1,500 500 26,300 24,100 141,700 100.0 Total % 51.2 4.2 2.9 1.4 0.4 2.8 1.1 0.4 18.6 17.0 100.0 ON Notes: 1/ Totals may not add up due to rcunding. 2/ For the Minstry of Hea1th tie total fixds e xerded under its own hbudgt 5s Z$77,384,875. Hiever of this amnunt, Z$3,113,477 is sDre properly regarded as capital expenditure, as it camprised (i) expenxlitures on capital grants to local autborities etc.;and (ii) expeniitures on furniture and equlipent. Also an anx of Z$1,666,000 was recovered in rewnue fran fees. Tie net recurrert amixut provided by the Mirdstry was tierefore Z$72,605,398. All figures are actual, not estimates. 3/ lie detai]s of tie allocations from the Ministry of Health to cther service providers are discussed in tie text of tie report. The exact figures are as follaos: paratatals (Z$1,284,000), district anl rural councils (Z$2,724,774), nunicipalities (Z$6,372,948), voluntary organizations (Z$172,610), industry (Z$946,458), anl the private sector (mainly care for tie infirm) (Z$436,014). 4/ For the irsrance schemer as a sourae of finance, it Is assmrd that the expernditures (Z$1,930,000) on the Parirenyatwa Kospital was in effect reverae to tie gvernrent. Mie remainder of their eKperditires (including administrati-ve expeanses) is classified as o being on the private sector. 5/ For private indlividuals as a source of finance, it is anssumed that Z$8 millimo wan spent on pharmaceuticals, Z$12 million on traditional mndicine, and Z$2.4 million on private mEdical services. -47- ANNEX 11 Page 3 of 11 (i) Ministry of Health 3. Actual spending by MOR in 1980/81 under its own budget amounted to Z$77,384,000. However, as explained in Note 2 to Table 11.1, Z$3,113,000 of this amount should be classified as capital expenditures, and thus MOH's operating and maintenance expenditures were Z$74,271,000. Moreover, an amount of Z$1,666,000 was recovered from the public in revenue from service fees (shown in Table 11.1 as contribution of private individuals to financing of MOH's expenditures). Hence, MOH's net financing of operating and maintenance expenditures was Z$72,605,000. The first column in Table 11.1 shows that, of this total, Z$57,600,000 went to finance MOH's own expenditures; Z$1,300,000 were allocated as a grant to the Family Planning Association, accounting for 96.4% of the Association's budget in that year; Z$13,200,000 were allocaterd as grants to health facilities operated by district and rural councils, municipalities, missions, industrial and mining concerns, and voluntary organizations other than missions; and Z$500,000 were paid to private health practitioners for the care of patients referred to them by MOH. (ii) Other Ministries 4. Some other central government ministries also provided funds to support health services and activities. The following table lists these ministries and departments, and attempts to provide estimates of the amounts of recurrent funds which they devoted to the health care system in 1980/81. -48- ANNEX 1 1 Page 4 of 11 Table 11.2: HEALTH CARE AND SUPPORT ACTIVITIES OF OTHER CENTRAL GOVERNMENT MINISTRIES, 1980/81 Ministry or Department Activities Funds Provided Ministry of Agriculture Control of zoonotic Say Z$5m. (Total budget diseases of Department of Animal Health is about Z$20m, and it is assumed that 25% is spent for human health reasons). Ministry of Natural Water supplies (but Unknown, but possibly Resources and Water mainly for agriculture a large amount rather than domestic use). Ministry of Labour Welfare of destitutes; Z$300,000 and Social Services rehabilitation and occupational health. Ministry of School health education Relatively small amount Education programs (very few school health programs; no feeding programs) Ministry of Industry Drug production policy Small amount (product- and Energy Development ion is done privately). Ministry of Women's Support for family Relatively small amount Affairs and Community planning activities Development Ministry of Works Maintenance of MOH Z$400,000 (i.e. approx. (Construction) buildings 25% of maintenance vote) Army Military health Relatively small amount services Source: Mission estimates ANNEX i1 -49- Page 5 of 11 5. Although it was impossible to obtain detailed recurrent expenditure figures for many of these activities, it is estimated that an amount of Z$6 million was provided in total by these other central government ministries for health activities (if expenditures on water supplies are excluded). This equalled only about 7.9% of the funds provided by the Ministry of Health, but their contribution should at least be acknowledged. As'in the case of the Ministry of Health itself, they also obtained their funds from central government revenues. (iii) Parastatals. 6. Although the term "parastatals" is not entirely appropriate, there are some institutions in Zimbabwe which are established and primarily funded by the government. For example, there is a Child Spacing and Fertility Association (previously the Family Planning Association), which in 1980/81 had a recurrent budget of Z$1,331,324. Nearly all (in fact Z$1,284,000 or 96.4x) of its income came as a grant from the Ministry of Health, however, and so these funds may be regarded as a transfer payment rather than as additional financial resources to the health sector. 7. On the other hand, the Medical School of the University of Zimbabwe received a grant of about Z$4.2 million from the Ministry of Finance; and as these funds did not come through the Ministry of Health's budget, they must be added to the calculation of resources which went into the health sector. (iv) Local authorities. 8. There are three types of local authorities in Zimbabwe -- district councils, rural councils, and town councils. The financing mechanism for the town council clinics before September 1980 was somewhat different to that for the district and rural council clinics, and may be considered separately. 9. District and rural councils. Prior to September 1980 the funds to operate the district and rural council clinics came ftom patient fees, general council revenues, and the Ministry of Health in roughly equal proportions. With the removal of the fees for all people earning less than Z$150 per mDnth, however, clinic attendances rose significantly -- and the Ministry of Health accepted responsibility for the full running costs. In the financial year 1980/81, the Ministry of Health provided a grant to the councils of Z$2,724,774 for this purpose. The councils ceased to be an independent source of finance for health operating and maintenance expenditures, as can be seen from Table 11.1. 10. Town councils (municipalities). Before the new fee schedule was introduced, revenue to operate the urban clinics was obtained from four sources: fees, local government rates, profits from beer sales, and a grant from the Ministry of Health. However, the Ministry of Health now accepts responsibility for mst operating costs; and its subvention to the municipalities in 1980/81 was Z$6,372,948. It is estimated that in addition the municipalities provided a further amount of about Z$2 million raised through fees and local taxes (as shown in Table 11.1). ANNEX 11 Page 6 of 11 (v) Missions. 11. Before September 1980 the Ministry of Health paid about one third of the operating costs of the mission facilities, but it now accepts full responsibility for their approved running costs; and in 1980/81 it gave a subsidy of Z$2,916,979 to them. The exact additional amount of money raised by the missions from other sources is unknown, but it might have been in the order of Z$500,000. (vi) Industry and mines. 12. According to the Ministry of Health, it is thought that industry and mines provide about Z$4 million to operate health services (though a significant proportion is in effect derived from government through tax rebates). In addition the Ministry of Health paid Z$946,458 in 1980/81 (mainly to Wankie Colliery Hospital) for patients for which it was responsible. (vii) Voluntary organizations (other than missions) 13. There are many voluntary organizations active in Zimbabwe, and some of them are supported by the government. In 1980/81 the Ministry of Health provided a grant of Z$172,610 to assist with the operating costs of some of them; but it is estimated that a further amount of perhaps Z$1.5 million was raised independently by these voluntary organizations in 1980/81. This amount includes expenditures on various nutrition programs and feeding schemes. (viii) Foreign assistance. 14. The bulk of foreign aid is provided in the form of capital assistance (whether or not it actually passes through the government's accounts). However, there are certain types of non-capital aid -- for example in the form of technical assistance, fellowships, and food or medical supplies. It is likely that the value of such assistance may have been quite significant, but in view of the lack of data (and also some difficult valuation problems) the only estimate to be included here is an amount of Z$0.5 million spent in 1980/81 on nutrition programs and feeding schemes. (ix) Insurance schemes. 15. There are five voluntary medical insurance schemes each with over 10,000 members, and a relatively large number of other smaller ones. In total the number of members of these schemes was 219,371 in 1979/80 and 231,528 in 1980/81. About 80% of the members were Europeans, i.e. about two thirds of all Europeans were covered by one or another of the schemes. In contrast about 20% of the members were Africans, representing about 0.5% of the total African population. Of the five largest schemes, two are operated on a commercial basis and open to the general public, two are confined to specific industries, and one is for public and parastatal workers. In each the employer ANNEX 11 -51- Page 7 of 11 pays 50% of the contributions, with the employee paying the other 50%. Not only does the government support the system financially through its contributions for its own scheme (not shown separately in Table 11.1), but it also gives tax rebates for both the employers' and employees' contributions (also not shown in Table 11.1). In addition the premia are kept low because of the highly subsidized level of government hospital fees. 16. In 1980/81 it is estimated that an amount of about Z $26.3 million was channelled into the health care system through these medical insurance schemes. An approximate breakdown is as follows: Table 11.3: MEDICAL INSURANCE EXPENDITURES (Z $'OOOs) Expenditures General practitioners 5,550 Specialists 9,630 Parirenyatwa Hospital 1/ 1,930 Private hospitals 950 Others 2/ 2,030 Dental 4,260 Administration 1,950 Total 26,300 Notes: 1/ The revenue accruing to the Parirenyatwa Hospital does not go through the government accounts. 2/ For appliances, spectacles etc. No reimbursement is allowed for drug expenditures. (x) Private Individuals 17. It has already been pointed out that private individuals paid Z$1,666,000 to the government in the form of fees for health services in 1980/81. In addition they paid approximately Z$13.15 million as premia for medical insurance under the insurance schemes, but this has already been considered separately. However, some individuals who were not members of medical insurance schemes also paid for private medical care. Although exact data on this are not available, it is believed that these expenditures amounted to about 10% of the amounts paid through medical insurance. Therefore, excluding the administrative costs of the insurance schemes, those expenditures would have been about 10% of Z$24,350,000 or about Z$2.4 million. 18. Account must also be taken of the amounts spent by private individuals on the purchase of drugs. In 1980/81 it is estimated that about Z$16 million worth of pharmaceuticals may have been consumed in Zimbabwe. Of this amount approximately Z$5 million was bought by MOH health facilities from the government's medical stores, and about Z$1 million was bought by other health providers from those stores. If it is assumed that a further amount of perhaps Z$2 million was bought -52- ANNEX 11 Page 8 of 11 directly from suppliers by government (both central and local), missions and industrial and mining hospitals, then the balance of about Z$8 million must have been bought by private individuals from pharmacies and private clinics. Although only rough estimates, it is therefore believed that about half of the total drug consumption may have been purchased privately. 19. Another most important area concerns private expenditures on traditional medicine. These amounts are even more difficuilt to estimate, but the task is facilitated slightly by the ongoing registration of traditional doctors in Zimbabwe. So far about 11,000 have registered, and the President of the Zimbabwe National Traditional Healers' Association has estimated that the eventual number to register may be about 20,000. In addition, of course, there will be other traditional doctors who do not register, especially if they are not full time or live in particularly remote areas. Nevertheless, if one makes the rather heroic assumption that the 1980/81 average income (in cash and in kind) of these traditional doctors from their healing activities was approximately equal to the per capita GNP of the country (ie. about Z$400), then the amount spent on traditional medicine in that year would have been in the order of Z$8 million. Given that the estimate of 20,000 traditional doctors is probably on the low side, and that it is known that many of them are probably relatively wealthy, it is suggested that the total expenditure figure might be in the range Z$8-16 million. If so, then the annual per capita expenditure on traditional medicine would be roughly Z$1-2 p.a. Clearly very little reliability can be placed on a figure such as this, but at least it provides a sense of the broad magnitude of expenditures on traditidnal medicine. (xi) Self-help. 20. Finally recognition should be given to the fact that some recurrent health activities are already being financed through community efforts. It is indeed the intention of the Ministry of Health to try to encourage local communities to accept (at least eventually) the responsibility for paying their local village health worker. For the year 1980/81, however, no estimate was attempted of the value of community self-help efforts. Capital Expenditures 21. In 1980/81, capital expenditures for health were incurred in connection with (future) provision of services by MOH, other ministries, district and rural councils, municipalities, voluntary organizations, and private clinics/hospitals. Sources of finance of these expenditures included the central government (through the Ministry of Works and MOH), voluntary organizations, foreign donors, and insurance schemes. This is summarized in Table 11.4 below, and details concerning the figures shown in that table then follow (organized by source of finance). ANNEX 1 1 ~53- Page 9 of 11 Table 11.4: TOTAL CAPITAL EXPENDITURES ON HEALTH CARE 1980/81 (Z$ '000) - Source of Funds---------… Service Central Voluntary Foreign Insurance Total Providers Government Organizations Assistance Schemes Total % Ministry of Health 5,942 5,942 42.1 Other Ministries 4,000 4,000 28.4 District/Rural Councils 1,895 1,895 13.4 Municipalit- ies 144 144 1.0 Voluntary Organizations 115 1,000 1,115 7.9 Private clinics 1,000 1,000 7.1 Total 6,201 1,000 5,895 1,000 14,096 100.0 Total % 44.0 7.1 41.8 7.1 100.0 Note: Totals may not add up due to rounding Source: MisBion estimates (i) Central Government 22. Funds for the construction of MOH facilities appear on the votes (Public Sector Investment Programme) of the Ministry of Works (renamed Ministry of Construction in April 1982). The Ministry of Construction keeps a cost estimate of each individual project and subsequently a record of such expenditure by individual Ministries. If it is assumed that the percentage of actual to approved expenditures in 1980/81 was the same for MOH as for the entire Ministry of Works program, then actual capital expenditures associated with MOH facilities were about Z$4,983,000. This figure does not include the grants which MOH itself made (mainly with external assistance) for development of health facilities operated by other health providers, nor its own capital experfditures, which altogether amounted to about Z$3,113,000 (as was pointed out in paragraph (3) above). This figure breaks down as follows: ANNEX 11 -54- Page 10 of 11 Table 11.5: MINISTRY OF HEALTH CAPITAL EXPENDITURES IN ITS RECURRENT BUDGET, 1980/81 Item Amount (Z$) Furniture and equipment 942,600 Housing in rural areas 16,738 Grants to councils: infrastructure 1,894,903 Grants to municipalities: infrastructure 125,878 Grants to municipalities: furniture and equipment 18,421 Grants to voluntary organizations: infrastructure 114,574 Grants to voluntary organitations: furniture and equipment 364 3,113,477 23. Of this amount, however, some was actually financed by foreign aid. Although it is again difficult to be precise, it is thought that the main foreign-aid financed item was the capital grant (of Z$1,894,903) to the councils for the renovation/construction of clinics in rural areas. It is possible that some of the expenditures under the Ministry of Works' vote were also financed externally, but this is hard to ascertain as the government's budget gives no indication of funding sources. In view of this it will here be assumed that the total amount of government finance spent on capital health expenditures in 1980/81 was Z$6,201,000 (i.e. Z$4,983,000 plus Z$3,113,000 minus Z$1,895,000). (ii) Voluntary organizations 24. In the earlier section on sources of finance for operating and maintenance expenditures it was indicated that voluntary organizations were very active in 1980/81 in providing funds for nutrition programs and feeding schemes. In addition, it is estimated that they provided about Z$1 million to finance various capital expenditures. (iii) Foreign assistance 25. At the time of independence there were widespread hopes for considerable amounts of foreign assistance to help both the country's recovery and reconstruction, and also its development. However, although several donors were very anxious to expedite their aid flows, throughout 1980/81 (the first year of independence) there were some major problems in carrying out the plans. Indeed it was only in March 1981 that the Zimcord Conference took place. Nevertheless, it is estimated that nearly Z$8 million was spent on foreign assisted health related development activities in 1980/81--half of which was on water programs excluded from Table 11.4. It has already been indicated that Z$1,895,000 was spent on council clinics reconstruction. (iv) Insurance schemes 26. The final major source of development finance in 1980/81 was through the medical insurance schemes. At present there are four private clinics/hospitals--one (Mater Dei) in Bulawayo, two (Montagu and St. Anne's) in Salisbury, and one (surgical clinic) in Umtali. However three more (two new ones in Salisbury and an extension in -55- ANNEX 11 Page 11 of 11 Bulawayo) have been proposed, and work on one of these (Baines Avenue Clinic in Salisbury) started in 1980/81. It will have about 150 beds, and the total estimated capital cost is Z$9.5 million. In the fiscal year 1980/81, it is estimated that maybe Z$l million was actually spent on it. (v) Other sources of finance 27. The other sources of finance which were considered in the analysis of recurrent expenditures were less important for development expenditures in 1980/81. Apart from the development of water supplies (which were funded essentially from foreign aid), there do not appear to have been any major health-related development activities in the other central government ministries. This also applies to the "parastatals"; and in the case of the local authorities, their development activities were entirely financed through the Ministry of Health's budget. Possibly there was a little development expenditure by the missions, and by industry and the mines, but no data are available on this. And finally there was probably a significant amount of self-help activities (especially in the clinic reconstruction program), but no estimate is attempted here of the value of this. -56- ANNEX 12 Annex 12: INPATIENT OOSTS AND SlJBSIDIES Table 12.1: AVERAGE COSS AND 9UBSIDIES FaR INPATIE2T CARE IN VARIXJS HLSPITALS (1979) Total Cost Total Charges Deficit/Subsidy Expenditure Total per Patient Earnings per Patient as % lt Patient Day Day Z$ of Cost Hospitals Z$ Days Z$ Z$ Z$ Central: Ardrew Flemixng2/ 8,736,103 201,179 43.42 2,440,505 12.13 31.29 72.1 Harare 6,986,939 416,470 16.78 418,618 1.01 15.77 94.0 Bulavayo 2,595,178 90,800 28.58 965,151 10.63 17.95 62.8 Mpilo 4,804,286 430,104 15.01 331,120 1.03 13.98 93.1 District: Banket 104,678 25,668 4.08 13,796 0.54 3.54 86.8 Belinrwe 44,293 19,805 2.24 6,253 0.32 1.92 85.7 Beitbridge 55,956 9,175 6.10 12,309 1.34 4.76 78.0 Mrewa 73,652 30,378 2.42 19.976 0.66 1.76 72.7 Pluntree 115,972 18,831 6.16 13,760 0.73 5.43 88.1 Lmbvw 119,599 24,891 4.80 9,944 0.40 4.40 91.7 Shabani 316,623 42,883 7.38 29,490 0.69 6.69 90.7 Rural: IAwosi 22,888 21,156 0.92 8,726 0.35 0.57 62.0 Psychiatric: Ingutsheni 1,752,251 275,978 6.35 49,465 0.18 6.17 97.2 Geral: SinDia 465,260 48,528 9.55 43,328 0.89 8.66 90.7 Source: Ministry of Health. Notes:l/ Exluding overhead costs, i.e. H.Q. affdnistratimx, staff training costs. 7 This is now called the Parirenyatwa Hospital. The cost per unit in 1980/81 wa Z$54, and the cdaugm per unit Z$12. -57- ANNEX 13 Anex 13: 1*OSTCN OF HE ED= Table 13.1: ANNDL ESIIMS AND EXPENDIIURES CF ME MENIS CF HEALTH BY MAIN PART 1974/75-1982/83 (Z$ 000) of wid Salisby Admnistration Mdical Care Group of rewrtive and General Services Lmspitals Servies &earch Total 1974/75 Estimte 1,104 24,911 (9,316) 2,515 340 28,870 % 3.8 86.3 (32.3) 8.7 1.2 100.0 Expenditre 1,044 23,799 (8,056 2,517 349 27,710 X 3.8 85.9 (29.1) 9.1 1.3 100.0 1975/76 Estiimte 1,106 26,286 (8,415) 3,007 410 30,809 % 3.6 85.3 (27.3) 9.8 1.3 100.0 Ependiture 1,354 25,897 (8,415) 3,079 3B9 30,719 % 4.4 84.3 (27.3) 10.0 1.3 100.0 1976/77 Estimate 1,614 30,388 (9,420) 3,304 463 35,769 Z 4.5 85.0 (26.3) 9.2 1.3 100.0 Eexenditure 1,498 29,441 (9,102) 3,122 408 34,469 X 4.4 85.4 (26.4) 9.1 1.2 100.0 1977/78 Estimte 1,501 34,616 (11,461) 3,692 428 40,237 % 3.7 86.2 (28.5) 9.1 1.0 100.0 Experiiture 1,215 33,399 (11,120) 3,534 414 38,562 % 3.2 86.6 (28.8) 9.2 1.1 100.0 1978/79 Estimte 1,449 39,749 (13,605) 4,090 542 45,829 X 3.2 86.7 (29.7) 9.0 1.1 100.0 aE anditure 1,355 39,997 (14,005) 3,804 464 45,621 X 3.0 87.7 (30.7) 8.3 1.0 100.0 1979/80 Estimate 2,113 47,053 (16,729) 4,522 538 54,226 X 3.9 86.7 (30.8) 8.3 1.0 100.0 Eyxpnditure 2,139 46,575 (16,729) 4,234 515 53,463 % 4.0 87.1 (31.3) 7.9 1.0 100.0 1980/81 Estimate 2,525 74,906 (21,537) 5,598 700 83,729 Z 3.0 89.5 (25.7) 6.7 0.8 100.0 Eqxenditure 2,695 68,140 (21,537) 5,910 640 77,384 % 3.5 89.4 (27.8) 7.6 0.8 100.0 1981/82 Estimnte 3,887 95,802 (21,720)1/ 8,442 805 108,936 % 3.6 87.9 (19.9) 7.8 0.7 100.0 1982/83 Estiute 6,051 107,290 (15,205) 15,999 960 130,300 X 4.6 82.3 (11.7) 12.3 0.7 100.0 NDtes: i/ In tie 1981/82 fiscal year Harare HospiLtal reverted to tle Miristry of Heaith in tie accourts (i.e. it was m longer included in tie sibyertion for tte Salisbury Group o£ bspitals). 2/ Totals may not add up dt to rotnding. -58- ANNEX 14 Page 1 of 10 Annex 14: HEALTH DEVELOPMENT PLANS, COST IMPLICATIONS AND AFFORDABILITY Government Proposals 1. At the time of writing of this report, the Government's three-year "transitional" national development plan (originally to be implemented over the period FY81/82-FY83/84, but later pushed back by one year to the period FY82/83-FY84/85) had not been finalized. It was thus necessary to resort to the Zimcord Conference Documentation (March 1981), including its annex prepared by MOH and entitled "Equity in Health", plus discussions with government officials and officals of donor agencies active in the health sector, in order to obtain a picture of the plans for the development of the health sector over the next few years. The mission also attempted to assess the extent to which some of these proposals have been, or are in the process of being implemented, and the amount and distribution of foreign aid already secured or pledged for development of the health sector. The outcome of these efforts is an estimate (see Table 14.1 below) of the capital needs of MOH outstanding as of mid-1982, assuming that all the health development projects proposed by the post-independence Government would be carried out. ANNEX 14 -59- Page 2 of 10 ZflW Table 14.1: HRA D IEVELIt PLA1 AMD OUISrAIIG CAPITAL NEWS AS CF MD-1982 FinandxW Provided or Comitted O(tstwadig Uimber Ulit Cost Total Cost Amt Capital Needs Project Ttle of hiits Z$000 Z$000 Z$00 Srce Z$000 Village IHalth Workers 1,270 1,270'/ Gwt. Rurl Halth Centers 1/ Ne IEA 316 48 15,168 7,9686/ SIDA, Africen 7,2)0 Deelo xt Bawk, European Dev. Bak Upgraded (clinics upgraded 450 12 5,400 - 5,400 to standard RHCs) Rual anx District Hoepitals NMw District Hospitals 6 6,000 36,000 12,000 Govt., Said 24,000 Arabia ded 2/ 21 500 10,500 - 10.500 Strgteed 3/ 29 100 2,900 - 2,900 Scools for Awdijaries (Mls, HAs) 8 700 5,600 7005/ USAAID 4,900 Maternal and hild MMalth 1,011 1,0UM6/ GDVt., SE - - ICEF, WHD Nutrition 400 - 400 Malaria Control n.a. n.a. Bilharzia Control 800 800 Health ducatitn 900 900 Mdical Store, Bulawyo 1 1,400 1,400 1,4005/ UAID - Pro1ncial Madical Stores 6 200 1,200 1,2)0 SIDA- Hintenarxce Unit, NM n.a. n.a. SID - Ibuss for Caxmity Nurses 20 12 240 240 sm - Support for District Health Tea=4/ 55 60 3,300 - 3,3D0 Maial Hospital Efepnsion 10,000 - 10,000 Upgrading of General/Provincial tHopitals7/ 11 28,900 4,0005/ ovt. 24,900 Total 124,989 29,789 95,200 NDtes: 1/ This ass that 149 bealth centers remin to be finaned. H}ewr, it is knrwn that tie African Dewelopmit Ftd will be c sidering a second pts to its existing prodect. 2/ pgrading of wamiler facilities into district hospitals. 3/ StrergthAng of existing district hospitals. 4/ Ihis assmes tat each team will require four 1uses (at Z$12,000 each) arii tw vehicles (at Z$6,000 each). It is possible, however, that scce allowance for tise was made by tle goverment in its estimtes for tie upgrading of district hospitals. 5/ Already spent o of mid-1982. 6/ Partially spenrt a of mid-1982. 7/ See Zimrord Co-iference Domertation, pap 109. 8/ All figures are in 1980/81 prices -60-. ANNEX 14 Page 3 of 10 2. Two general comments may be made about the Ministry of Health's proposals. First, there was a review of development projects in mid-1981, but at the conclusion of this a revised programme was finalized. In consequence of the revision some changes were made in content and priority, although the programme is still based strictly upon the proposals and priorities set out in "Equity in Health" as it was presented to Zimcord. In illustration of this it may be stated that rural health care remains paramount and that where projects have not yet come to fruition, e.g. the 6 new district hospitals, this is the result of financial constraints. The first two district hospitals are now expected to be started in the course of 1983, and funds are currently being sought through the Ministry of Finance, Economic Planning and Development to enable the remaining 4 to begin construction during the financial year 1983/84. Secondly, the above cost figures should be regarded as only rough estimates at best. The Ministry of Construction is now assuming that the annual rate of inflation for construction is about 36%, and especially in the remote areas building costs are rising very rapidly. As an example, the estimated cost for the upgrading of Binga District Hospital is now put at approx. Z$700,000, although the estimated unit cost assumed for upgrading existing district hospitals in "Equity in Health" was only Z$100,000 (the Ministry of Health, in the light of rapidly rising cost is now considerably increasing its bid for funds under this heading). Status of Proposed Projects 3. The following paragraphs deal with each of the proposed projects, describing what is known about their current status of implementation. 4. Village health workers. Support has been received from Save The Children (Binga District), UNICEF (MCH components and training funds), WHO (equipment and seminars) and the Government of Sweden (accommodation for the tutors). The government has put about Z$1.4 million into the program so far. The implementation of this project. apparently is going well. 5. Rural health centers. The government is aiming to have about 766 rural health centers eventually. About 450 rural clinics are now in existence, of which about 150 were restored after the war with USAID funds. Most of the existing rural clinics need to be upgraded to convert them to the new standard RHC. For the construction of 316 new RECs external support has been committed by the African Development Fund, European Development Fund, and the Government of Sweden. However, the number of facilities expected to be constructed with each of these contributions has varied depending on unit cost estimates. It appears that there have been three assessments of the funding position, as follows: ANNEX 14 -61- Page 4 of 10 Table 14.2: ASSESSMENT OF FUNDING NEEDS FOR NEW HEALTH CENTERS First Second Third Funding Agency Assessment Assessment Assessemnt African Development Fund 200 82 82 European Development Fund 115 115 75 Government of Sweden _ - 10 Subtotal (Funded RHCs) 315 197 167 Outstanding 1 119 149 Total 316 316 316 6. There have been problems with the implementation of this project; and although 55 new health centers are now almost ready (as compared to the plan to build 100 in 1981/82, the first year of implementation), none of them were actually in full use at the time of the mission. In particular there were problems with adequate water supplies, both because there was a confusion of responsibilities between MOH and the Ministry of Water Development, and because of poor siting of some of the facilities. However, problems of water supply are now in the process of being solved by close liaison between MOH and the Ministry of Water Development. 7. Strengthening and development of rural and district hospitals. Of the six new district hospitals proposed, two (Mudzi an Nkayi) are about to go ahead, with likely partial funding from the Saudi Arabian Government which has pledged Z$3 million for each of them. The balance of funds will apparently be put up by the government itself (refer to para. 2 above). 8. Schools for auxiliaries. One of the proposed eight new integrated training schools has already been virtually completed (at Gwelo), with USAID financial assistance. Standard designs are being used, but implementation of the rest of the project has been delayed due to manpower constraints. The government has requested some financial support from Saudi Arabia for this project, but the amount is not known. 9. Maternal and child health. Support for the MCH program has been received from UNICEF; and further assistance has been given by SIDA, WHO, Oxfam and Save the Children to the expanded program of immunization. In addition a child-spacing project has been submitted to USAID by the government (see Annex 2). 10. Nutrition. None of the proposed nutrition villages have yet been constructed. It is planned for them to be located near the village health worker training sites, and for them to consist of compounds of rondavels. -62- ANNEX 14 Page 5 of 10 11. Malaria and bilharzia controls. Little progress has yet been made in formulating either of these control programs. 12. Rural water supply and sanitation. There are ten components of this project, as follows: (i) preparation of a master plan; (ii) rehabilitation of damaged boreholes; (iii) borehole construction; (iv) dug well construction; (v) water supply for health centers; (vi) laetrine construction; (vii) training for village pump operators; (viii) training for health assistants; (ix) rural water supply, quality surveillance and geophysical borehole siting; and (x) co-operation in execution of rural water supply and sanitation program. Although it was not possible to discuss the implementation of these individual project components in detail, it appears that manpower constraints are possibly more serious than financial constraints. For example, the engineering staff of the Ministry of Water Development are now apparently only 38% of the pre-independence level. On the other hand, it is understood that financial assistance has been offered, committed or approved by the Governments of the Netherlands, Japan, Saudi Arabia, Italy, Australia and Sweden; and by the African Development Bank, UNICEF, UNDP and the Lutheran World Federation. 13. Health education. Little progress has yet been made in formulating this program. 14. Rehabilitation plan. The proposal for the Ministry of Health to build its own rehabilitation center is again under discussion in view of the fact that the Ministry of Labor and Social Services is also building one near Salisbury. 15. Medical stores. The new medical store (funded by USAID) in Bulawayo is almost finished. The final construction cost is estimated to be Z$1,4 million, as compared with an initial estimate of only Z$510,000. 16, Provincial medical stores. The Government of Sweden has agreed to finance six provincial medical stores (including construction, equipment and transport). The unit cost is put at Z$200,000. No building work has yet started. 17. Maintenance unit. The Government of Sweden has agreed to finance the establishment of a maintenance unit (including equipment and technical assistance). No building work has yet started. 18, Houses for community nurses. The Government of Sweden has also agreed to provide funds for the construction of these. No building work has yet started. 19. Support for district health teams. The detailed requirements have not yet been worked out. 20. Mental hospital expansion. The expansion of Ingutsheni Hospital at Bulawayo has been delayed. Funds for this project are provided in the 1982/83 budget of the Ministry of Construction, but their amount is unknown. -63- ANNEX 14 Page 6 of 10 21. Upgrading of general/provincial hospitals. The government's plans for the upgrading of general/provincial hospitals are unclear. In 1981/82 approximately Z$4 million was allocated to complete such projects which had already been started, and there will be some carryover of these expenditures into the 1982/83 fiscal year. The budget of the Ministry of Construction for the latter year includes Z$2 million for upgrading of existing hospitals, under the heading "*new works". Consistency of Planned Projects with the PHC Approach 22. The pattern of planned capital expenditures that emerges from Table 14.1 is largely consistent with the new orientation towards a primary health care approach. Clearly, the last two items in the table (which together account for about one-third of all capital expenditures planned) would seem to be of lower priority within this new scheme, and hence should be scrutinized with greater care by MOH. Alternatives to expansion of the mental hospital, in particular, should be investigated--e.g. to establish a decentralized community-based treatment program. Strengthening of the referral/screening system at general/provincial hospitals could, likewise, substitute at least in part for expansion. 23. As of mid-1982, about Z$30 million had been already spent or committed to the various development projects in Table 14.1 Thus, total outstanding capital needs to carry out all projects amounted to about Z$95 million, in 1980/81 prices. The total budget allocation for health capital expenditures in FY82/83 (including both Ministry of Health and Ministry of Construction allocations) amounts to Z$21.5 million, or possibly about Z$16-17 million in 1980/81 prices. Hence outstanding capital expenditures in Table 14.1 would be equivalent to between five and six years of budgetary allocations at present levels. Recurrent cost implications 24. For some of the proposed development projects it is extremely difficult to estimate their additional recurrent (i.e., operating and maintenance) costs. Particularly important are assumptions about staffing levels, and salaries. However, in order to be able to compare the anticipated total recurrent costs of the development program with the likely real increase in the Ministry of Health's recurrent budget, it is important to make some estimates (even if only very tentative) for at least the most important components of the development program. This is attempted in Table 14.3 below. -64- ANNEX 14 Page 7 of 10 Table 14.3: ESTIMATES OF RECURRENT COSTS OF MAJOR COMPONENTS OF THE HEALTH SECTOR DEVELOPMENT PROGRAM (arising from planned capital expenditures outstanding as of mid-1982) Unit Recurrent Total Annual Number of Costl/ Recurrent Costl/ Project Title Units Z$O0 Z$000 Rural Health Centers New RHC 2/ 316 20 6,320 Upgraded 3/ 450 5 2,250 Rural and District Hospitals New District Hospitals 6 1,000 6,000 Upgraded 4/ 21 100 2,100 Strengthened 4, 29 20 580 Schools for Auxiliaries 4/ 7 140 980 Bulawayo Medical Store 47 1 280 280 Provincial Medical Stores 4/ 6 40 240 Support for District Health Teams 5/ 55 80 4,400 Mental Hospital Expansion 4/ 2,000 Upgrading of General/ Provincial Hospitals 4/ 11 5,000 Total 30,150 Notes: 1/ In 1981/82 prices. 2/ The estimated recurrent cost for a new health center is based on the assumption of the following staff: 2 medical assistants, 1 health assistant and 1 attendant. 3/ The estimated recurrent cost for an upgraded health center is based on the assumption of the employment of one additional trained staff per center. 4/ This assumes that the annual additional recurrent costs are 20% of the capital cost. 5/ It is assumed that there are two vehicles (each costing Z$6,000 p.a. to operate), four staff ( at an average salary of Z$15,000), and miscellaneous expenses amounting to Z$8,000 p.a. 25. From Table 14.3 above it can be seen that the annual additional recurrent costs of these selected components of the development program amount to about Z$30 million. Several expanding -65- ANNEX 14 Page 8 of 10 programs, moreover, are not included in Table 14.3. The recurrent costs of the village health worker program would depend on population covered. If the entire rural population were to be covered by mid-1985, about 7,000 VHWs would be needed (assuming a ratio of one VHW per 1,000 population). At the present level of remuneration, salary costs would amount to about Z$3 million per year, and drugs and supplies are likely to amount to at least as much as salaries. Annual costs of the VHW program would continue to increase after countrywide coverage is reached because of increasing population. The planned expansion of the child spacing program would add about Z$1.5 million per year (in 1981/82 prices) to the MOH's budget, once USAID's assistance phases out after FY85/86. Expansion of other high-priority programs (malaria and bilharzia control, nutrition, health education), anticipated in the Zimcord documents, would add another about Z$2.3 million per year in recurrent costs, in 1981/82 prices 1/. Summarizing all of the above estimates, it would appear that a figure of about Z$40 million could be a reasonable estimate, in 1981/82 prices, of the overall addition to MOH's annual recurrent costs implied by the sixteen development projects listed in Table 14.1, plus the proposed child spacing project. Affordability of the Recurrent Costs of Health Development Plans 26. It is important to consider the question of over what period of time could the incremental recurrent costs associated with the planned health capital expenditures (outstanding as of mid-1982) be absorbed into the MOH's budget. Table 14.4 below shows that if all planned capital expenditures were to be carried out by the end of FY86/87, and assuming that total government budget remains constant as a proportion of GDP, incremental recurrent costs could be absorbed into the MOH's budget with only a modest increase in the proportion of MOH's recurrent expenditure in the total government budget, provided that GDP grows in real terms at an annual average rate of about 4-5% over the projection period (which is the current Bank's forecast). However, given the recent downward trend in MOH's budget as a proportion of total government budget, the required increase in this proportion cannot be taken for granted. On the other hand, if GDP growth were to fall to a low level of 2% p.a., the required increase in MOH's recurrent budget as a percentage of total government budget would be larger, to a level of 6.3%. 1/ This figure was obtained by dividing the estimated recurrent costs in "Equity in Health" for these programs by three, and adjusting the price base. -66- ANNEX 14 Page 9 of 10 Table 14.4: REJIR GpDWM IN HE B1DGET FR P1ZfCN CF WrSADIN CAFEA END1URES AN) IrS COERATI(N (Z$ million, 1981/82 prices) (1) (2) (3) (4) (5) (6) (7) Total Gwt. MO1 WI Birget GIP at Budgetl/ Biget Recurrent (2)/(1) (3)/Cl) Market Prices (1)/(6) 1980/815/ 1,353 93.5 91.0 6.9 6.7 3,8872/ 34.8 1981/821/ 1,687 108.9 98.4 6.4 5.8 4,35(?7/ 3B.8 1982/83S/5/ 1,981 116.7 103.8 5.9 5.2 1987/88X(4% GDP growth) 2,4104/ 138.46/ 5.7 M87/88 (5% GP growth) 2,528t/ 138.4sJ 5.5 1987/88 (2% GDP growth) 2,187 138.4t/ 6.3 Noe: I/ Excluding CoDstitutional arnd Statutory Appropriations 2/ 1980 GDP 3/ Asanirg rate of increase in corner price index (for lowr incom urban families) will be tbhe san betwen 1982/83 and 1981/82 as it wa betwen 1981/82 and 1980/81, i.e., 11.7%. 4/ Assming that total gMverrmext hidget remains cortant as a proportion of GIlP at tie 1982/83 level. 5j/ kiget etimates, not amtual exepnditures. 6/ ! reqtl ired anrual rate of growth in real terms of MI1's recurrent bidget in tie fif-year period 1982/83-1987/88 would be about 6%. 7/ 1981 GM?, provisional estimate. 27. It is likely, moreover, that the required increase in MOH's recurrent expenditures would be somewhat larger than indicated in Table 14.4, since increasing population over the period will result in more intensive utilization of now existing services, quite independently of any new additions to the public health capital stock. Also, it is possible that salaries of MOH's staff may be substantially raised in real terms in response to political pressures. These factors would result in either a lengthening of the implementation period of present health development plans beyond 1986/87, or an increase in the proportion of MOH's recurrent expenditure in total government budget beyond what is indicated in Table 14.4. This trade-off should be explicitly taken into account by MOH in considering any prospective increases in staff salaries. 28. On the other hand, MOH may be able to curtail the growth of selected recurrent cost items through improved expenditure control. The need to take steps towards more cost-effective usage of medicines dispensed by public health facilities was pointed out in -67- ANNEX 14 Page 10 of 10 para. 2.66. Certain hospital cost items may sustain some cutting. Identification of suitable opportunities for cost-cutting would be greatly facilitated by the adoption of a program budget by MOH (if necessary in tandem with the existing budget), which in any case would be an important step towards better planning in general. It is however the view of MOH that such an addition to its financial control function would necessitate the incorporation of additional staff. 29. Yet another important factor to take into account in determining what would constitute a feasible time frame for implementation of existing health development plans is the question of constraints in the MOH's detailed planning capacity and in construction implementation capacity, as MOH attempts to increase its annual rate of capital expenditures. To complete all health development projects outstanding as of mid-1982 over the subsequent five-year period would require annual health capital expenditures of about Z$21 million (in 1981/82 prices). This amounts to about two and a half times the corresponding actual figure for FY80/81 (Z$8.1 million in 1981/82 prices 2/). At the time of the mission's visit, less than 40% of the established professional and technical staff posts of the Ministry of Works were filled. Local consultants were already being used a great deal, but serious delays were occurring in design work. There was also evidence of strains in the construction industry's capacity, with inflation in construction costs estimated to have risen to 3% per mDnth. Thus it would seem that the time frame assumed in Table 14.4 above, though apparently financially feasible, may be too optimistic in view of non-financial constraints. 2/ This includes health capital expenditures financed out of both the MOH's and the Ministry of Works' budgets. For FY81/82, the corresponding estimate was about Z$19 million (in 1981/82 prices), but actual expenditure figures are not yet available. The corresponding estimate for FY82/83 is also about Z$19 million. ANNEX 15 -68- Page 1 of 48 Annex 15: NUTRITION Part I: Magnitude and Nature of Malnutrition in Zimbabwel/ A. Overview 1.01 The most useful and most accessible measure of nutrition status is nutritional anthropometry, particularly on children 6-to-36 months of age. (Beyond that period the data become progressively less meaningful and less nutrition-related.)2/ The anthropometric measures most commonly used are: (a) Weight for age -- which considers children below 60% of an accepted standard as third degree malnutrition, those 60-75% as second degree and those from 76-90% as first degree malnourished; (b) Height for age -- a good measure of long-term malnutrition; and (c) Weight for height -- an indicator of recent malnutrition. In this system the child is generally considered "normal" if his or her height for age is above 90% of the standard and weight for height is above 80% of the standard. A child is said to suffer from "acute undernutrition" (wasting) if height for age is normal but weight for height is low. A child suffers "chronic undernutrition" (stunting) if weight for height is normal but height for age is low. And, finally, a child is said to have "concurrent acute and chronic undernutrition" (stunting and wasting) if both indices are low. 1.02 Little information on nutrition conditions in rural areas was collected before 1980 and portions of that were not made public. In 1977, an unpublished confidential report to the Government concluded that 37% of the children in Gutu Tribal Trust Land (TTL), 32% in Matshetshe (near Gwanda TTL) and 43% in a "protected village" in Chiweshe suffered from some degree of malnourished stunting (138). From 1978 data sets collected for other purposes in Gwanda and Gutu, it can be seen that a very high 11.3% of children were under 60% of the expected weight for their ages. / All bibliographical references are listed in Attachment 1 to this annex. 2/ Although nutritional status measurements are, in theory, the true measure of nutritional well-being, they may be somewhat less valuable than consumption data because generally they relate exclusively to children. (An exception is birthweight data--unavailable in Zimbabwe for a cross section of the population--which is a good reflection of maternal nutrition status.) To some extent the nutritional status of young children may be a proxy for the nutritional status of the community as a whole. But our ability to generalize children to the community is limited by the fact that young children are relatively more affected by infection (particularly diarrhea) and by deleterious belief patterns than are adults. At the same time young children suffer more quickly and more severely from the consequences of malnutrition. ANNEX 15 -69- page 2 of 48 1.03 Nearly all pre-1980 published materials reflected hospital reports. A 1973 study of pediatric admissions to Harare Hospital found that severe malnutrition in the form of marasmus or kwashiorkor (which reflect gross deficiencies of calories and/or protein) was the first, second or third diagnosis for one-third of the 2,354 children admitted. Malnutrition was the second most common reason for admission and was the leading cause of death (31%, more than double anything else). Related diseases in which malnutrition probably played a large role also ranked high (e.g., measles -- 10%, gastro enteritis -- 5%)(4). During the same period, a medical school professor was reported saying that "Harare admissions probably represent less than one-tenth of the clinically apparent patients with protein energy malnutrition" (114). Of 3,958 people hospitalized with nutritional deficiency diseases in 1978, 17.4% died. This was double the percent of fatalities from any other disease except pneumonia (179). Nutrition problems were the direct cause for about 5% of all hospital deaths in 1979; measles, diarrheas and other nutrition-related deaths were not included in this figure (180). Communal Areas 1.04 Broader survey coverage began in 1980. An OXFAM study in the Mtoko TTL area in the spring of 1980 found 15% of the children in a well-baby clinic with second and third degree malnutrition and 42% of the children in another area of the TTL at that level (61). Additional OXFAM studies carried out in mid-year 1980 in Dande, Chiliamanzi, Ndanga, and Ndowoyo TTLs found 30% of the children suffering from second or third degree malnutrition and 36% showing current deprivation (175). These studies were either of children attending "well-baby clinics" or of those mothers that were accessible. So soon after independence the mothers who walked the distances to these clinics were those who felt their children needed some attention. This could account for the high rates. There is no evidence to suggest that the more accessible a population (near roads, clinics, service centres) the better its nutritional status; therefore, this bias could have been significant. 1.05 The Ministry of Health, with UNICEF cooperation in September 1980, measured the arm circumferences (a simpler and cruder measure than heights for weights, but nonetheless useful) of 4,777 one-to-five year old children in 54 districts and concluded that 29% were suffering from second or third degree malnutrition. The worst cases were in Victoria, Matabeleland and the Midlands, mainly along the border areas (178). Reports from OXFAM doctors in April-June 1981 stated that 30% of one-to-four year olds had second or third degree malnutrition at Dotito Clinic, as did 33% of the children in Musengezi and 25% in Hoya and Rushina. 1.06 Fifth year medical students doing field work in April 1982 in Nyaderi, Musame, Mnene, Musiso and Chisumbanje areas, found that 35.5% of children in under-five clinics had second or third degree malnutrition based on weight for age and 24.5% of hospital outpatients and 66.8% of the inpatients could be categorized as second or third degree (96). In Mberengwa District, 9% to 25% of 2,100 children measured in 17 under-five clinics were found to have second or third degree malnutrition (57). ANNEX 15 -70- page 3 of 48 1.07 In March/April 1982, 52 of the 80 children admitted to Mnene Hospital had second or third degree malnutrition and 21 of these were admitted with the first diagnosis of malnutrition. (In the first three months of the year, 138 adults and children were admitted for malnutrition; five died of kwashiorkor, two of marasmus.) A count in April 1982 found 30 current cases of kashiorkor or marasmus in Rusape District Hospital. 1.08 Although too small a sample to draw any conclusions, a May 1982 survey in Gutu of 50 children found that 6% had severe (third degree) malnutrition and 16% had second degree. Severe stunting was seen in 14% of the children and moderate stunting in 40%, some of these within five kilometers of a business center (77). A still smaller sample (of 38 children) during the same period in Wedza found 8% severely and 16% moderately stunted (80). 1.09 Finally, a survey in May 1982 carried out in Bindura District communal areas (in Madziwa and Masembura) found that 18% of 428 children measured were suffering from second or third degree malnutrition and that 13% were severely stunted. Seven percent were severely wasted (82). 1.10 Although certain of the above studies and reports do not differentiate their cases by type of community (urban, commercial farms, communal areas, mines), most relate to communal areas. The data are sketchy and scattered and collected in different forms but sufficiently common in conclusion to suggest that malnutrition is rife in these areas. Nineteen of 45 doctors from health facilities, mostly representing populations of largely (but not restricted to) peasant farmers, cited malnutrition first among the leading problems they faced in the six month-to-three year old age group. Kwashiorkor and/or marasmus was seen as the major or a major problem in eight places. Of 94 Agritex field staff surveyed in May 1982, 45 found "much" or "some" kwashiorkor or marasmus in their areas, 36 reported "little" and six reported that there was "none." Commercial Farms 1.11 Approximately 25% of the African population of Zimbabwe consists of farm workers and their families living on the 5,000 to 6,000 large commercial farms. Earlier unquantified reports about the conditions of farm worker families indicated noticeable features of starvation (24) and more recent research confirms a major problem. In 1981 a series of studies was undertaken that found severe conditions. In a commercial farming area in Matabeleland, 14% of children in Beitbridge and 20% in Nyamandhlovu were judged severely malnourished based on weight for age (the range was from 10% in some farms to 47% on another) (79). Then, in a survey of 227 children carried out on farms in Mashonaland, Raffingora District, 24% of the children were second or third degree malnourished and 49% showed some stunting (81). Further samples in a 30 kilometer radius of Bindura city found 53.4% of the children measured were severely stunted and that over half had second or third degree malnutrition based on weight for age (75). -71- ANNEX 15 page 4 of 48 Urban Areas 1.12 About 18-20% of the population live in urban areas. A small sample taken in 1981 in a well-off area in Harare showed 8.5% of the pre-school age children had second or third degree malnutrition and this more than doubled, to 20%, in worse off areas of Harare (153). A recent study in the city of Bindura, where a clinic was accessible to 94% of the families and 88% of the children had "road-to-health" growth measurement cards, found less than 1% (five of 317 pre-school children) were severely malnourished, both weight for age and stunting. An additional 11% were moderately malnourished on both scales (83). Mines 1.13 Relatively little information is available concerning the nutrition status of the 70,000 mine workers and their families. The early literature makes references to mine rations being of insufficient quality to maintain the health of the African miners. The pattern is one of a history of inadequate diets, recommendations for improvements, protests lodged by mining companies about the recommendations and little change over time (113). 1.14 Relatively few families live with the workers because of acute shortages of accommodations at the mines. One study, in December 1981, was made of 626 children under six living with fathers working in two nickel mines and three gold mines in the Bindura District. The study showed 3% severe stunting and 12% moderate stunting and 1% severe malnutrition based on weight for age. Although over half the children were to some extent stunted, the number of serious cases reflects a somewhat better picture, comparatively than commercial farm and communal areas (84). B. How Serious the Problem? 1.15 By any measure, the available fragments of nutrition status data add up to a malnutrition problem of major magnitude. Table 1 provides a composite of 23 of the above-mentioned surveys that used similar measures. These were undertaken in different seasons (although it is noteworthy that the majority of surveys were undertaken March through June, when nutrition is at its best) in different areas of the country by different researchers with different levels of training and different sampling techniques and quality controls. Therefore, the table should be interpreted with caution. Nonetheless, the general pattern and consistency of the findings is striking. -72- ANNEX 15 Page 5 of 48 mm= - RX PIm , Br T Table 1 IGHI PMF AGE (X) RelGH FOR A (%) EZ LFO HEIGHT (Z) Total Total Total - o------of * idch ch idernwrishud - id -h - Uknermrrished --of ,d ch h- Undernurished S]pe less than 60% less an 75X (less than 90% Less tlw 85% lss thm 90% (less thn 95% less than 70% Less hn 80% (Less thm 90% Sim of Standard of Stadard of StAard) of Standard of Stsndai of Stmard) of Stanard of Standard of Stasiard) C01MIAL FARI ERS 1. h1tbr1 (7-8/81) 112 1/ 14 46 28 46 9 33 2. _ b u ( * ) 93 'r/ 20 38 32 47 9 34 3. Id - (balmaDt.) (WU8 ) 227 24 36 49 66 4 17 4. N (1983) 223 50 68 53 64 7 16 40 5. (6/81) 128 38 53 43 53 23 51 T 1A1U 783 32 5D 44 58 2 12 33 6. e ' 5 nys. 418 10 29 3 8 Q (12/81) 4 Mn. 174 2/ 28 5 7. EA (1281-1/82) 53 0.09 6 31 OC9 7 24 1 7 19 - 3/ (10t74) 352 3 S.8 .mam -- p- , )kn* (417/80) 61 15 1Al thbn 4/ 961 < I 8 31 <1 4 13 I 5 14 9. PA-1n- (12/81) 623 1 20 51 3 15 53 1 6 22 TlaL. AMS 10. ZItshetsbe (near wainda) (5/76) 155 14 32 11. ChitBngo Clinic, lmde TEL (12/80) 61 36 61 12. GWy TIE (1980) Not glsn 18 52 13. Qaechce PV, mcmyo TEL (1980) Not given 0 6 14. 8B1na, Ymembura, Madziwn 398 3 14 54 13 31 57 7 13 26 15. lm6ga TEL (5-6/80) 184 24 49 16. (liilsmnzi TIm (1980) 250 24 54 17. kNimv TEL 230 3 20 18. Lbda (5/82) 38 0 8 55 3 21 63 0 0 11 19. Guut (5/76) 198 18 43 20. Qutu (1978) 91 21 37 55 44 64 70 3 13 33 21.L)a ( 6) (1978) 85 9 26 44 27 39 49 1 9 31 22. Q,tu (4/82) 50 6 22 78 14 52 72 0 8 16 23. Uzinxa (5-6/80) 148 30 I/ Sap lOe slu3s a -11 nmber of cd lrn mer 5 yrs.: in Bitridg 4>5 yrs; in , 9) 5 yrs. Cn only ba sepurated out In *ght for Ae argory. 2/ S11le of 4 clinics. 3/ we ed 3 gr8p of children-wry little data reprted. 4/ Used dota fro Hare and Chit,i.a (only tte 418 <5) an id . -73- ANNEX 15 page 6 of 48 1.16 Overall, using weighted averages to reflect sample sizes we see a picture of 21% of the under-five population with second or third degree malnutrition based on weight for age (see Table 2). Using a weighted Bindura figure which probably reflects a better cross sample of the population, 23% fall in this category. This is roughly comparable to Cameroon, Lesotho and Liberia, lower than Sierra Leone at 31% and higher than Togo at 15% and Egypt at 9%. (The number of second and third degree cases of malnutrition combined in North Africa, the Middle East and Latin America is 15-20%.) Stunting is seen in 28% of Zimbabwean children (30% in the cross-community Bindura sample), considerably higher than the 9.1% in Togo, the 18% in Liberia and the 21-24% in Lesotho, Sierre Leone, Cameroon and Egypt. Wasting is found in 9% of Zimbabwean children (12% in Bindura), which generally is at least triple all of the above countries. ZIDBABWE Table 2 PREVALENCE OF UNDERWEIGHT, STUNTED AND WASTED CHILDREN, INFANT MORTALITY AND CHILD DEATH RATES FOR SELECTED AFRICAN COUNTRIES % 2nd & Infant Child Death Children 3rd Degreel/ % % Mortality Rate (1-4 yrs) Sampled Malnutrition Stunted2! Wasted3! Rate-1980 1980 Zimbabwe 3,029 21.0 27.9 8.5 100 (1969) 15 (1969) Bindura 1,787 22.6 29.6 11.8 - - Togo 6,094 15.3 19.1 2.0 109 21 Liberia 3,479 24.1* 18.0 1.6 154 34 Lesotho 1,706 22.5* 22.7 3.4** 115 23 Sierre Leone 4,882 30.5* 24.2 3.0 208 50 Cameroon 5,638 21.1* 22.1 1.0 109 21 Egypt 8,016 8.8 21.2 0.6 103 14 1/ Less than 75% of reference median weight-for-age, except those marked *, which are less than 80%. 2/ Less than 90% of reference median height-for-age. 3/ Less than 80% of reference median weight-for-height, except Lesotho, which is less than 85%. OQ Nutrition data for Zimbabwe, Bindura, Liberia, Lesotho and Sierre Leone refer to age group less than 5 H years; nutrition data for Togo and Egypt refer to age group 6 month-to-71 month; nutrition data for 0 Cameroon refer to age group 3 month-to-59 month. X ANNEX 15 -75- page 8 of 48 Comparisons of Communities 1.17 Almost no comparisons have been made of the relative severity of the problem among the various communities. Based on the 1969 census, infant mortality rates, generally a good indicator of nutrition conditions, are two and a half to four times higher in rural areas than urban. A 1975 study showed that the malnutrition problem in the TTLs was four-to-five times as bad as it was in urban or semi-urban populations (130). Four reports from the Mtoko area in 1980 showed that the nutrition problem among peasant farmers in communal areas can be more than four times as great as for those living in a township (61). In a 1968 study, twice as many of the 41 cases of hospitalized nutritional disease and 30 cases of kwashiorkor were found in children from the TTLs than from children from commercial farms (51). However, since the population of commercial farm workers is less than half that of communal areas, this would suggest that the situation may have been more severe on commercial farms. Table 3, an aggregate by type of community, indicates families of commercial farm workers are the worst off nutritionally. One-third of the commercial farm children are below 75% of their expected weight for height, compared to one-fourth of the children in communal areas. Similarly, stunting is found in 44% of the former; 36% of the latter. Children from mine areas come next and the best off are urban children. Serious stunting is 11 times mare prevalent among commercial farm children than their urban counterparts. _/ 1.18 The best cross comparison of the severity of the problem by type of community can be seen from the studies in Bindura. They were undertaken in the same District, over roughly the same recent period and largely used the same measures. From Table 4, the same community pattern of the severity of malnutrition appears as in the aggregate table. Differences by Age 1.19 The onset of malnutrition generally coincides with the start of the weaning period. In one relatively well-off township children gained weight almost normally until the start of weaning at five-to-six months 3/ Little or no nutrition data is available for the 74,000 people living on resettlement plots, or of the 8,600 families on African purchase lands. One doctor working with resettlement scheme families in Bindura District reported in May 1982 no nutritional problems in the area. Table 3 TD E CFOM91 AGT Y A TAKE WKM FM sAGE HUM FMt AGE WE) FaT T ( TiOW1 itn Total - o f i thch b- Undmoursh1sd -of hich i- Umdrxmurlshmd %tddkh- Umhrmsulmhud S_Ie Las du 6(X lam tun 7X Omu thn 90X las Om 8 lms dm 90 as" am 95 ims dun 7(X ine dmn 8(K (Less dun got Size of Stard of Stward of StmArd) of St_ard of Staud of Studazd) of Starad of Stard of Stadrd) OCQtWlL FD W 783 32 50 44 58 2 12 33 11E 961 < 1* 8 31 < 1 4 13 1 5 14 lHlN3S 623 1 20 51 3 15 53 1 6 22 L D'Z uw (A) 264 11 27 56 (B) 1,157 22 54 (C) 662 19 36 59 (D) 892 4 9 25 * 7, not 6CK For caqxuititn of gmups, refer to Table 1 and belfw Coral Farm Workers: 1 - 5 Urban: 6,7 Mines: 9 TIL: (A) 18, 20, 21, 22 (B) 11, 14, 15, 16, 18, 20, 21, 22 (C) 14, 18, 20, 21, 22 , (D) 14, 17, 18, 20, 21, 22 o uu BEluA - BY TYPE (V WM= Table 4 MUM PVR HKI (X) FM (X) W= KR a1l( C) Total TOW Total - o f ic..LrL tk2dern&w uri*e -Of dicd d - xIerm hdw vkdc h eierdriaI Suwy Siple est dm 6O.1 Le tha 7 Ls than 9(s 1w tan9 L 8I M than 9( (90 s than 952 LOSs than 7 (1 LM then 8(A1 ( m 9(1 BIURA Date Size of Staxtard of St.mrd of Stanrd) af Stmxdrd of StadIhrd of Stantbrd) of Stanhrd of St.drd of StmNrd) (XMCIAL FR WMS 12/8D-1/81 223 12.0 42.0 68.0 53.0 64.0 7.0 16.0 40.0 UDM ANA 12/8-1/82 543 0.W9 6.0 31.0 0.49 7.0 24.0 1.0 7.0 19.0 ISl3D 12/81 623 1.0 20.0 51.0 3.0 1l.0 53.0 1.0 6.0 22.0 41 TIL 5/82 398 3.0 14.0 54.0 13.0 31.0 57.0 7.0 13.0 26.0 Cimedal Farm Waders: Survey carried out In 6 large fam betwm Bimhwa 2d Haiziw TIL (1omemm) Uran: Survey aried out ain wf -1za and (hipudze 'txaeup1' hin Bin wa urdm arm (Iammi) WLnes: Survey carried ca m 5 .1w InlInmurq dist-ict (Iomml) TIL: S&ver carried out in INabwa and dziv o i arm ( I) 0 ANNEX 15 page 11 of 48 when they started to suffer an abnormal reduction in the rate of growth. The velocity of growth, as judged by weight gain over a fixed period, was within normal limits during the first three months, then fell behind slightly until six months. From six-to-nine months the children gained barely more than half the weight expected and substantial shortfalls in growth continued until 18 months when expected weight gains continued. These were of children from a relatively privileged and disease-free situation compared to other urban townships and most rural areas (159). 1.20 Studies of children of commercial farm workers in Matabeleland found that severe malnutrition was four times higher in a six month-to-two year age group as the zero-to-six month group. And the rate then remained relatively constant in a two-to-five year group (79). Only 4% percent of children of commercial farmworkers in Mashonaland had second or third degree malnutrition in their first six months, compared to 33% in the following 18 months; this dropped to 21% between ages two and five (81). Similarly, among the children of farm worker families near Bindura, the largest percentage of severely and moderately malnourished children was between six months to two years for every measure. The survey of doctors from 45 health facilities found that in only two of the responses was malnutrition the most important illness in the zero-to-six month group, but was cited first in importance in 19 responses in the six month-to-three year group. Kwashiorkor and marasmus were seen as major problems in eight of the facilities in the older group and none for the younger group. 1.21 When figures are compiled by year, nearly all studies show that children are hit hardest during their second year of life. The malnutrition seen in the second year of 2,745 children weighed in Bulawayo in 1981 was nearly double that of the first year, peaked in the third year and then started down (11). In three of the four December 1981 studies in Chitungwiza and Harare, the problems of the second year made a marked jump over the first year (152), Other samples in Harare showed that nearly four times as many children have severe malnutrition in the second year as the first year (153). 1.22 Malnutrition in the first year accounted for 4% of the deaths in Harare in 1980. From ages one-to-four, however, malnutrition accounted for over 21% of all deaths (122). Of nationwide hospital admissions, 2.3% were attributed to nutrition deficiencies under age one, 10.8% between one to four and 2.2% for the next 10 years (161). 1.23 The 33,000 school children measured in Harare in 1980 showed a decline in malnutrition with years, from 23% second and third degree malnutrition in the first grade of school to 15% in the third grade to 9% in the seventh grade. Although there is no direct evidence, this in part could be a reflection of a lower school drop-out rate among the better nourished. There are substantial differences in neighborhoods; the malnutrition in some areas being three times as great as in others (122). 1.24 No satisfactory studies have been carried out to make it possible to establish a relationship between the age of the mother and the nutritional status of the children. -79- ANNEX 15 page 12 of 48 Differences by Sex 1.25 Are boys and girls treated differently, as far as feeding? The result of the farm survey in Chiweshe showed there apparently is a slightly greater degree of stunting in the zero to two-year age group of girls compared to boys while for other measures the boys and girls were approximately the same (76). In Mtchabezi, boys and girls 13-and-under did not show great differences in weight for age although boys in this case showed a higher prevalence of stunting (119). Girls also were better off at each age group up to five in both Gutu and Gwanda. In Bulawayo, boys and girls had the same growth through the first two years but between two and three years more girls were judged under weight than boys (11). In the urban Bindura study, girls semed to be better off from six months to two years and the situation was reversed £rom two to five years (83). Thus, the picture is mixed. Overall, however, these are not the kinds of substantial differences that one finds in cultures where boys in the early years of life are given preferential feeding treatment. A comparison of the types and varieties of food given boys and girls in Gutu and Gwanda in 1978 shows no special attention in the feeding of boys. Seasonal Differences 1.26 Some periods of malnutrition are much worse than others. Reports of serious malnutrition cases by OXFAM doctors in Matibi and Bondolfi for twelve months in 1981-82 found that, by far, the November-January period was the worst. Responses from the questionnaire to health facilities found that October through December was the period when serious malnutrition was most frequently found. This coincides with the period when food is in short supply. Nutrition status was best from March to June, just after harvest. Tabulations of monthly data on children hospitalized due to malnutrition in Gwanda district over a fourteen-year period (1963-1976) found November to be the most serious month, with October second. April and May were the best months; April having 40% of the cases of November (177). A 1975 analysis of medical pediatric admissions to Harare Hospital found that malnutrition rose markedly in the agriculturally slack period (4). 1.27 The basic picture is one of chronic nutrient deprivation, intensified during seasons of reduced food availability. At that time, moderately malnourished children tend to sink into more acute malnutrition. Although perhaps not as much so as other countries, they become more vulnerable to the debilitating effects of diarrhea and infectious diseases. As for adults, the peak months for energy expenditure in agriculture are exactly those when food supply is at its lowest (24), C. Micronutrient Deficiencies 1.28 All of the above relates to calorie, and, to a lesser extent, protein problems; nearly all of the survey work undertaken in Zimbabwe to date has been restricted to these. Although these problems clearly are -80- ANNEX 15 page 13 of 48 the mDst important, surveys conducted in conjunction with this study also suggest that serious micronutrient deficiencies may be highly prevalent. Moreover, conditions predictably may deteriorate with regard to certain of the vitamin and mineral deficiencies. Pellagra (Niacin Deficiency) 1.29 Pellagra, a nutritional disorder that is common in populations whose diets depend heavily on maize, is characterized by cracked, scaly, peeling skin and cracked fiery lips. The patient often is confused, suffers loss of memory, insomnia, is irritable and dull. Serious diarrheas are common. In Zimbabwe, the highest number of pellagra cases are encountered from late August to November. 1.30 The prevalence of pellagra in Zimbabwe is not known but of 32 health facilities that responded to the question, 16 reported they see pellagra "often," and 10 "aometimes" see pellagra. (Five reported they "rarely" see pellagra and only one facility reported that it never saw pellagra cases.) Of an additional 10 facilities that were interviewed,five found pellagra "often," four "sometimes." 1.31 A study in the 1950s of patients at Salisbury African Hospital found that of the 54 consecutive admissions for nutritional disease, 22 were cases of pellagra (97). Another study of nutritional disorders (reported in 1971) found that 269 of 361 mostly-adult cases examined over three years were suffering from either frank pellagra or pellagroid state (near pellagra, with some of the same symptoms) (51). 1.32 The main cause of pellagra appears to be inadequate niacin in a heavily maize-based diet. In Zimbabwe, the problem currently is being exacerbated by the dramatically increased consumption of highly refined maize meal in which the niacin content is only 40% that of the village- processed product. In certain other maize-eating cultures, pellagra has been inexpensively and efficiently eliminated as a public health problem through fortification of maize meal with niacin. Goitre (Iodine Deficiency) 1.33 Data on prevalence of goitre is sparse. One investigation in Chimanda TTL found a 35% goitre prevalence among the studied population (93), A study among Tonga. in Omay Tribal Trust Lands in the 1960s found 45% of a community with goitre and, as is common elsewhere, the highest rate (77%) was among adolescent girls. The rate among 6-to-12 year olds was 68%. A study about the same time in the Chikwaka Communial Area found a 74% prevalence in a village population. (Twenty-six of 40 adult males and 56 of 71 adult females had goiterous thyroid enlargement.) (36). -81- ANNEX 15 page 14 of 48 1.34 The indications from this scattered data that goitre is common in Zimbabwe was confirmed by staffs of public health facilities. Of the health facilities responding to the questionnaire in May 1982, 18 saw goitre "often," 15 'sometimes," 10 "rarely," and two "never." Staff interviewed from an additional 10 centers reported that goitre was seen "often" in five cases, "sometimes" in three, and "rarely" in two. 1.35 The appearance of goitre is common but the consequences in Zimbabwe are not clear. There is little recorded deaf-mutism or cretinism that frequently accompanies severe goitre in other cultures. Several doctors have reported that the main concern is cosmetic. 1.36 The likely cause of endemic goitre in Zimbabwe is lack of iodine in the soil and hence in water and food (1). The only reference found in the local literature to testing for iodine content found it to be very low in drinking water (36). 1.37 Many countries deal with the goitre problem by iodizing the salt supply. Currently, iodized salt is on the market in Zimbabwe but generally at a cost $0.01 higher than unfortified salt. This is enough to discourage that portion of the population that most likely needs the extra iodine, given their lack of knowledge about the advantages of iodized salt. Vitamin A Deficiency 1.38 Less prevalent than pellagra and goitre but nonetheless not uncommon in Zimbabwe is vitamin A deficiency, which affects growth, skin condition, the severity of other nutritionally related illnesses and vision. Severe vitamin A deprivation can lead to blindness and is a major cause of blindness in many countries. Its role in blindness in Zimbabwe is not clear. A 1979 paper referred to vitamin A deficiency as a major cause of blindness among preschool children in Zimbabwe (58). However, a report for WHO in July 1981 stated that frank keratomalacia (a severe form of vitamin A deficiency, reflected in complete corneal destruction) was uncommon according to the medical records reviewed (95). 1.39 A 1982 school health survey of 1,314 students routinely examined in Musami, Murewa, and Mtchabezi found eight corneal scars, reflecting a severe deficiency (96) (119). In the 1960s, a study in Matabeleland found 76 cases of xeropthalmia, a term applied to all ocular manifestations of vitamin A deficiency. An additional 22 cases were reported of children that had either died or were unavailable for examination. Based on this, the investigator estimated a minimum of 250 cases in the area (87). An unquantified report in the late 1970s claimed that children from Matabeleland were going blind from measles and vitamin A deficiency (20). A study of cases of nutritional disease in Harare Hospital found vitamin A deficiency to be the second most important nutrition disease at 24% (4). A larger study of mostly adult nutritional diseases found vitamin A deficiency to be the major problem in 7% of the cases (86). 1.40 In the above-mentioned survey of health facilities, two reported that vitamin A deficiency is seen "often," 17 "sometimes," 19 "rarely," and one "never." This ratio approximates the interviews with an additional 10 health facilities. -82- ANNEX 15 page 15 of 48 1.41 Most cases of severe vitamin A deficiency are seen from May to December, the measles season in Zimbabwe. It is also the season when milk is less available, and when the green leaves generally are consumed dry and therefore have less vitamin A (87). The most serious cases of vitamin A deficiency usually are related to measles, which interferes with the uptake of the vitamin in the gut. Even though the diet may provide adequate vitamin A under normal conditions, it is not sufficient in times of stress (58). In fact, the severity of measles is largely determined by the state of nutrition at the time of the attack (5). In the above Matabeleland study, most of the xeropthalmia cases were associated with measles (the others with marasmus, kwashiorkor or dysentery) (87). The problem is almost always found among people whose diets are limited in variety. A study in 1967 of 988 children hospitalized in Lupana found ocular lesions from measles much more severe among blacks with limited vitamin A intake than Europeans (35). 1.42 Rural children in Mashonaland have much higher plasma vitamin A levels than urban children, according to a comparative study of 180 rural children and 145 urban children in the Bindura area (17). Few of the rural children studied were in vitamin A deficit except in isolated instances. This may in part reflect the availability of wild fruits and vegetables, less accessible to city children. However, with the decline in availability of wild foods, and the decline in consumption of other traditional foods due to diet preference changes, the possibility exists for increased vitamin A deficiencies in rural areas as well. Iron Deficiency Anemia 1.43 Determination of iron deficiency anemia is based on biochemical measurements that rarely exist in Zimbabwe other than for hospital patients.4/ A reading of a sampling of hospital admission charts in Rusape in May 1982 found a range of hemoglobin among children from 6.1 to 12.0, with the average being 9.4, a low level. Of the health facilities surveyed by the mission, 18 saw iron deficiency anemia "often," 17 "sometimes," seven"rarely," and none "never." The relative infrequency of cases of severe iron deficiency anemia was attributed by several doctors interviewed by the mission to the common use of iron pots by low-income populations, a situation that could change with "modernization." 1.44 A study in the 1960s found that of 341 adult outpatients of Harare Hospital, anemia was found in 29.2% of the cases; the prevalence rising with age. However, iron deficiency accounted for only 2.7% of the anemia in the case of males and 8.3% in the case of females, some of this to a moderately severe degree. Anemia due to other causes was found in 4/ Current studies are underway by Dr. Forest in the Department of Hematology of the Medical School of the University of Zimbabwe, who is studying the hemoglobins of 300 Batonka, and Dr. Joyce Choto, Chief Dietician of the Office of Nutrition, Ministry of Health, who is studying hemoglobin levels of hospital admissions. -83- ANNEX 15 page 16 of 48 26.5% of the men and 13.5% of the women. The rest of the anemias, other than iron deficiency, may partly be nutrition related, but this is unlikely in that men have better diets than women in this population. More probable, it is related to cirrhosis of the liver (10). Other Deficiencies 1.45 There probably is not much rickets (due to vitamin D deficiency) in Zimbabwe today because of the large amount of sunshine to which children are exposed. But there is almost no data to substantiate this. One study in the late 1960s included x-rays of 224 infants, without finding any rickets (68). A review of admissions at Harare Hospital in the late 1960s revealed eight cases of rickets, the patients ranging in age from two to 12 years (68). By contrast, a study in the 1960s in Cape Town found 17% of Bantu babies had some degree of rickets (118). Early in the century, rickets was common in Rhodesian mining areas (58) but there is no data indicating whether the problem still exists in this community. 1.46 Similarly, scurvy (from vitamin C deficiency) was commonly reported in the early years of the Rhodesian mining industry. In the first quarter of the century, 35% of the Africans working in the mines in Gwanda were found to be suffering from scurvy and in 1908 13.5% of mine workers' death were attributed to this nutritional deficiency. As late as 1945 there were 100 serious cases among mine workers (58). Not much scurvy is reported today in sub-Saharan Africa and there probably is little in Zimbabwe. Of 54 hospital patients admitted for nutrition disorders in 1954, only one "pure" scurvy was identified (97). An investigation in 1976 found that the vitamin C status of a group of Africans was better than that of a corresponding group in Scotland (9). 1.47 Ber-ber, resulting from a lack of thiamine, apparently is rarely encountered in Zimbabwe and it seems unlikely that it should occur as the thiamine content of maize is good. 1.48 Ariboflavinosis is commonly reported from diet studies elsewhere in Africa and probably exists in Zimbabwe, although no studies are available to support this. Since riboflavin plays an important role in many body processes, deficiency of this vitamin may perhaps be associated with an ill-defined lowering of general health. 1.49 A majority of doctors interviewed reported a deficiency of folic acid, especially among pregnant women, but there is no data available to corroborate this. It has been reported that folic acid deficiency also is found among men in Zimbabwe (58). 1.50 Deficiencies of vitamins rarely occur singly. Deficiencies of vitamins of the B group, vitamin C and vitamin A probably occur together as a multi-deficiency. Generally, the results of this multi-deficiency are sub-clinical. -84- ANNEX 15 page 17 of 48 Part II: Causes of Malnutrition 2.01 There are no good studies available on the causes of malnutrition in Zimbabwe. It is possible, however, to begin to get an understanding of some of the more prominent influences on the problem by looking at food availability, purchasing power (incomes in relation to prices), food consumption patterns, dietary practices, social problems and interactions between disease and malnutrition. A. Food Production and Availability5/ 2.02 To what extent is malnutrition in Zimbabwe a reflection of food availability? There is only the sketchiest of notions about the relationship of food availability and incomes and nutrition conditions among the poor, particularly those living in communal areas. Analysis of data collected in the 1980 Ministry of Health Survey suggests that in four of five provinces examined, there is a close correlation between nutritional status and availability of food, but data gaps preclude reliable judgments (178). 2.03 Overall, Zimbabwe is a food surplus nation that is not vulnerable to the international price fluctuations and changing donor priorities that often plague most other African countries. Generally, Zimbabwe is a substantial food exporting country, a kind of granary to the region. (After a shortfall in 1980, large exports started again with the bumper crop in 1981. Exports of maize had dropped from $25 million in 1978 to $7 million in 1980 but they were up to $35 million in 1981.) The major import is wheat. Domestic needs are estimated to be 205,000 tons, a shortfall from local production of 20 to 25% that is made up of imports valued at something over $10 million. Imports of other foods in 1981 were valued at $14 million (169). 2.04 After adjusting for exports and imports, the 2,576 calories available per day per person in Zimbabwe in 1978 compared favorably to the 2,205 calories per capita in Africa generally and the FAO target of 2,394 for Zimbabwe (99). Per capita figures, however, reveal little of unsatisfied food needs, which vary greatly by season, by region and by vulnerable segments of communities within the regions.6/ 2.05 One-quarter of the over 1,000 rural families surveyed in 1981 needed to buy what was considered by most as their basic subsistence food. In addition, over half the families had no beans at the time of the interview and almost three-quarters of the sample had no groundnuts (175). 5/ Food production issues are touched upon only briefly here; a study by an agricultural sector mission that visited Zimbabwe in May 1982 provides more detail. 6/ Per capita estimates also are extremely sensitive to how large the population is assumed to be. At present, there is considerable uncertainty about the size of Zimbabwe's population, an issue that will be resolved with publication next year of the new census. -85- ANNEX 15 page 18 of 48 2.06 About half of the Agritex field staff (47 of 92) queried by the mission in May 1982 reported "most" families in their areas had sufficient foods (through farming or purchase) to satisfy their needs throughout the year and an additional eight responded "all" families in their areas had enough. However, 33 said either "half" or "few" and three reported "none" of the families had sufficient food. (Thirty-eight said food was in short supply one-to-three months, 30 said from three-to-six months, and nine from six-to-twelve months.) Similar responses were received from interviews with home economics advisers. Eight of nine interviewed said there was not sufficient food, even in an average year, for the families they cover. 2.07 Some local observers suggest the food shortfall is a reflection of the war and its aftermath. With three-quarters of a million urban squatters displaced by the war, and another quarter million returning refugees, lands had been unattended, and some 800,000 head of cattle had been lost due to theft, lack of dips, and tsetse. In some areas there was a breakdown of normal agricultural services. In addition, the pre-independence Government's policy of "protected villages" involved a quarter of a million people in 220 villages, generally miles from the fields. In some areas security fqrces destroyed crops and, in others, blockaded food supplies where guerrillas were operating. 2.08 Yet, piecing together information generally collected for other purposes suggests that nutrition problems among those living in the Tribal Trust Lands may have been aggravated by the war, but existed long before the war. One confidential report to the Ministry of Internal Affairs in the early 1970s said two-thirds to three-quarters of the peasants did not produce sufficient food for their own needs (60). Another study (P. W. Jordaan) about the same time reported that in the three most progressive headmen's areas of Rusape District, only two-thirds enough food was grown two-thirds of the time (142). 2.09 A recent farm management study in Chibi South found that 27% of farm families said that the maize they grew usually lasted them for the full year, but 34% of the families responded that the maize never lasted for the full year (being out of supply from August to February for some households) and 28% responded "some years" (26). Another survey, in Gokwe, found over a third of the families with insufficient food (34). 2.10 A 1969 study in Gutu demonstrates the dangers of per capita figures. On average, cultivators were able to grow 15 bags in a year to meet their subsistence requirements in terms of grain and still sell five bags worth some $30. However, 50% of the cultivators in the sample failed to produce 15 bags of grain and in 1970, a year of late summer drought, the proportion was considerably higher. Also, although stock holding was 4.2 head per family, 30% had none (85). In the areas surveyed in May 1982 by medical students, 24% of families had no livestock. In Bikita (Mamvura), 43% had none (47). In Chibi South, those who owned cattle produced 25.7 bags of grain, retaining 14.7. Non-owners produced 9.4 bags, retaining all but one of them. ANNEX 15 -86- page 19 of 48 2.11 In short, the long-standing lack of resources amoag certain groups to produce/obtain sufficient food rather than disruptions of the war may be the main cause for the considerable amount of malnutrition now seen among families of peasant farmers. The 800,000 farming families on communal lands grew approximately one-third of the 1.6 million tons of maize estimated to be produced in 1981/82 and retained about 80% of that for home consumption. On a daily basis, this translates to about 900 calories per person. As cereals account nationally for 72% of calories (a percentage that can be expected to be still higher among low income populations) and maize accounts nationally for 77% of the calories from cereals, this means a daily caloric shortfall in communal areas of at least 500 calories per person, unless additional calories are obtained through purchases of food produced outside the communal lands. Land 2.12 What are the main reasons for insufficient food? Lack of resources (capital or draught power) was cited in 45% of the Agritex responses. Drought was cited by 37%, and 18% cited land quality or land size. 2.13 Studies on the latter that also looked at the relationship between the nutrition status of 709 school children and landholdings in Que Que TTL in the 1970s found that 71% of children from families in the lowest categories of landholding were suffering from some degree of malnutrition, a substantially higher percentage than the next highest landholding categories (133) (139). 2.14 A study in the late 19709 concluded that each family living in communal areas required 27-to-250 hectares for producing adequate food, depending on the region. However, the 800,000 farming families living on 16 million hectares have an average of 20 hectares per family. Thus, the average availability would not be adequate even on the best of lands. Moreover, the land distribution on TTLs was highly skewed; the above study found that 70% had less than 15 hectares (157). Another study found at least 20% in Gutu were landless (85) and still another reported that 40% of men between 16 and 30 were without land (154). 2.15 Land carrying capacity estimates suggest that communal areas already have a surplus population; one estimate being upward of 2.5 million people (38). A 1977 study concluded TTLs could safely carry 275,000 cultivators; by then there already were 675,000 (103). Another study looked at soil production potential as it related to existing food requirements on four TTLs. In three of the four (Gutu, Serima, Eastdale) there were deficits of 38 to 60%. Only on Chikwanda were prospects good. Meanwhile, because of impoverishment, and attempts to get a higher production from the land without benefit of fertilizer and other purchased inputs, land degradation is said to be "increasing at a rapid and frightening pace" (85). Ten of the health facilities surveyed listed "poor soil" as a cause of the malnutrition in their areas. One analysis of the potential of communal areas for rural development - based on density of population, agro-economic conditions and proximity to urban centers and transport -- concluded that 9.4% of the land had "fair" -87- ANNEX 15 page 20 of 48 potential, 39% had "poor," 28.2% had "very poor," and 23.4% had "nil." None was rated as "good" (67). 2.16 Increasing food availability means not only increasing food production; also important is the reduction of food losses. No good data is available on the extent of these losses, but the Minister of Agriculture estimated they may be as high as 35-40%. Nearly two-thirds of the families in the areas surveyed by medical students had storage problems, primarily with rodents, ants and borers (interestingly, those who had some advice from extensionists had considerably less loss) and one nationwide survey found that only 18% had no storage problems. (The highest proportion with problems were seen in Victoria, Mashonaland and Midlands; the least in Matabaleland and Manicaland) (175). Inadequate storage contributes to the seasonal fluctuations in food supplies, as do poor methods of home preservation of foods. The storage of food products for later consumption is largely by dehydration and, therefore, the quality and shelf life of the foods are limited (88). B. Incomes and Expenditures 2.17 Efforts to analyze root causes of malnutrition in Zimbabwe are complicated by the very limited availability of rural income and household budget surveys. Moreover, the data on incomes is reported in different ways (per capita income, family income with or without remittances, city averages and low-income deciles) making difficult overall assessments or comparisons. From the varied sources, however, indications are that insufficient purchasing power (considering both incomes and prices) among large segments of the population is a principal constraint to better nutrition. Urban 2.18 A 1976/77 survey of lower-income urban households found an average monthly income of $80.92 (167). (20% of this population earned $50 a month, 60% between $51 and $110 and 20% over $111.) This compared to a poverty datum line requirement in September 1978 of $1077/ for the average-sized family. (This meant that, on average, those with families living in the urban areas would require an additional $36 a month to satisfy their minimum necessary consumption needs.) (31) Some of the shortfalls in urban wages are made up with ties to communal areas -- at least part of the year -- but they are unlikely to make up the difference. 2.19 The families in the lower-income survey spent 49.5% of all expenditures or $38.58 per month on food. Similarly, the urban African budget surveys in Umtali in 1971 and Salisbury in 1969 showed 47% and 52% respectively for average family food expenditures (57% and 59% for the lowest income quintile). Meanwhile, the lowest quintile of the European 7/ By sector, monthly incomes in 1978 were $87 in manufacturing, $78 in restaurant and hotel work, $68 in construction and $37 for domestics (170). -88- ANNEX 15 page 21 of 48 population, in 1975/76, spent 20% on food. About $106 or 13.8% of the expenditures of the higher-income population as a whole went for food, compared to the 49.5%, worth $38.58, by the lower-income group. The Europeans spent 2.5% of total expenditures on cereal products; the Africans 23.2% (166). 2.20 Since independence, the urban picture is considerably brighter. The 1982 study of the Bindura urban population found an average monthly income of about $131 with 1.08 wage earners per household (83). This compared to a December 1980 poverty datum line of $128. Communal Areas 2.21 No poverty datum line exists for communal areas. However, a comparison of nutrition status to average family income using 1978 Gwanda data reveals the following: Current Nutrition Condition (Weight for Height) Annual Income of Child's Family Normal $229.50 Mild malnutrition $168.25 Moderate malnutrition $114.83 Severe malnutrition $51.00 2.22 Accurate data on incomes from peasant production on a national or regional basis is practically non-existent, but peasant incomes clearly are considerably below urban incomes. A 1978 estimate of per capita income of people in communal areas was $28 or $168 for a family of six (157). A year later an analysis of the composition of the incomes on communal lands estimated that an income of $220 a year included $27.50 from sales; the rest was in the form of subsistence (116). A May-June 1982 survey of 259 households in Gwanda found an average farm cash income of $250 ($70 from crops, $150 from stock sales and $25 from handicraft and brewing) (38). 2.23 There are significant variations in income in communal areas. Surveys of six areas in the Midlands and Mashonaland in January 1981, found income of cash and kind ranging from $80 per peasant farmer in Lower Gwelo to $97 in Nharira to $164 in Chiweshe and $427 in Wedza (116). Cash earnings for 1980-81 in Chibi South averaged $105 for non-cattle owners to $240 for owners. The latter group spent 16% of its cash income on food, compared to 25% for the former (26). 2.24 Central Statistics Office data for 1980 show that $170 million value of food was produced for subsistence consumption. Divided by the estimated 800,000 communal area farm families, this would amount to a value of $146 a year. This was supplemented by a sale of crops (of $28.9 million, or $36 per family) and 5.2 million head of livestock (meaning an additional $6.50 per family). This annual income of $188.50 was increased in 1981 by an estimated $44 because of the boost in marketed crops. In short, the average annual farm income could be estimated then at approximately $233 per year, or roughly $20 per month, per family. ANNEX 15 -89- page 22 of 48 The Role of Remittances 2.25 Although, on average, families on communal areas grow only 60% to 75% of their maize requirements, a sizeable portion of the families have incomes and food supplies supplemented by a member, working in the modern sector, who provides remittances.8/ In Korekore, in 1977, nearly half of the adult malc population was away from home in (or seeking) wage employment. The reason given for leaving in 95% of the cases of the migrants in one study was "a need for money" (106). The 1982 survey in Gutu shows that only 27% of the families have no migrant workers; in Gwanda 50% (62) (37). Of the latter, 34% had off-farm work elsewhere in the District, 36% were working in either Bulawayo or Harare, 25% were in the army, 5% worked on commercial farms, 8% worked elsewhere in Zimbabwe and 3% in South Africa or Botswana. Amounts of remittances are influenced by the nature of the migrant's job. If he is in the city working in a factory or on construction, his earnings and thus his remittances likely will be higher than if he is working on a commercial farm or in a mine (170). A rough 1982 survey of 85 households in three areas of Harare suggests average urban remittances from urban areas may be upwards of $400 (112). But the average amount received by the 245 families in Gwanda in 1982 was $285 (37). Overall, on average, remittances in cash and kind may be on the order of at least $250, thus doubling the communal peasant family's income. Remittance amounts also vary greatly, depending on the recipient. More than twice as much is sent back to a wife, children and parents than when the remittance is sent to parents alone (112). Currently in Murewa, remittances from heads of households average $400 compared to $145 from other family members (120). 2.26 Preliminary multiple regression analysis of the 1978 Gwanda and Gutu data sets demonstrates that nutritional status improves with increased remittances. Bringing this principle up to date (with the use of the 1982 Gutu data) suggests that a remittance per family of slightly under $200 will lead to a normally nourished child, that under $190 will result in mild malnutrition and under $110 in moderate malnutrition (assuming all other independent variables at their mean values). 2.27 The report of the Commission of Inquiry into Incomes, Prices and Conditions of Services stated that "those families which do not have migrant workers are possibly the most disadvantaged group of farmers in the peasant sector" (116). This group can be identified still further. The most disadvantaged are those which have migrant workers who do not send remittances. In Gwanda and Gutu, where in 1978 78% of the households had migrant workers, 42% of them sent nothing home (116). In Gwanda in 1982, 52% sent nothing home. Analysis of the 1978 Gwanda data shows that severe malnutrition is six times higher (29% to 5%) in families where the migrant does not send remittances compared to those who do. The least amount of severe malnutrition appears in those families where the father does not migrate but someone else sends remittances. 8/ A form of "ukama," of sharing and helping others, in "mhuri" -- the extended family. -90- ANNEX 15 page 23 of 48 2.28 In Murewa, in 1982, one-third of the migrants were heads of households (120) and a study currently being undertaken in Wedza found that 34% of the families have a father away (16). He remits both food and cash, usually during his once-a-month trip home. Fourty-five percent of the families get remittances from someone other than the father, and 21% are nuclear families with no outside income. A quarter of these are single women, usually old and often responsible for grandchildren, yet with no outside income. It was found in Wedza that this was the segment of the population that is usually the worst off (16). Others without direct access to any earned income -- the unemployed, the number of whom is unknown but unemployment is considerable, and a high percent of the old, the infirm and the handicapped and their dependents -- also are among the very needy. Commercial Farm Workers 2.29 Wages in 1979 of 90% of the 227,000 commercial farm workers were less than $30 per month. These were supplemented with some form of a food ration (of differing types and sizes -- in one attitudinal study, 60% of the farm workers listed inadequacy of rations as a major dissatisfaction) (106) and a small amount of land generally was provided for production of family crops. It was unlikely that the total income of most farm employees -- including rations and home production -- would have been higher than $540 a year or $45 a month (116). 2.30 The 1981 study of commercial farm families in Bindura District found a monthly average family income from wages of $28.09 with 1.09 wage earners per family. The approximate cost of living (poverty datum line) established for the study, using local prices for an average-sized family of five, was calculated at $92.73 per month; the gap between this and the average monthly income being $63.64 (75). Since then, the minimum wage for commercial farm workers has been raised to $50 a month and the poverty datum line for the same area as of December 1981 was re-estimated at $99.50.9/ In the unlikely circumstance when a farm family would be given 50% more than the $50 minimum wage, there would still be a shortfall of $25 to meet minimum requirements. In addition to the cash income, however, there still is some payment-in-kind but apparently considerably less than before minimum wages were established. Although hard data does not exist, impressions from interviews both of farm owners and commercial farm workers suggest a substantial decline and in some cases an elimination of the provision of rations. Institution of the minimum wage for commercial farm workers has in some situations also led to longer working hours. One effect of this, according to women extension workers and commercial farm workers interviewed, is at least in some instances less time devoted to the small plot of land -- sometimes, but not always (12) -- provided to the commercial farm worker families. 9/ From 1979 through December 1981 there was a steady increase of consumer prices for foods, the consumer price index for foods rising from 217.3 to 257.5. -91- ANNEX 15 page 24 of 48 Mine Workers 2.31 Estimates as of December 1980 were that $98 a month would be required by the 8,000 Africans employed in the mines to meet their minimum needs. The minimum wage has been increased to $105 per month and a recent study of mine workers in the Bindura area found that average income was now $126 a month, plus subsidized rent. This would indicate that people are living at or above the poverty datum line. Mine worker families spent $50 a month (or 40-43% of their income) on foods, averaging $7.36 per family member per month (84). 2.32 In addition to wages, there is sometimes a small amount of land made available for farming. Four percent of the recent Bindura mining study sample said their farming was the source of food; 57% had access to an average of 0.1 acre. None of this food was sold. Also, poultry was owned by 29% of mine worker families and over a third of them had some income from the poultry (84). Food Prices 2.33 Retail food prices vary significantly for some items, depending on locale an4 the type of community served. As can be seen from Table 5, the highest prices were generally in stores in communal areas and the lowest prices in the township market and urban supermarket. The former, in part, is a reflection of transport and other distribution difficulties. Retail prices in rural areas are as much as 36% higher for mealie meal, 60% higher for margarine and 81% higher for cooking oil than the urban areas and it is probably because of this differential that remittances increasingly are in the form of food rather than in cash. In Gwanda now, $110 of the $285 in remittances is in the form of food (37). Recent surveys in both Harare and Wedza show that two to three times the amount of cash remittance comes in the form of, food (112) (14). - T~~~~~~~~~~hhle 5 MML FD E (April 22-25, 1982) Stores Serg: Saw Mill and Govt. Worlers, Ccammrcal Farm Peasant Farmers Peasant Farnmrs Fbrest Reserve Traders aml Urban Tow3sbip Woxrers (ommal Area Comwal Area Ebmploye Peasant Farners Supermarket Market (Bindura) (Wedza) (Maramba) (E. HinLj!ds) (Mzera) (Haz) ( t ) Roller Nal $5.45 $6.25 $6.62 $5.17 $5.98 $1.99 $4.88 (50 kg.) (20 kg) Cooldkg Oil 1.05 1.00 1.25 1.10 .95 .69 .75 (750 iL.) Bread .25 .25 .28 .26 .25 .25 .25 Margarim .37 - .40 .35 .34 .27 .25 (250 gr.) Bron Sgar .37 - .32 .35 .34 .27 .25 (1 kg.) Lactogen - 8.50 3.67 2.62 8.70 7.10 4.50 (2 kg.) (500 gr) (500 gr) (1 kg) Nespray 5.55 4.79 4.06 2.55 (1 kg.) (500 gr) Coca Cola .16 .17 .17 .16 .16 .15 .15 O Table Salt .17 - .16 .24 .11 .14 u I (500 gr.) (1 kg) o Iodized Salt .18 - .17 .12 - 1,0 (500 gr.) -93- ANNEX 15 page 26 of 48 Comparison of Communities 2.34 What, then, is the picture after looking at information on food availability, incomes and expenditures? As with nutrition status information, the urban poor and, next, the mine worker families again seem to be relatively better off. By contrast, the worst off community seems to be the commercial farm workers. Data here and observations of the mission confirm the Report of the Riddell Commission that "the social conditions on some commercial farms are below an acceptable standard of human decency."(116) In terms of sheer numbers, the largest group in need is the population of communal areas. Theirs is, in large part, a land problem (quality and quantity) and related overcrowding. What is required to bring this group to nutritional adequacy goes beyond what can be achieved through conventional short term nutrition interventions. Family Size 2.35 Looming large over all of the previous discussion is the number of mouths to be fed in a family. The multiple regression analysis of the 1978 Gutu and Gwanda data sets show the larger the family on communal areas, the more malnourished the children of the family. In communal areas, per capita food availability generally is calculated based on a six person family. The figure may well be considerably higher. Average size among the 452 families surveyed in Gwanda in May-June 1982 was 9.7 (38). In the 1978 sample, 28% of the women had six to nine living children; 9% had nine to twelve. (In Gutu, 24% had lost at least two children and over half had lost at least one.) 2.36 The poverty datum line for commercial farm workers was based on five members per family, as noted. For some areas this is a gross underestimate. An unpublished survey of farm workers in the Wedza area, found that 170 farm workers were responsible for 1,694 people, i.e. a dependency ratio of 10 to 1 (54). This was a similar order of magnitude of dependency ratios of 14 families on other commercial farms where informal interviews were conducted. The 1982 census, to be available in early 1983, will help clarify this. C. Patterns of Food Consumption 2.37 Low-income urban families spend almost all of their income on eight items: mealie meal, bread, beef, milk, tea, sugar, rent, and paraffin (116). Nearly 30% of all the expenditures on food are for meat, 14.5% for bread, 12.6% for mealie meal, 7.4% for sugar and 5.4% for oil, most of it groundnut or cottonseed oil. The lowest quintile from the lower-income survey spends a higher percentage on bread and a lower percentage on milk and meat (116) (167). An effort to establish income elasticities of demand for food in general in communal areas (based on the Gwanda 1978 data set) suggests a slight increase in elasticity when moving from family incomes of under $50 to over $400, but it is still low. 2.38 Cereals account for almost three-quarters of the calories consumed per capita and maize accounts for slightly over three-quarters -94I ANNEX 15 page 27 of 48 of the cereals. Less than 5% of these calories, as consumed in such forms as mealie meal, is dietary fat. Of the remaining calories, only 4% come in the form of oils and fats, three-quarters of this from vegetable origin. The FAO/WHO recommendations are that 15-20% of the calories should be in the form of dietary fats (41). The per capita protein intake in 1977, when livestock was more available, e.g. the dairy herd had dropped from 129,000 in 1973 to 106,000 in 1980, was a seemingly plentiful 74 grams compared to 55 grams in Africa as a whole. Eighteen grams were in the form of animal protein and 56 in the form of vegetable protein. Of the latter, 88% were from cereals, more than three-quarters of that amount from maize. Maize so dominates the diet that it is also the leading source of other nutrients such as iron and calcium. 2.39 Other than for urban samples, food consumption surveys and dietary surveys (that record food intake either for the household as a whole or for the individual household member) have not been undertaken in Zimbabwe. All available fragmentary data, however, point to sadza, a thick cereal porridge, and vegetables as the primary foods, particularly of children. In both commercial farm and mine worker families in Bindura, 97% of children under age five had sadza and vegetables twice daily. Meat was consumed less than once a week by 79% of the children of farm workers, 59% of children of mine workers and 49% of the urban children. Milk, eggs and beans were never eaten by children of commercial farm workers in 65%, 87% and 84% of the cases respectively, compared to comparable figures of 12%, 9% and 16% in the urban population (75). The diets of women surveyed are not more varied. Of 488 women interviewed in Chiweshe, Matibi and Tsholotsho communal areas, 76% had fruits less than once a week and 71% had meat or chicken less than once a week, although it was popular in all areas as far as taste (111). 2.40 To relieve monotony, cereals are prepared in several ways: boiled mealies, roast mealies, roast mealie meal, thin porridge, and thick porridge. Sadza is made with maize, sorghum, or millets. Substantial amounts of maize also are eaten roasted or boiled as sweet corn or green maize during the summer season and in winter when harvested, cooked and dried on the cob. Vegetables play an important role in the diet, particularly in the relish (usavi), which is a kind of vegetable stew used with sadza. Pumpkins, potatoes, especially sweet potatoes, and tomatoes also are important to the diet. Most rural people generally like milk but the supply is variable because most milking is done only in the summer. The milk is largely consumed sour. A lactose fermentation takes place that makes the product tasty and largely lactose-free and therefore is not likely to cause problems for those susceptible to lactose intolerance, as is so common in neighboring countries (88)e10/ 2.41 Breastfeeding is common and prolonged. Only 2% of the mothers in the areas surveyed by medical students in 1982 were not breastfeeding at six months and only 14% were not still nursing at the baby's first 10/ A similar milk product called Lacto is produced commercially for urban areas by the Dairy Marketing Board. 95 ANNEX 15 page 28 of 48 birthday. At 19 months, 44% of the mothers were still breastfeeding. The same survey found that 45% of mothers had not given other foods by the beginning of the baby's fifth month, 28% by the sixth month, 13% by the seventh month, 8% by the eighth month and 2 1/2% by 12 months. The Nutritional Effects of Modernization 2.42 Although consumption data is limited, and in rural areas is particularly sparse, it is apparent that there has been a significant shift to a more monetized consumer economy. On communal areas this partly reflects the shift from production of subsistence to cash crops. Among commercial farm workers, this reflects elevation of the minimum daily wage and the accompanying decline of payment-in-kind. Although commercial farm workers' wages are now at least $50 a month, it is not clear that diets are improved. (Eight of 11 home extensionists interviewed were of the view that more food came into the commercial farm worker's household during the era of partial payments-in-kind than with the current higher cash incomes.) The reason most commonly given: the extra income does not always go for nutritionally-useful food, or in some cases, not for food at all. There is no direct data available to confirm this notion although several doctors surveyed cited the use of income on sugared drinks and other junk foods as a contributing factor to the nutrition problem.11/ 2.43 Indirectly there are indications that the net effect of increased commercialization, even with increased income, may not always be positive. In Tsholotsho communal area, for example, where land increasingly is used for producing maize for the market, only 25% of the women had vegetables more than once a day, compared to 97% in Chiweshe and Matlbi where less food is marketed (111). One of the unexpected findings of a small sample multiple regression analysis of the 1978 Gutu and Gwanda data sets was that the value of crop sales of the 110 families examined seemed to have a negative relationship with nutrition status. It is not possible to determine in either of the above cases whether the families would be even worse off, nutritionally and otherwise, if they could not sell as much as they do. (The studies do not specify the kinds and amounts of food purchased as a result of increased cash incomes.) 2.44 Mealie Meal: One of the most dramatic changes in food habits, associated with "modernization" is the increased consumption of highly refined mealie meal. The nutritional value of the more refined mealie meal is not as high as the cruder processed meal. The straight-run meal contains 4 1/2% fat, compared to 1 1/2% in the highly refined meal and this affects caloric density, an important nutritional issue in Zimbabwe. Similarly, the protein content of straight run meal is higher 11/ The only doctor working in a resettlement area who was surveyed answered the question, "Do you think there is a nutrition problem in your area?" with "Not yet, at least not before shops are built in the resettlement area." If the home extensionists' views referred to above are valid, it raises the dilemma of consumer sovereignty--i.e., that people should spend their earned resources as they wish. -96- ANNEX 15 page 29 of 48 than the more refined product, according to the old Nutrition Council (43).. There is more than twice as much iron (five mg., compared to two), nearly four times more riboflavin, more than ten times the thiamin and a quarter more calcium in the village-refined meal (176). Discussion above pointed to the problem of pellagra, resulting from niacin deficiency. The niacin content in the village-processed product is 2 1/2 times that of the highly refined meal.12/ 2.45 The switch to the highly refined meal partly reflects tastes and partly the Government's pricing policy which made it advantageous for farmers to sell maize to the Marketing Board and buy it back in the form of refined meal. Similarly, it sometimes was cheaper for a rural family to buy mealie meal from town than to buy less refined food from the farmer next door. 2.46 Given the income effect of low subsidized consumer prices of mealie meal (and what may also be a marginal increase in production/income in communal areas resulting from producer subsidies--although 95% of the maize purchased in the program came from commercial farms) one can in the absence of hard data speculate that the switch to refined mealie meal, on balance, could have been nutritionally positive even though portions of the increased income went for non-food items and specific groups may have been directly adversely affected (e.g., rural maize milling which had been a major industry has largely disappeared in many places as a result of the incentives to buy highly refined meal from heavily subsidized large millers; one estimate suggests 2,000 rural mills have been closed) (14). Even though for many families the switch to refined mealie meal means an increased quantity of food consumed, the nutrient composition of the diet no doubt has been altered. 2.47 Sorghum/millets: With the increased commercialization of communal areas and the attactiveness of maize production has come a per capita decline in some areas in the production of millets and sorghum, nearly all of which is used by peasant farmers for human consumption (26). Millets and sorghum are both better nutritionally than maize (e.g., sorghum has twice the niacin as maize; millet has 25% more) and also are more drought-resistant, the latter an important consideration for drought-prone countries such as Zimbabwe. Whether an increase of production by switching to maize more than offsets the reduction in nutrient quality cannot be determined from available data. 2.48 Groundnuts: Groundnuts, traditionally an important part of the Zimbabwean child's diet for both protein and caloric density, are regarded by 32 of 40 people interviewed as a less important part of the diet today than had been the case in the past. The use of dhovi (groundnut butter) in children's morning sadza is said to be less common than before; in some areas it is regarded as "old-fashioned." An 12/ The processing done by the village-level, power-driven hammer mills produced a more nutritious product than the still more traditional techniques of pestle and mortar, grinding stones or quern and winnowing baskets when nutrient losses were considerable (19). -97- ANNEX 15 page 30 of 48 extensive survey by the supplementary feeding program found that one-third of the children had no groundnuts in the past year and a further one-third ate them either once a month or once a week (175). (This ranged greatly by area; in Victoria Province 63% had not eaten groundnuts, double that of Matabeleland and more than five times the percent in Mashonaland and Manicaland. Among commercial farm workers' children, 85% in the Bindura area never eat groundnuts) (75). For those who do consume groundnuts, the supply generally is available for only a few months a year (175). 2.49 Whereas groundnut production was common in earlier generations, 38% of those surveyed under the supplementary feeding program now grew none, 33% grew for sale and subsistence and 3% grew only for sale. (The remaining 26% retained all production for home consumption.) (175) Only 24.7% of urban migrants who had families in communal areas reported that groundnuts were grown on their farms (112). Total groundnut production in Zimbabwe, most of which is grown in communal areas, had declined by 1981 to 31% of what it was five years earlier. Again, as in the case of sorghum and millets, there presumably are economic incentive factors related to the decline. Available data is not adequate to sort out the nutritional trade-offs 2.50 Fruit: Other foods also now appear to be in shorter supply for the low-income population. Although domestic demand for beef is rising at about 12% a year, almost all low-income respondents reported that formerly they consumed more meat than they do today. Fruits, once a common part of the Zimbabwean diet are less common. In Bindura, 76% of the urban population has fruit less than once a week and 6% never has it (83). Similarly, 76% of women in the Chiweshe, Matibi and Tsholotsho communal areas had fruits less than once a week (111). Even the higher income mine workers' families do not commonly consume fruit. The reason given in Bindura was that it was too expensive (84). This may reflect the diminished supply of fruit due to the large number of trees destroyed during the war and the trees lost due to the increasing demand for firewood. 2.51 Bread: The "modernized" Africa also increasingly consumes bread instead of more traditional and more nutritious grain forms. In Wedza, almost everyone buys bread, if only a loaf a month (16). In Chiweshe, more than half the women eat bread more than once a day (111). In the survey by medical students, 54% of the respondents bought bread regularly. The lower-income urban survey found that 7.2% of total expenditures, and 14.5% of food expenditures went for bread (167). One reason for the increased demand for bread may be the shortage of firewood needed for traditional food preparation. Another is convenience. Already the more highly refined and less-nutritious white bread has largely replaced brown bread. Only 2% of bread sold to the lower-income urban population isbrown, although the lowest quintile of that population consumes about 2 1/2 times more brown bread than the low-income average. 2.52 Sugar: Another nutritionally questionable change accompanying modernization is the increased consumption of sugar, which accounted for -98- ANNEX 15 page 31 of 48 7.4% of food expenditures in the low-income urban survey. A leading sugar distributor reports that over the past two years there has been more than a two pound increase per capita in the annual consumption of lower socio-economic groups. Currently, the lower socio-economic urban group consumes 51 pounds a year, and the rural population 31 pounds. White sugar now constitutes more than 98% of all sugar sold, but 14% of the urban poor and 40% of the rural poor still consume cruder brown sugar. Generally, there is about $.05 a kilo difference in retail price. 2.53 Increased sugar consumption also results from increased consumption of soft drinks. Eight million cases of Coca Cola reportedly are sold per year, 60% of them in rural areas. The company estimates average adult consumption of 65 (300 ml) bottles per year at $0.17 per bottle. In Luveve, 13 bottles of soft drinks were consumed a month, both by those with incomes under and over $300 per month (91). A 2 1/2 year study of 5,376 Africans found that with an increased consumption of "Western diet" foods, dental caries began to increase (40). 2.54 Infant foods: Another example of "modernization" is the increased consumption among the low-income population of infant formula and, more importantly in the Zimbabwean context, commercial weaning foods or supplements. Doctors at the health services surveyed uniformly reported that breastfeeding is common unless, as five doctors reported, it is interrupted by another pregnancy. Some 9.5% of the mothers used bottles in the 1982 surveys by medical students. A 1981 Health Ministry survey found three times as much bottle feeding in cities than in communal areas and six times more than on commercial farms (174). 2.55 Breastfeeding appears to be almost universal among rural women but in the Luveve survey 37 of 68 mothers had introduced supplements before three months, 20 of them with family incomes under $300. It was reported that a "high proportion use expensive commercial preparations" (91). Pronutro was purchased regularly by 25% of the mothers interviewed in six areas. Infant formulas and weaning foods are found in all stores in all areas of the country servicing all income groups and in all occupational communities.13/ Quantities of sale are unknown. Willards reports they produce about 500 tons a year of Pronutro and baby cereals. Retail price of a 500 gm box of Pronutro is as high as $1.15 (April 1982). Two 50 gram servings a day, each equivalent to 22 grams of protein and 413 calories would come to $6.90 a month or about 14% of the total family income of commercial farm workers. 2.56 In addition to spending increased income for food other than basic staples, demand with modernization has increased for non-food items. From 1979 to 1981, the overall retail trade value index for non-food items went up higher than the food index. This was not the case for the preceding eight years (169). 13/ Among the commonly seen products are Nestum, Lactogen, and Cerelac of Nestle, Pronutro of Willards, Nutresco and Instant Nutresco from the Nutrition Research Company and Mahewu (a traditional corn-based drink) produced by Chibuku. -99- ANNEX 15 page 32 of 48 The Calorie Density Problem 2.57 While lack of sufficient food is the most important factor in the etiology of malnutrition, it is not the only factor. The bulkiness of maize makes it difficult for a child to meet his caloric needs without either frequent meals or some supplementary form of caloric-dense food (e.g., foods with high fat or oil content). Dietary fats and oils, as earlier noted, are unusually low in the Zimbabwean diet. Moreover, current trends are toward more refined mealie meal, with 1% instead of 4 1/2% fat, and fewer groundnuts in the diet, while the Agricultural Ministry is pushing for greater marketing offtake of groundnuts produced by peasant farmers. There is a perceived shortage of oil among the low-income population. Demand for edible oils rose by 46% in 1981 and a further increase of 20% was forecast for 1982. (The 1981-82 shortfall between oil availability and requirements was 2,500 tgns or about 6%.) Shortages can be expected to continue into 1984 and 1985 unless major shifts in price policy are undertaken (38). 2.58 There is no current data set available that states definitively that energy is the main culprit in the malnourished condition commonly seeni in Zimbabwe. There are suggestions to this effect that emerged from the review of the supplementary feeding program and this is the position taken among those prominent in Zimbabwe's nutrition community. One can assume that the increasing flow of data from other countries pointing in this direction probably also would be applicable to Zimbabwe. In December of 1981 it was found in a small sample of urban children that nine out of 19 children had less protein consumption than their requirements, but 18 of the 19 had not met their energy needs. In all 19 cases the extent of the energy deficiency was greater than the protein deficiency by a considerable margin (153). With the bulkiness of the primarily sadza diet, a small child needs five or six small meals a day to satisfy his caloric needs. Yet 55% of the large sample surveyed in connection with the feeding program was fed three times a day (all but 5% of these mothers thought three times was the right amount), 18% fed more than three times and 27% fewer times (175). In the areas surveyed by medical students, only 20% fed more than three times a day; 35% fed fewer than three times. Roughly the same ratios emerged from the Gutu, Bindura and Wedza surveys. A 1982 small survey of 15 children in Mt. Darwin found a direct relationship between the number of feedings and nutritional status (12). D. "Nutritional Ignorance" 2.59 A substantial body of opinion in Zimbabwe is of the view that most of the malnutrition seen in the country is a result of "ignorance." (This diagnosis is similar to pre-Independence views.14/) Yet, among 14/ Former Secretary for Health, M.W. Webster, for example, was quoted as saying, "There is no doubt that under-nutrition or poor nutrition is the biggest single cause of the remaining health problems of the African population. There is also no doubt that this problem is not due so much to the lack of food or lack of ability to procure food but to lack of knowledge of proper feeding, particularly the feeding of infants and children." (45) -100- ANNEX 15 page 33 of 48 the field health facilities surveyed, only 14% of the responses to the question "Why do you think there is a (nutrition) problem?" related to ignorance of feeding practices. Our analysis of limited existing data confirms the field workers' perception. 2.60 Taboos exist, but not to the extent they likely would make a major nutritional difference. Forty-one percent of the 488 women surveyed in Chiweshi, Matibi and Tsholotsho had one food taboo and 14% had two. Two-thirds of these taboos involved some form of meat, generally restricted by the totem of the particular group. (In some instances this means that white ants could not be eaten during the rainy season or small mice, which are abundant after harvests). Twenty percent of the sample said they never ate eggs but it is not clear whether this is a taboo or a question of availability (111).15/ The avoidance of eggs appears elswhere in the literature; in one area 80% of the poor avoided eggs (91). Three doctors surveyed for this paper indicated that people in their areas believed that eggs cause convulsions in small children. Eggs never were eaten by 87% of commercial farm workers' children in Bindura, 72% of mine workers' children or 68% of the urban rural children, but again it is difficult to sort out taboos from economics. 2.61 More impressive is the evidence that mothers seem to understand nutrition concepts. Two-thirds of the 568 respondents in the supplementary feeding survey prepare special drinks for their children when they have diarrhea, most commonly mahewu and salted water. The survey also reflects that, by and large, mothers understand the causes of diarrhea and the value of breast feeding (175). Another study found that "many women seemed very conscious of the role that adequate diet played in the well-being of their children" (94). Most mothers also have a pretty good idea of the foods local nutritionists regard as most important, although often wrong foods are promoted by the nutritionists (see section III). Why, then, from the women's view, the food problem? Surveys in Umfurudzi, Mtoko and Tangwena found references to "not enough food," "water too far," and "arduous time-consuming processing" (100). 2.62 The major information gap concerns the frequency of feeding. Of importance from data available is not only that the child was fed less frequently than necessary (as this could result from other demands on a mothers' time) but that the mother does not appreciate the need for more frequent meals (175). Only 44% of mothers were found by medical students to believe more than three feedings a day were necessary; 13% thought two or one feeding was adequate. Also, the findings suggest that supplements to breast milk appear to be needed earlier than they are now introduced by many mothers. 2.63 Related to nutritional ignorance/education is the expected positive correlation elicited from all data sets where comparison can be made of years of mother's schooling and nutrition status of their children. In Gutu, for example, mothers of well-nourished children 15 A fuller list of food taboos in Zimbabwe is provided in Gelfand (pages 188-190) (51). -101- ANNEX 15 page 34 of 48 averaged six years of schooling, compared to 3.6 years for mothers of severely malnourished children. (Five years of schooling generally is considered necessary for the retention of functional literacy.) However, years of schooling also generally correlated with higher education levels for the husbands and, therefore, more opportunities for higher incomes. A 1972 study in Que Que TTL showed that the education level of family heads, independent of income, had significant positive effects on nutrition status (139). 2.64 An interesting note from a confidential report to Government in 1977 was the relationship observed between church attendance of women and the nutritional status of their children, even when holding constant other important factors, such as livestock holdings. The report, based on a study in three TTL communities (a study regarded by some as so biased by subjective evaluation it could be misleading), concluded that church attendance was more important to nutrition status than maternal education, i.e., those better educated women that attended church less frequently had a higher percentage of children with some degree of malnutrition (28% compared to 9%) than lesser educated church-goers. Similarly, the non-regular church-goers had significantly higher rates of child mortality in their families compared to regular church-goers. Beyond, children of the Dutch Reformed Church were usually taller for their ages than were children of the Roman Catholic Church. The researcher attributed this to the higher incidence of beer drinking in families of the latter and the relationship he drew between beer consumption, lower crop yields, poor diets and poor nutrition status (138). 2.65 It is difficult to discuss the malnutrition problem of Zimbabwe without mentioning the issue of heavy beer consumption. Cheap village beer has long provided an important and sometimes productive bond (in the sense of community harvesting and community construction) among villagers. The habit, however, goes beyond social drinking gatherings and, to some extent, probably is both a reflection of poverty as well as a contributor. No hard data exists on the number of those who drink heavily but the impression that it is largely a male problem may be misleading. Our interviews in three communal areas and two commercial farms suggest approximately 30% of the women also are heavy drinkers. A recent study in Nyanda District estimated that two-thirds of the adult population weekly averaged 5.3 to 7 liters of traditional beer plus an unspecified amount of clear beer. 2.66 No data exists on trends; interviews indicate that beer drinking traditionally has been a significant factor in the country but that quantities consumed today are increasing. This, at least partly, reflects successful commercial marketing practices. The Annual Report of the City Health Department for Salisbury reported that advertising budgets of beer firms are "large and effective" (122). Sales of National Breweries' clear beer increased 95% in 1978-1979; 121% in 1979-1980; 161% in 1980-1981 and 135% in 1981-1982. Rural sales accounted for 40% of the growth. (Cost per bottle is $.25 and the average retail price is $.43. Some rural retail markups are as much as 160%.) The study of Bindura farm worker families found 13% of their income was spent on beer. Interviews in the Wedza area suggest an even higher figure. -102- ANNEX 15 -- page 35 of 48 2.67 The increase in sale of clear beer in urban areas apparently has not reduced the consumption of traditional beer. The market for traditional beer is now 60% urban, compared to 25% five years ago, according to Chibuku Breweries. 2.68 Home brew contains high levels of iron but, in excess, can contribute to siderosis and cirrhosis of the liver, commonly found in the country (10). In addition, there are suggestions that home-brewed beer, with its high iron content, interferes with niacin absorption. Practically every adult sufferer of pellagra admitted to the hospital is an alcoholic (58). Heavy drinking also contributes to nutrition troubles of the family in other ways; e.g., interfering with work, diversion of monies to beer that could better be spent for basic foods, and reducing positive parent/child interactions. Twenty-five percent of the doctors surveyed listed beer drinking by parents as one of the causes of child malnutrition. E. Social Problems 2.69 One-third of the cases of severe child malnutrition result from social problems, often related to alcoholism, according to two long-time field doctors. (Other social problems cited were imprisoned parents and low earning power of the handicapped.) Severe cases of kwashiorkor or marasmus, they say, may often be a form of child abuse, as seen in the withholding of food from the child. The literature suggests this sometimes happens because parents believe the child is possessed or something else is wrong with the child. Serious nutrition cases also result often from deserted, separated, divorced and widowed wives who have to fend for themselves and their children. In Wedza, a higher proportion of the malnourished came from family situations of marital instability or divorce and, as noted above, even more so when children are left with grandparents with no income earning capacity. The problems related to migrant labor can be a form of social problem. In the Nyafaro cooperative settlement and Tangwena communal area, 19.2% of women are heads of households; in Mtoko 27.7% (100). One study shows that, other things being equal, the absence of the head of household had an adverse effect on nutrition status (133). Generally, however, things are not equal. In nutrition status terms, the absence of a father is offset by his remittances. When these are not forthcoming, however, the nutrition consequences, as noted, are likely to be considerable. That kwashiorkor is caused in some cases by social problems was confirmed by mothers interviewed in nutrition centers at Nyaderi in August 1981 and also by an analysis of nutrition centers at St. Theresa's Hospital in Umvuma (149). Forty-one of the 45 health facilities surveyed agreed that social disruptions had an effect on nutritional status, especially (in 25 responses) as reflected in kwashiorkor. F. Interactions Between Disease and Malnutrition 2.70 Malnutrition is not exclusively associated with inadequate food consumption. Although production/income/expenditure/consumption data that is available demonstrates that food intake is a major issue in Zimbabwe, the nutrition status of a population often also is affected by infections which may inhibit absorption of nutrients and often result in loss of appetite. -103- ANNEX 15 page 36 of 48 2.71 The interactive relationship of nutrition and infection is so strong in other countries where it has been studied that it is reasonable to assume it plays some role in the Zimbabwe malnutrition problems discussed above. The issue is discussed in the literature either in very general terms only or with reference to very small samples of clinical data. Most of what is said reaffirms the familiar observations that (a) disease often precipitates borderline cases into severe malutrition and malnutrition exacerbates the incidence and effects of disease, (b) gastroenteritis, measles, and upper respiratory diseases are among the most serious problems (as far as child nutrition is concerned), but parasitic diseases also may be widespread and debilitating, and (c) lack of adequate hygiene, sanitation, and clean water facilities reinforce the vicious circle of disease and malnutrition. Given the existing data, however, it is impossible to estimate the importance of infection in the Zimbabwean context. 2.72 There are hints that the problem is not paramount here. First, Zimbabwe's infant and child mortality rates, both of which reflect infection levels, compare relatively favorably to other sub-Saharan countries. The estimated infant mortality figure for Zimbabwe, based on the 1969 census, is 100 per thousand, which compares favorably to present estimated infant mortality rates of 145 for all of sub-Saharan Africa. Similarly, the one-to-four year old death rate in Zimbabwe is relatively low for sub-Saharan Africa, 12-15 per thousand compared to 25. Nutrition conditions, meanwhile, appear worse in Zimbabwe than these same African countries (see Table 2). This would suggest that the infection/disease environment in Zimbabwe is better than elsewhere and that, as a result, malnourished children do not succumb as commonly as elsewhere in Africa to infection. Second, although the water supply is uneven and in many instances bad, it still is better than in many other countries. Similarly, sanitation is more highly practiced. Third, one cannot help but be struck by the high premium placed on cleanliness and tidiness, even in the most impoverished circumstances in rural Zimbabwe. This is unusual in societies of this income level. All this suggests the incidence and impact of infection on nutrition status may not be as great as elsewhere. 2.73 There is no simple answer one can give about the cause of Zimbabwe's malnutrition. Thirty-five of the doctors surveyed at health facilities cited some form of poverty. Twenty-four responses related to ignorance, but this included ignorance of farming practices as well as ignorance of feeding practices. Drought and inadequate infrastructure (including underdeveloped water supply, underdeveloped transportation, underdevloped storage, lack of adequate extension) were next at 22, followed by population pressure, 10, social causes (family disruption), nine, and high incidence of disease/poor sanitation, six. Agritex staff surveyed cited poverty (shortage of food and income) followed by food habits as the main causes of malnutrition. 2.74 Even with data limitations certain conclusions at this stage can be drawn: -104- ANNEX 15 page 37 of 48 Despite being a substantial food surplus nation, Zimbabwe has extensive malnutrition. The problem probably is primarily a calorie rather than protein problem; for small children there is an added dimension of need for caloric density. The cause of the malnutrition is some mix of poverty, nutritional ignorance and family disruption and related social problems. Incomes of commercial farm workers and communal area farmers are inadequate to satisfy nutritional needs, even with increasing remittances. Mine workers are better off and incomes of urban employees appear to be sufficient. The shifts in diet accompanying modernization are not always nutritionally advantageous. The full trade- offs of the new-food-replacing-old are not known at present, but of particular concern is the loss of nutrients in highly refined mealie meal and the decline in consumption of sorghum, millets, groundnuts and fruit. Rural women understand nutrition concepts and needs better than they are given credit for. The major information gap relates to the number of feedings a day required for a small child on a primarily sadza diet. Alcoholism, family separations and other social problems play a role, particularly in cases of kwashiorkor and marasmus. Infection may not play as large a role in malnutrition in Zimbabwe as in most other countries. ANNEX 15 page 38 of 48 Part IIT., P:c>. rograms 3.01 Zimbabwe has several s: Sna. address the nutrition problem, the major categories o9 oasumer food subsidies, supplementary feeding schemiseo v1 u'ds, nutrition education and nutrition rehabilitation. A. Consum- -.".-c5 _^ebsidies 3.02 By far the Government:r3 nutrition program -- although not always perceived in that ligh '1o gYne consumer food subsidy. In 1981-82, the Government spent ap .8124 million or 2.8% of GDP, on combined producer and consuTe 'S a cost more than double the previous year. Table 6: Budgetary Food 1 81/82 (estimated) 16/ Milk _ 10.4 million Maitz'. 5.1 Beef 27.7 Soya be 1.0 Wheat 'o 8.5 Veget t ' ' 6.2 Maize 64.8 13.7 million 3.03 The portion of this att-i^'1-X Lo consumer subsidy varies by commodity and is difficult to pete n peclisely, but about $98 million of the total appears to be a dlr1e c--`;F, to consumers. Maize is a producer subsidy, but maize meal l o er subsidy. In the case of maize meal, the Government makes egh dl fference between the $86 per ton the miller is permitted to c Zl. "-' ml-e and the $137 price paid by the miller plus the millers macis tsosting $64.8 million in the last year. Nearly all of the $10.- > milk subsidy accrues to the consumer; the Government's subsyid ''.t *i- is about 20%. In the case of beef, about half of the $28 millOo '' goes to consumers, half to producer. The current gap bet-'ss - e price and selling price of beef is $.23 per kilogram. The c3-nz _e szubsidy on bread is about 44% or $.11 per loaf, leading to a $1i 1 for the year. In the case of vegetable oil, the subsidy esems -s.gy go to the oil expressers (suggesting they are either ent!mi n ient or extremely profitable). Consumers of veg_t_3.s.1 -1 S-piaar to be taxed slightly to help cover this. (For a mors Kine lysis of who benefits from subsidies see (63).) 16/ The edible oils subsidy is paid' oil expressors, the flour subsidy to the millers, the dairy subsidy >e the Dairy Marketing Board, the beef subsidy to the Cold Stcinge Cormission, and the wheat, maize and soya bean subsidies to the C.'- ^sg Board. In the budget these are charged either t S' of Agriculture or the Ministry of Trade and Commar,-7' clear reason for this division of specific commoStl -106- ANNEX 15 page 39 of 48 3.04 The Government had inherited subsidies from an era when producer prices largely had been set in accordance with the needs of commercial farmers. From 1964 to 1978, 35% of net commercial farm incomes were said to come from subsidies. Concern for stability in urban areas toward the end of the war led to the introduction of consumer food subsidies. At present, consumer food prices in Zimbabwe are among the lowest in Africa (116). 3.05 The major justification for blanket consumer subsidies presumably is that the real incomes of the poor will be increased by lowering the prices of staple foods. (The gains would be less than those for the rich in absolute terms, but greater relative to total income.) Relatedly the subsidies should increase food consumption of the poor, both absolutely and relatively more than the rich. 3.06 The question, then, is whether the benefit to the poor is taking place and, if so, if it is taking place in an economically efficient manner. Analysis of the available information suggests that at least on the surface there are some nutrition benefits to the poor resulting from the subsidy program but the benefits are modest relative to costs. First, other than maize meal, those living in rural areas do not benefit from the subsidy (except in the case of food remittances). All of the other subsidies accrue to the urban dwellers who constitute well under a quarter of the population. Moreover, there is a strong bias within the urban population. While maize meal, white bread, and milk subsidies have provided some benefit to the low-income urban population, it has been mainly the high-income urban households to whom the beef and milk subsidy largely accrue. (14) 3.07 There are strong differences on benefits to income groups, by product. With maize meal, for example, $.72 of every dollar goes to the low-income urban householder rather than the high-income households, but for beef, of every $1.00 of subsidy only $.36 goes to the low-income urban household. Milk benefits the low-income urban consumer even less. For each dollar of milk subsidy only $.23 goes to the low-income urban consumer and virtually none goes to the rural poor. (63) Table 7: Benefits in Urban Areas of Subsidies, 1976/77 % of Total % of Total Subsidy Subsidy Accruing to Accruing to Amount of Amount of High-Income Low-Income Subsidy to Avg. Subsidy to Avg. Urban Urban High-Income Low-Income Households Households Urban Households Urban Households Beef 64% 36% $19.32 $10.81 Milk 77% 23% 10.50 3.37 Maize Meal 26% 74% 1.87 5.30 White Bread 41% 59% 5.92 4.18 Source: (63) (167) (168) -107- ANNEX 15 page 40 of 48 3.08 Other inequities to the poor also may sometimes result from the subsidies. Because beef pricing policy results in such an artificially low price for beef, consumers substitute beef for other products which are close substitutes. Poultry and pig production by farmers in communal areas is undoubtedly being discouraged because of the competition with subsidized beef (63). Moreover, as noted earlier, the manner in which the maize meal subsidies are provided has led to a concentration of processing, so much so that over the last five years an estimated 2,000 rural millers have gone out of business as they could not compete with the heavily subsidized large millers. In summary, the main beneficiaries of producer subsidies are the large commercial farmers and the main beneficiaries of various consumer subsidies are generally the urban wage earners most of whom are not poor. The real poor are almost all in rural areas (14). 3.09 The current program is not an efficient means of reaching the poor. Both the Income/Prices and Agricultural Industries Commissions concluded that blanket subsidies are a haphazard and inefficient means of achieving any objective of equity. To some extent they are having the reverse effect (7) (116). At the same time it is important to recognize that there are large portions of the population in serious need of food and that more carefully targeted subsidy programs designed to reach them could have considerably greater nutritional impact than the current programs, even if held to a lesser cost. 3.10 At the moment there is no forum, as would be desirable, that objectively assesses all these issues. The nutrition consequences of food pricing policy have not received serious attention by Government, in contrast to, and sometimes in conflict with, the attention given to issues of concern to larger producers. B. Feeding Programs Emergency Food Programs 3.11 Rhodesia did not have a history of extensive child feeding programs, as existed elsewhere in the region. As things began to deteriorate in the late 1970s, however, the International Red Cross started a program directed to children in ten "protected villages" and two villages of Tonga. The ICRC claims that despite local shortages, particularly in the pre-harvest period, there had been a decrease or steady state of malnutrition in nine of 12 places where one-to-five year olds were fed, and in five of seven centers where six-to-nine year olds received food. The ICRC attributed this to the success of the feeding program (18). 3.12 The new Government's first experience in providing large-scale nutrition programs came shortly after the signing of the Lancaster House agreement. An estimated 1.4 million people, almost one-fifth of the total population, had been displaced by the war. Roughly half of these had been moved to 200 "protected villages," nearly 20% were refugees in neighboring countries and most of the remainder had left their homes to live with relatives or in squatter camps in towns and cities. Each of 235,000 families was given enough seed and fertilizer to sow half a hectare in time before the November rains. In areas where sufficient water already was available, 70,000 vegetable packs were distributed, ANNEX 15 page 41 of 48 each containing the requirezc-sff to reap one kilogram of vegetables per day beginniqgi °m, 7Ktek ' -,lanting, and extending over six months. 7/ Where animal s unavailable or insufficient, mechanical tiIl -'-ade available. The cost was something on the order of $13 3.13 In addition, 7,600 t=o :f D , e given out each month to 700,000 to 800,000 people at sa.-Qen 535 and 570 distribution points across the country at (-2d million. (In all, the refugee program cost about $60 milli$= e'= was received at the outset from external donors.) The was undertaken by the Government's Department of So'W -- and funded, at approximately $3 million per month, by the High Commission for Refugees (UNHCR). Wastage and theft , be low. Pre-School Age Feeding Progra 3.14 In addition, a Chil d.- ,-tary Feeding Program was launched to protect children if -z ar old who were at risk. At its peak, in May 1981, 100,C0 'e provided a diet made up of familiar staples prepared in - : a1 manner. Special attention was given to making the rati3a u The program was regarded as both a relief and educational 3 using locally-cultivable and affordable foods, the parents - L1hed children were to see the nutritional value of these fcs' n their children improve. It was hoped that this message, ene would encourage rural parents to grow and retain for . --,ing the foods promoted through this program, particularly g.. i - n e Cost per child per month was $1.07. 3.15 Overall direction C of the program was provided by a national working group ia <-1 , rescntatives of relevant ministries and national and 1 . i,tary organizations, under the umbrella direction of the Mu -'lth Provincial committees were organized by the PMOH and, at level, the administrative infrastructure developed duria 'n -w a used to organize the measuring of children, the es`. ",`.`,^-. of feeding points and the cooking. At the village level 3, i ay registration, preparation and feeding was performed by ',- w7 ,- of the children. 3.16 An evaluation of th .:,'5 i the program concluded that children attending the supplea`.- --le, la put on weight at twice the rate of better nourished childŽ.` a ildren attending 30 or more supplementary meals gained weiI "h i times the rate of the better nourished children (175). In S3;-i,--% data limitations, it is reasonable to conclude that there was a t- :. effect on nutrition status. 3.17 Moreover, the educatin'= e5-oLzi appears to have been considerable, this varying by a.^3vaty-nine percent of the mothers reported general or specific in their children's health and 17/ Included were 12 envelopcs s-A five tins of pesticides, 40 kg. of fertilizer, garden impli =:-`. aind instructions. -109- ANNEX 15 page 42 of 48 85% of the women said they would prepare the same foods for the children at home. 3.18 In short, the program organizers learned from mistakes in other countries the importance of providing foods appropriate to local circumstances and nutritional needs. They also involved the communities themselves in the program (e.g., 85% of the mothers participated), and used the program as an educational device. A large number of external agencies participated in the program, the major of which were OXFAM, Save the Children Fund, and the Swedish International Development Authority (SIDA). 3.19 With the 1982 drought, some continuation is likely of the Children's Supplementary Feeding Program, which since September 1981 has been taken over by MOH and funded by SIDA. In addition, a more permanent $1.1 million per year pre-school nutrition program was under preparation by the Ministry of Community Development and Women's Affairs. Over 1,000 preschool centers already exist, providing some form of organized care and feeding. The expanded program would include feeding, early detection and referral service and related nutrition education. The aim is to reduce by half malnutrition in the three-to-six age group in three years. As funding had not yet been agreed with the Ministry of Economic Planning and Development at the time of this writing, further details were not available. 3.20 Another proposed program being considered by MOH is the transformation of the emergency feeding points into play centers and production units, where under-fives from the surrounding area would come to be looked after by women of the community. At these play centers, health and nutrition education talks and demonstrations would be given by Ministry of Health personnel and the centers would become production units at which nutritious foods, particularly groundnuts, could be grown by the community for feeding of their children. Production and distribution of the food would be communal and shared equitably among the producers.18/ School Feeding 3.21 School feeding programs have not been common in Zimbabwe, although in some areas a mid-morning drink (usually Nutresco Mahewu) is provided at approximately $.01 per cup. The only evaluation of a school feeding program found in the country, this between 1973 and 1976 in Que Que TTL, concluded "there can be little doubt that the school feeding scheme has had a significant influence in physical development." This study of 1,004 students in Siwundula, St. Barnabas, and Gunde found, after attempting to control for weather and successful agricultural seasons, that 73% of the children participating in the feeding program 18/ The aim is to have 100 half-hectare plots in each province. The supplementary food production scheme has been pilot tested (support came from both OXFAM and SIDA), but the 1982 drought has had an inhibiting effect on progress. -110- ANNEX 15 page 43 of 48 grew faster than would be expected by their past performance, and that there had been an overall 12% improvement for children participating in the school feeding scheme. A related study showed that the number of children who benefit from the scheme depends on the severity of malnutrition before the feeding. In schools where the nutrition problem was not as severe as others (i.e., where no less than 80% of the children were above the tenth centile), significant improvements in the numbers benefiting from the scheme did not result (139). Food Aid 3.22 Being a food surplus country in most years, Rhodesia/Zimbabwe had not generally been the recipient of food aid as other countries in the region. An exception was 1980 when 13,000 tons of food were brought in by the World Food Program (WFP). This was sold for livestock feed; the $1.5 million proceeds were used to help finance the relief feeding program. The presence of the World Food Program office in Zimbabwe largely is to purchase food for distribution to neighboring countries. In the 10 months up to April 1982, for example, the World Food Program had purchased 100,000 tons of grain worth $12 million for distribution in 11 countries -- Mozambique, Tanzania and Angola being the largest recipients. 3.23 Relatedly, currently under consideration is an ambitious five-year program put to EEC for 1,500 tons of skim milk powder, worth on the order of $100 million. The milk would be sold to the Dairy Marketing Board at world market prices and the proceeds used to build up the dairy herd that was hard hit by the war and again by the drought. The objective would be that, by the end of the five-year period, Zimbabwe would be self-sufficient in milk. C. Nutrition Education 3.24 Apart from the nutrition education associated with pre-school feeding programs, nutrition education in Zimbabwe is undertaken by the Ministry of Education and Culture, the Home Extension Service of the Ministry of Community Development and Women's Affairs, the Ministry of Health, the city Health Departments and a plethora of non-government organizations, both domestic and expatriate. 3.25 Nutrition education plays a prominent role in the Ministry of Education's imaginative science and social studies programs, taught at varying levels of sophistication at all grades in 4,500 schools (173). In addition to classroom presentations, the Ministry plans to mount a program of school gardens (to be piloted in 100 schools) that would include pre-packaged agricultural kits featuring seeds, implements and teachers' handbooks. The main constraint for gardens is water and, in some urban cases, availability of land. 3.26 The Home Extension Service has about 450 demonstrators who receive a three-month training course, about one-and-a-half weeks of which is devoted to nutrition. These demonstrators develop and take advantage of a variety of field opportunities to communicate messages and -111- ANNEX 15 page 44 of 48 liaise with the Ministries of Health and Agriculture in the dissemination of nutrition-related education (mostly to women's clubs). A focus of the home extension service is the impressive savings club movement which provides a basis of community participation in a variety of subjects, nutrition being among the more important. An estimated 50,000 families, represented mainly by the women in communal areas, are now participating in this rapidly growing movement. 3.27 The Ministry of Health has been responsible for publishing nutrition education posters and currently is preparing a film. It has also published 29,000 copies of a breast feeding booklet, one of the more ambitious national responses to the WHO/UNESCO infant feeding code. 3.28 Much of the nutrition education from the Ministry of Health is designed to come from the village health worker, who has been trained in how to use the road-to-health card and to encourage breast feeding. The village health worker also receives some training from the agriculture extension service, particularly on how to plant gardens, and Is encouraged to have a garden as a community model. One-third of the health facilities surveyed by the mission said they were involved in gardens. Aside from its nutrition value, vegetable gardening in many areas is the most common income-generating activity for women (94). 3.29 Recently assigned provincial nutrition officers hope to coordinate the nutrition work already going on by the nutrition promoters of other organizations, give lectures at training centers, and coordinate work related to the supplementary feeding programs. Dieticians, working out of the Ministry of Health, deal mainly with hospitals. 3.30 The city Health Departments also conduct nutrition education and, in some cases, feeding sessions. In 1980, for example, 361 well-baby clinics were conducted in Harare, with an attendance of 58,000 people. 3.31 The Voluntary Organizations in Community Enterprise (VOICE), formerly the National Council for Social Service, works with women's clubs in developing courses and training trainers. They report that in the past decade they have trained 3,000 women who, in turn, affect 50,000 children in pre-school groups. Commonly, children are fed mahewu for which parents are charged about $0.02 a day. 3.32 A substantial nutrition education program has been mounted by Silvera House, a center "which trains trainers and development promoters to combat hunger, malnutrition, oppression and injustice" (126). Since the nutrition program was started in 1978 by Ms. Sabina Mugabe, some 30,000 people have attended 300 workshops. The training includes cooking classes with a nutrition bent, poultry raising (in 1981, 48,000 chicks were delivered to 167 groups in nine areas), cooperative gardening (there are now 133 groups involving 6,000 women) and play centers prepared by the community, with a plot of land to raise groundnuts, chickens and rabbits. The 24 women trained in 1981 increases the total of Silvera House promoters to 54. No additional training has been provided this year due to funding problems. The Government supports this NGO, as do seven external agencies. -112- ANNEX 15 page 45 of 48 3.33 Zimbabwe's Freedom from Hunger Campaign, now in its 18th year, considers nutrition education the most important aspect of its work and makes wide distribution of booklets, pamphlets and posters. Twenty-nine nutrition demonstrators who assist nurses at well-baby clinics are employed from profits from the sale of high protein food through the clinics. In addition, the Freedom from Hunger Campaign provides $100,000 a year in seeds for vegetable gardens every year and assists in the fencing of gardens. It also has helped in the building of 10 nutrition centers for rehabilitation. These include instruction in nutrition and hygiene, as well as gardening. 3.34 The program of UNICEF, now the most active of the U.N. agencies in nutrition in Zimbabwe, includes a heavy emphasis on nutrition education. In 1982, the line item for nutrition in UNICEF's budget was $95,000. 3.35 Other agencies that have been involved in nutrition education, feeding or other nutrition-related work are Christian Care, Save the Children, OXFAM, Salvation Army, the Quaker Protein-for-the-People Program, Red Cross, the Mennonite Central Committee, Medicins sans Frontiers, Bread for the World, and the Swedish, British, Australian and Dutch governments as well as other countries through the EEC and the World Food Program. 3.36 In sum, substantial nutrition education has taken place and is taking place in Zimbabwe and there are indications that the education efforts have been successful in what the messages were trying to achieve (175). Unfortunately, the messages often were different and sometimes contradictory between agencies and the actions proposed often inappropriate for the Zimbabwean circumstances. Those mothers participating in the Children's Supplementary Feeding Program, for example, when asked whether they thought the meal made a balanced diet, said there should be different foods, in addition. Most frequently mentioned were milk, eggs and meat (by contrast, groundnuts and oil were mentioned with one-third the frequency) (175). This, in part, reflects the thrust of nutrition education provided over the years by some of the demonstrators. A Freedom from Hunger campaign poster seen commonly in health facilities in the country portrays milk, meat, eggs and commercial milk food products (Nespray and Nestle condensed milk) as important foods for good nutrition. Home extensionists interviewed in April 1982 in Manyika said they had been trained that children "must have milk" and they, in turn, were encouraging low-income mothers to purchase Nespray. A large number of health workers are either ignorant about the bottle feeding dangers or are uncertain about it, according to a 1981 survey (174). Doctors and clinics were cited by 47% bottle feeders as the sources of advice on artificial feeding measures (27).A January 1981 report from St. Paul's mission Murewa on the mobile clinic work said "... Nutresco, Mahewu, skimmed milk powder and Pronutro are necessary to keep children well fed. Milk and Pronutro are necessary for underweight babies ... But we do not always manage to get these supplies (121)." In May 1982, primary school teacher trainees in Masvingo who were asked to prepare nutrition posters all pictured affluent diets -- red meat, eggs, -113- ANNEX 15 page 46 of 48 milk, etc. Interviews with school students suggest that there also is a concentration on foods of the affluent in the school curriculum. Changes are needed. 3.37 Similarly, additional attention may be merited in the use of "road-to-health" cards as an educational tool, which is one of its major purposes. In a 1982 evaluation at a clinic in a stable community in Harare, mothers generally did not understand the purpose of the card; rather, it was viewed as a tool for health workers. Little was communicated to the mothers during weighing, even in cases of nutrition risk. The reasons: the pressure of numbers that needed to be given attention and the orderlies involved in the weighing may not have had the necessary education themselves. When messages were communicated to the mothers, little was said about energy-rich foods and, in some cases, questionable dietary practices (e.g., the promotion of commercial infant formula and commercially processed infant foods) were being advocated. None of the mothers of children suffering from second or third degree malnutrition was given any advice of what to do (78). A similar look at a Borrowdale clinic, a peri-urban and farming community, found that in only eight of 30 cases was anything said to the mother after the child was weighed (78). As education is a main point of the weighing and the card, clearly the message is not getting through. 3.38 There is need for an understanding of what foods are appropriate (some earlier work was done on this but received limited exposure) (139) and then a standardization and coordination of messages would seem to deserve a high order of attention. D. Nutrition Rehabilitation 3.39 Traditionally, the most common form of care for severe malnutrition was through hospitals and, although data are not available, this probably continues to be the case. Of 26 health facilities responding to a query, 23 had nutrition rehabilitation, three of them with over 100 patients a month. This is costly and not always effective. In 1980, 41 cases of severe malnutrition were followed up from Bindura General Hospital. Sixteen died in the hospital and a further four were dead on follow-up. A further case was ill again in the hospital. Of the remaining 15 children that could be located, eight were severely undernourished (74). 3.40 As in other countries, Zimbabwe has taken the position that it is both less costly and more useful to rehabilitate severely malnourished children in so-called Nutrition Centers or, as sometimes called in Zimbabwe, Nutrition Villages. The idea is that mothers would help in the care and preparation of foods for the malnourished children and learn in the process, thus reducing future risk. Certain of the Villages also are to be used as training centers for women running creches (121). Nutrition Villages currently constitute a sizeable portion of the Ministry of Health's expenditure for nutrition. (In 1982, $160,000 was approved by the Government for the establishment of new Nutrition Villages.) However, there is limited data to demonstrate the -114- ANNEX 15 page 47 of 48 cost-effectiveness of this approach. Only one substantial follow-up study of such care was identified. An analysis of the Nutrition Rehabilitation Center concept in 1977 by St. Theresa's Hospital found in Umvuma that 11% of the children who had gone through the program had died and 20% were still severely malnourished. (There was no estimate of how many would have died without the care.) The report concluded that mothers could relate to everything they had been told in lectures with posters, "but they did nothave gardens because they did not have water; they did not have chickens because they were too expensive and rabbits because they did not have water to give them." Among the reasons cited by mothers who were readmitted to the Nutrition Center were that the family had no vegetables or groundnuts, the migrant husband was not sending money home, the baby had been taken off the breast because of pregnancy, medical reasons, the mother was a mental case or an alcoholic, the child was left behind when the mother went to town to be with her husband, and genuine poverty. The conclusion of the study was "we could not encourage the establishing of Nutrition Rehabilitation Centers on a large scale as we feel that it is just another institution adjacent to a medical center. We feel that the money could be much more effectively used training village health workers on how to prevent malnutrition at the village level" (149-150).19/ 3.41 In short, Nutrition Centers/Villages do provide a less costly means than hospitals of rehabilitating malnutrition. The extent to which the educational/preventive dimension of the program is effective depends largely on the cause of the nutrition problem. In those instances where nutritional ignorance is the main cause and resources to improve the condition are otherwise at the mother's disposal, the long-run value of the Nutrition Village can be considerable. By contrast, when the constraint is basic resources or a severe social problem, it is unlikely that the Nutrition Village can do more than solve the immediate problem. There is an unfortunate perception among some in Zimbabwe that by devoting resources to Nutrition Villages, as is now being done, the problem of malnutrition is being looked after. Even under a much more ambitious program than now exists, the coverage of these Nutrition Villages will be modest. At any given time generally fewer than 10 children are treated in a center. At the Nutrition Village at St. Paul's in Murewa, 151 children passed through in 1981, staying an average of 13 19/ Interviews conducted with mothers of Nutrition Village patients in Nyadiri in August 1981 confirmed the dilemma: "My child has kwashiorkor because I have nothing to give my children. This Nutrition Village is helping us very much but I am sorry I won't find milk, eggs, meat, and peanut butter when I go home, so it's going to be the same...I have a field but I have no cattle or a plow so I can't do anything to earn money." In another interview: "I have learned many new things here. I didn't know how milk was boiled and I didn't know that we can put cooking cooking oil or peanut butter in porridge. But we still have a question that we won't find these foods at home, so how could we manage to follow these new helping methods." -115- ANNEX 15 page 48 of 48 days each for an average of five children in the Village at any one time. The malnutrition problem, of course, is much broader and more pervasive. E. Food Technology 3.42 Most of the food science and food technology capacity in the country resides with the private food industry. A food science course is now being provided in the Bio-chemistry Department at the University of Zimbabwe, in which more attention is being given to food technology as it relates to traditional foods, instead of Western foods which largely occupy the food companies. Attention is being addressed to the problem of food losses through waste, pests and poor processing and distribution. Zimbabwe is the headquarters of the SADCC Food Coordinating Secretariat and among the projects being supported under this program by IDRC (Canada) is a sorghum milling project, being conducted with the assistance of Silvera House. 3.43 A new Food and Nutrition Association of Zimbabwe is getting started with 80 members representing the food industry, the medical and academic communities and government and international organizations. The purposes are to promote nutrition education, to provide a forum for identification of problems and exchange of information, to promote ethical practices and to promote cooperation in scientific study of nutrition-related areas. 3.44 In sum, a considerable number of nutrition-related actions are now being undertaken in Zimbabwe both by Government and non-government agencies. The lack of a policy context, and of coordination, however, have limited the impact of these activities. The need for coordination is most evident in nutrition education, where perhaps a dozen programs promote different and sometimes conflicting messages. The current heavy emphasis on Nutrition Villages may, at least in part, be misdirected. Feeding programs appear to have been successful, having learned from mistakes of other countries. The government program with potentially the greatest impact on nutrition -- consumer food subsidies -- is not adequately geared to the needs of the truly malnourished. There is currently no effective focal point in government for formulating and pressing support for policy proposals that take account of the critical linkages between production measures on the one hand and the complex of consumption issues on the other. Solving this problem is a prerequisite for a rational policy to deal with malnutrition. -116- ATTACHMENT TO ANNEX 15 Page 1 of 14 BIBLIOGRAPHY 1. Affleck, H. "Iodine Deficiency in Southern Rhodesia," Rhodesia Agricultural Journal, Vol. 55, No. 1, January-February 1958. 2. Allaart, L. M. E. "Nutrition Education in Rhodesia," mimeo, undated (circa 1979). 3. American University Area Handbook for Southern Rhodesia, Washington, D. C., 1975. 4. Axton, J. H. M. "Analysis of Medical Paediatric Admissions, Harare Hospital, 1975", The Central African Journal of Medicine, Vol. 39, No. 9, September 1977. 5. ----- "Measles and the State of Nutrition," South Africa Mediese Tydskirf, January 1979. 6. Berg, E. "Alternative Statrategies for Zimbabwe's Growth," Center for Research on Economic Development, University of Michigan, 1980. 7. Blackie, Malcolm Paper prepared for Commission of Inquiry into the Agricultural Industry, under the chairmanship of Prof. C. L. Charunduka, 1982 (in press). 8. Bourdillon, M. F. C. "Korekore Labour Migrants," Paper for the Association of Sociologists in Southern Africa Conference, Lesotho, 1973. 9. Buchanan, W. M. N. Krasner and A. C. Wicks, "Body Iron Distribution and Ascorbic Acid Status," Central African Journal of Medicine, Vol. 22, No. 11, November 1976. 10. -- "Iron Deficiency Anemia in Rhodesian Africans," The Central African Journal of Medicine, Vol. 14, No. 1, January 1968. 11. Bulawayo, City of Annual Report of the Medical Officer of Health for the Year Ended June 30, 1981, October 26, 1981. 12. Brown, Kent Survey data of Mount Darwin, medical student report for Department of Pediatrics and Child Health, University of Zimbabwe, April 1982. 13. Cairns Holdings Ltd. Annual Report, 1981. 14. Callear, Diana "Food Subsidies in Zimbabwe," St. Anthony's College, Oxford University, undated paper (circa 1981). -117- ATTACHMENT TO ANNEX 15 Page 2 of 14 15. "Special Focus - Resettlement: Zimbabwe's First Step," Food Policy, November 1981. 16. ----- Wedza data, work in progress. 17. Candy, E. J. and M. G. T. Pawandiwa, "Vitamin A Levels in Rural and Urban African Preschool Children During Summer Months in Rhodesia" (source and date unknown). 18. Carlstrom, Anders "Nutritional Survey in Rhodesia - September 1979-January 1980," Comite International de la Croix-Rouge, Geneva, February 26, 1980. 19. Carr, W. R. "Observations on the Nutritive Value of Tradi- tionally Ground Cereals in Southern Rhodesia," British Journal of Nutrition, Volume 15, 1961. 20. Carver, Richard and David Sanders, "Zimbabwe's Biased Health Service," New African, Salisbury, August 1980. Also, "Malnutrition in Rhodesia," 1979. 21. Chale, Freda U. FAO Report, Duty Travel to Zimbabwe, Kenya and Tanzania, January 13-February 4, 1981. 22. Chikanga, I. C., D. Paxton, R. Loewenson, and R. Laing, "The Health Status of Farmworker Communities in Zimbabwe," The Central African Journal of Medicine, Vol. 27, No. 5, May 1981. 23. Clarke, D. G. Agricultural and Plantation Workers in Rhodesia; A Report on Conditions of Labour and Subsistence, Mambo Press, Occasional Papers, Socio-Economic Series No. 6, 1976. 24. Cleave, John H. African Farmers: Labor Use in the Development of Smallholder Agriculture, Special Studies in International Economics and Development, Praeger, New York, 1974. 25. Colborne, L. A. "Indigenous Foods, Their Role in Combatting Malnutrition in Rhodesia," Therapeutic Dietetics, Salisbury, 1975. 26. Collinson, M. and K. Billings, "A Diagnostic Survey for Adaptive Research Planning in the South of Chibi District, Victoria Province," 1982 (work in progress). 27. Cooper & Lybrand Survey on Child Feeding in East and Central Associates Africa, Tanzania, December 10, 1981. -118- ATTACHMENT TO ANNEX 15 -118- Page 3 of 14 28. Cross, E. G. "The Tribal Trust Lands in Transition," The Rhodesian Science News, Vol. 11, August 1977. 29. ----- "The Tribal Trust Lands in Transition: The National Implications," paper presented to the Natural Resources Board Symposium, Salisbury, June 1977. 30. ---- "Zimbabwe: Strategies for Economic Development. Agricultural Development and Equity," January 1980. 31. Cubitt, Verity S. 1979 Supplement to the Urban Poverty Datum Line in Rhodesia: A Study of the Minimum Consumption Needs of Families (1974), Faculty of Social Studies, University of Rhodesia, Salisbury, 1979. 32. ---- and Roger C. Riddell, The Urban Poverty Datum Line in Rhodesia: A Study of the Minimum Consumption Needs of Families, Faculty of Social Studies, University of Rhodesia, Salisbury, June, 1974. 33. Danckwerts, J. P. A Socio-Economic Study of Veldt Management in the Tribal Areas of the Victoria Province, 1974, mimeo. 34. de Swardt, L. Socio-agrinomic Survey of Gukwe (work in progress). 35. Decker, J. M. K. and E. P. MacManus, "Complications of Measles in Rural African Children," Central African Journal of Medicine, Vol. 14, No. 12, 1968. 36. Dent, R. I. B. Lewis, J. D. Nelms, and A. E. Strover, "A Study of Thyroid Disease in the Chikwaka Region of Rhodesia," The Central African Journal of Medicine, Vol. 14, No. 4, April 1968. 37. Doran, Martin Gwanda Field Survey, May-June 1982. 38. Economist Zimbabwe's First Five Years: Economic Prospects Intelligence Unit, Following Independence, EIU Special Report #11, Ltd. London, November 1981. 39. DuPlessis, J. P. W. Whittman, et. al., "Effect of Enrichment of Maize Meal with Nicotinic Acid and Riboflavin Upon the Vitamin and Protein Nutritional Status of Young School-going and Pre-school Children," South African Medical Journal, Vol. 48, No. 39, August 1974 and "The Clinical and Biochemical Effects of Riboflavin and Nicotinamid Supplementation Upon Bantu School Children Using Maize Meal as Carrier Medium," South African Medical Journal, Vol. 45, No. 19, May 1971. -119- ATTACHMENT TO ANNEX 15 Page 4 of 14 40. Family Health Vol. VII, A Review of Health Care in Rhodesia: Care Inc. Issues, Analyses and Recommendations, January 30, 1979 and A.O. Pugh and S.R. Chademana, "Aspects of Rural Health: Part II-Better Water Supplies," Central African Journal of Medicine, Vol. 24, No. 2, 1978 41. Food and Agricul- Zimbabwe Food and Agriculture Sector: tural Organization Country Development Brief, Technical Cooperation Program, JCP/ZIM/6701, Rome, 1980 and Food Balance Sheets and Per Caput Food Supplies, Rome, 1980. For discussion of dietary fats and oils, see Dietary Fats and Oils in Human Nutrition, FAO Food and Nutrition Paper No. 3, Rome, 1977. 42. Food and Nutrition Draft Constitution and Minutes of First Annual Association General Meeting, March 6, 1982. 43. Freedom from Hunger Chairman's Report, 16th Annual Conference, Salisbury, September 19, 1980. 44. ----- Chairman's Report, October 1981. 45. ------ Food For Your Family, Foreword, 1975. 46. ----- Food For Your Family, Nutrition Council, Salisbury, Zimbabwe, 1974. 47. Froude, M. The Mamvura Area in Bikita Tribal Trust Land, Victoria Province, unpublished, undated report (circa 1970). 48. Fuglesang, Andreas Applied Communication in Developing Countries, Dag Hammarskjold Foundation, Uppsala, Sweden, 1973; About Understanding, Dag Hammarskjold Foundation, Uppsala, Sweden, 1982; and Communication with Illiterates, The National Food and Nutrition Commission, Lusaka, Zambia, 1969. 49. Garbett, G. K. "Circulatory Migration in Rhodesia: Towards a Decision Model," in D. Parkin (ed), Town and Country in Central and Eastern Africa, IAI, Oxford, 1975. 50. Gavaghan, Terence "Zimbabwe Problems and Prospects," paper presented to the National Committee for the Study of International Affairs, Royal Irish Academy, June 19, 1980. 51. Gelfand, Michael Diet and Tradition in an African Culture, E. & S. Livingstone, Edinburgh and London, 1971. -120- ATTACHMENT TO ANNEX 15 Page 5 of 14 52. ---- Ukama, Reflections on Shona and Western Cultures in Zimbabwe, Mambo Press, 1981. 53. Gilmurray, John Roger Riddell, and David Sanders, The Struggle for Health: From Rhodesia to Zimbabwe, Catholic Institute for International Relations, London, 1979. 54. Grinham, S. Information on survey of dependents of farm workers/Wedza, unpublished. 55. Gumprich, D. E. F. Notes for a Course on Shona Customs, Salisbury,G.P.S. 18448-B, undated. 56. Hampson, Joe "Health In Zimbabwe," The Tablet, May 9, 1982. 57. Hay, June and C. Stolhofer, Food and Nutrition Situation, March/April 1982, Mberengwa District. 58. Holton, C. E. "Vitamin Deficiencies in Zimbabwe, with Special Reference to Vitamin A and Niacin," Therapeutic Dietetics, Salisbury, 1979. 59. Howden, R. H. G. Food Production in Communal Areas, Report of Department of Agricultural Development, September 3, 1981. 60. Hughes, A. J. B. Development in Rhodesian Tribal Areas: An Overview, Tribal Areas of Rhodesia Research Foundation, 1974 also see "Experimental Socio-economic Survey in Gutu Tribal Trust Land, 1963," CONEX, Salisbury, 1965. 61. Hunt, Sue Report of Nutritional Surveys in the Mtoko Area, April 7, 1980. 62. Jackson, Jeremy Gutu survey data, May 1982. 63. Jansen, Doris J. "Agricultural Prices and Subsidies in Zimbabwe: Benefits, Costs and Tradeoffs," draft report, April 1982. 64. Kachingwe, Ernest W. Social Welfare Services for Urban Africans in Zimbabwe: The Role of Social Work Education in the Distribution of Services, The University of Iowa, 1979. 65. Kay, George Distribution and Density of Population in Rhodesia, Department of Geography, University of Hull, Series No. 12, 1972. ATTACHMENT TO ANNEX 15 Page 6 of 14 66. -- Rhodesia, Human Geography, University of London Press, 1970, London. 67. 'Zimbabwe's Independence: Geographical Problems and Prospects," The Geographical Journal, Vol. 147, No. 2, July, 1981. 68. Kendall, A. C. "Rickets in the Tropics ard Sub-tropics," Central African Journal of Medicine, Vol. 18, No. 3, March 1972. 69. Kennan, P. B. "Extension Services to Agriculture," Paper presented to the International Economic Resource Conference on Zimbabwe, September 1980. 70. "Reasons Why Peasants Do Not Adopt Innovations," Zimbabwe Agriculture Journal, Vol.77, No. 4, 1980. 71. King, Maurice et. al., Nutrition for Developing Countries: With Special Reference to the Maize, Cassava and Millet Areas of Africa, Oxford University Press, Nairobi, 1972. 72. Kinsey, B. H. "Resettlement and Land Policy in Zimbabwe, Growth Equity, Trade-Offs and National Development," April, 1982. 73. Kwofie, Kwame FAO Report, Duty Travel to Zimbabwe, March 3-6, 1981. 74. Loewenson, Rene "An Evaluation of Hospital Management of Undernutrition" (work in progress). 75. ---- "The Health Status of Farmworker Comunities in Zimbabwe," Paper presented at Zimbabwe Economic Society Conference on Rural Development, June 6-10, 1981. 76. ---- Results of a Nutrition Survey at a Chiweshi Farm, June 25, 1981, unpublished. 77. ------ Results of the Gutu Agro-Economic/Nutrition Survey (in conjunction with Jeremy Jackson), University of Zimbabwe, April 1982. 78. ---- and K. Hakutangwi, 'Road to Health Card' Check; Results of Pilot Survey, March 1982. 79. ----- and G. Madlela, Results of the Health Status Surveys Carried Out in the Commercial Farming Areas of Matabeleland University of Zimbabwe, July/August 1981, unpublished. ATTACHMENT TO ANNEX 15 -122- Page 7 of 14 80. -- and A. Muuigai, Results of a Nutrition Survey Carried out in Wedza to Supplement a Food Consumption, Socio- Economic Survey (by Diana Callear), University of Zimbabwe, May 1982. 81. Dr. Sang and T. Z. Sithole, Results of the Health Status Surveys Carried Out in the Commercial Farming of Mashonaland, Raffingora District, August 1981. 82. ---- M. Tsapotsa and R. Laing, Results of a Nutrition Survey Carried out in the Bindura Area Communal (Peasant Farming Areas) in Madziwa and Masembura (work in progress). 83. ------ J. Zanza, D. Paxton, R. Laing, Results of an Urban Nutrition Survey Carried out in the Bindura Urban Area, University of Zimbabwe (work in progress). 84. ----- S. Zengeya, A. Sena, J. Zanza and R. Laing, Results of a Survey into the Health Status of Mineworkers, University of Zimbabwe Medical School, December/January 1981/82 (in press). 85. Loxton, R. F. and Associates, Report on the Survey of the Natural Resources and Socio-Economic Circumstances of Gutu District, 1974. 86. Lues, Shane Mark Thorogood, Sam Kusema, and Richard Dogherty, Rural Attachment: Reports on Students' Projects, Department of Paediatrics and Child Health, University of Zimbabwe, September/October 1981. 87. MacManus, E. P. "Xerophthalmia in Matabeleland," The Central African Journal of Medicine, Vol. 14, No. 8, August 1968. 88. Madhovi, Penias B. "Food Handling in Shona Villages of Zimbabwe," Ecology of Food and Nutrition, Vol. 11, 1981. 89. ---- "Nutritional Needs of Rural Population Studied," The Herald, Salisbury, October 16, 1981. 90. Martin, David and Phyllis Johnson, The Struggle for Zimbabwe, Zimbabwe Publishing House, Salisbury, 1981. 91. Mathe, S. and R. T. Mossop, Luveve Survey, undated. 92. May, Jacques M. Drinking in Harare, Institute for Social Research, Department of Sociology, University of Rhodesia, 1973. ATTACHMENT TO ANNEX 15 -123- Page 8 of 14 93. ------ and Donna L. McClellan, The Ecology of Malnutrition in Eastern Africa and Four Countries of Western Africa, Studies in Medical Geography, Vol. 9, Hafner Publishing Company, New York, 1970. 94. McCalman, Kate We Carry a Heavy Load, Report of Survey by Zimbabwe Women's Bureau, December 1981. 95. Meaders, Robert Report to WHO, July 1981. 96. Miller-Cranko, A., M. Mushambi, G. Pridgeon, S. McQuade, I. Ternouth and B. Waters, A Mini Nutrition Survey of Small Areas of Zimbabwe, April 1982. 97. Miller-Cranko, John and Michael Gelfand, "A Clinical Description of the Main Nutritional Disorders Encountered in the Salisbury Native Hospital in a Series of 54 Consecutive Cases Studied in 1954," The Central African Journal of Medicine, Vol. 1, No. 1, January 1958. 98. Mossop, R. T. Kadoma Survey, Quest for Health, undated. 99. Moyo, E. E. "A Preliminary Application of the FAO Balance Sheet Methodology to the Zimbabwe Food Situation," Economics and Markets Branch, Ministry of Agriculture, undated. 100. Muchena, 0. N. "Women and Work, Planning Rural Development with Women in Mind," paper presented to Zimbabwe Economic Society Seminar, University of Zimbabwe, June 1981. 101. Muir, K. Crop Production Statistics, May 1981. 102. Mushunga, Nyasha Food Patterns and Nutrition Problems in Southern Africa, M.Sc. thesis, California State University, Fresno, May 1978. 103. Mutsemi, M. V. The Planning Implications of Alternative Land Tenure System for Rural Development in Southern Rhodesia, dissertation for M.A. Degree, University of Nottingham, 1977. 104. Nutrition Council Annual Reports for 1953 and 1954, Department of Health, December 28, 1953 and December 31, 1954. 105. ----- Some Facts and Figures of Bantu Nutrition Southern Africa, undated (circa 1955). 106. Nyoni, M. J. M. Some Economic Aspects of Rural-Urban Migration from Rhodesia's Tribal Trust Lands, M.Sc. thesis in agricultural economics, Wye College, University of London, May 1979. -124- ~ATTACEMN TO AN~NEX 15 -124- Page 9 of 14 107. Nziramasansa, M. "Zimbabwe: Anticipation of Economic and Humanitarian Needs: The Agricultural Sector in Rhodesia," Consultant Occasional Paper, No. 7, African-American Scholars Council, 1977. 108. OXFAM British Aid to Zimbabwe, January 30, 1981. 109. Data from periodic field reports of OXFAM doctors, 1980-1981. 110. ------ Report of a Nutrition Survey Conducted in the Rural Areas of Zimbabwe in May/June 1980. 111. Owen, F. Women's Health Survey, May 1982. 112. Patel, Diana Data on urban remittances, 1982. 113. Phimister, I. R. "African Labour Conditions and Health in the Southern Rhodesian Mining Industry, 1898-1953," The Central African Journal of Medicine, Vol. 22, No. 4, April 1976. 114. Reiley, M. J. as quoted in "Protein and Energy Requirements and the Effects of Their Deficiencies," The Rhodesian Science News, Vol. 9, No. 6, June 1975. 115. Riddell, Roger C. Alternatives to Poverty: From Rhodesia to Zimbabwe-No. 1 Catholic Institute for International Relations, London, 1979. 116. - ---- Report of the Commission of Inquiry into Incomes, Prices and Conditions of Service, under the Chairmanship of Roger C. Riddell, June, 1981. 117. ----- "Zimbabwe: Problems for the Economy," ODI Review, No. 1, 1979. 118. Robertson, F. Paper on Rickets, South African Medical Journal, Vol. 35, 1969. 119. Rugg, I., et. al., School Health Survey in Musami, Muwera and Mtchabezi, 1982, mimeo. 120. Rukuni, Mandi Data on Murewa, 1982. 121. St. Paul's Report(s) on St. Paul's Hospital, Musami, Mrewa, Hospital January 2, 1981 and March 1, 1982. 122. Salisbury, City of Annual Report of City Health Department, Salisbury, 1980. 123. Sanders, David "Health, Nutrition, Food and Its Use As a Weapon in Zimbabwe and Southern Africa," 1980. -125- ATTACHMENT TO ANNEX 15 Page 10 of 14 124. Saravaza, V. S. Mack C. McCoy, B. S. Dando, F. D. Jangano, "Unified National Health Information System," The Central African Journal of Medicine, Vol. 28, No. 2, February 1981. 125. Save the Children Program Potential in Zimbabwe (Team Visit to Foundation (U.S.) Zimbabwe, June 27-July 11, 1981), August 1981. 126. Silveira House Annual Report, 1981. 127. ----- Nutrition and Child Care Project, Syllabus for Promoters and Coordinators. 128. --- Nutrition Department Report, January 1982. 129. ----- Wedza Nutrition, Child Care and Development, February and March Report, 1982. 130. Stewart, A. M. and B. P. B. Ellis, "Anthropometry in the Assessment of the Current Nutritional Status of School Children," The Central African Journal of Medicine, Vol. 21, No. 3, March, 1975. 131. TAICH Food Production and Agriculture. Development Assistance Abroad, American Council of Voluntary Agencies for Foreign Service, Inc., New York, April 1981 and Development Assistance Programs of U.S. Non-profit Organizations, Zimbabwe, February 1981. 132. Thiesen, R. J. Abstracts from Research Papers, 1964-1976, March 18, 1977. 133. ----- Agro-Economic Factors Relating to the Health and Academic Achievement of Rural School Children, published by the Tribal Areas of Rhodesia Research Foundation, Salisbury, March 1975. 134. ---- Classification of Stressed Families in the Chiwundura T. T. L; Families with Children, February 4, 1978. 135. ----- Livestock in Tribal Communities, December 16, 1977. 136. ----- Motivation and Extension in Tribal Communities, Institute of Social Research, University of Rhodesia, December 1978. -126- ~~~ATTACHMENT TO ANNEX 15 -126- Page 11 of 14 137. The Need for A New Approach to the Development of Consolidated and Protected Villages, Salisbury, November 26, 1977. 138. - The Nutrition and Physical Development of Children in Three Tribal Communities of Rhodesia, November 26, 1977. 139. ---- The Supplementary Feeding of School Children in A Tribal Trust Land of Rhodesia, December 12, 1976. 140. Thornycroft, Peta "Beating the Child Waster: The Frontline Women," The Herald, Zimbabwe, May 26, 1982. 141. Tickner, Vincent "Food Policy in Zimbabwe," Food Policy, August 1980. 142. The Food Problem: From Rhodesia to Zimbabwe - No. 8, Catholic Institute for International Relations, London, 1979. 143. ----- "Immediate Food Supply Problems in Zimbabwe," Section of the Conference on Zimbabwe held at the University of Leeds, Britain, June 21, 1980. 144. United Nations Assessment of World Food Situation, November 1974. 145. - "Opportunities for Cooperation in Southern Africa," March 1979. 146. U. S. Agency for "A Report to the Congress on Development Needs International and Opportunities for Cooperation in Southern Development Africa," Washington, D.C., March 1979. 147. U. S. Department Food Problems and Prospects in Sub-Saharan of Agriculture Africa: The Decade of the 1980s, Washington, D.C., 1980. 148. ---- Zimbabwe: Situation, Agricultural Attache Report, American Embassy, Pretoria, March 3, 1982. 149. Walsh, Sister "An Intensive Approach to the Problem of Patricia Malnutrition with the Hope of Eradicating It," Project Reports, March and November 1977. 150. ---- "Short Presentation on Experiences in Nutrition Education," Paper presented at Symposium on Nutrition Education, October 31, 1981, Institute of Continuing Education, University of Zimbabwe (in press). ATTACHMENT TO ANNEX 15 -127- Page 12 of 14 151. Waterston, Tony "Community Desk," M. C. H. Newsletter, September-October, 1981. 152. and David Sanders, Harare and Chitungwiza Nutrition Survey data, Department of Paediatrics and Child Health, University of Zimbabwe. 153. ----- and R. Masanganise, Feeding Patterns in Infancy, December 1981 (work in progress). 154. Weinrich, A. K. H. African Farmers in Rhodesia, OUP, London, 1975. 155. Whitlow, J.R. "Environmental Constraints and Population Pressures in the Tribal Areas of Zimbabwe," Zimbabwe Agriculture Journal, Vol. 77, No. 4, 1980. 156. ------ Land Utilitzation and Development Prospects in the Communal Lands of Zimbabwe. 157. Whitsun Foundation A Strategy for Rural Development, Data Bank No. 2: The Peasant Sector, 1978. 158. Whittle, H. and E. Walker, "Goitre Survey, Omay Tribal Trust Land, Kariba District, Rhodesia," The Central African Journal of Medicine, Vol. 14, No. 3, March 1968. 159. ------ A. Whittle, and A. Wicks, "The Weights of Young African Children in a Township in Rhodesia," The Central African Journal of Medicine, Vol.16, No. 1, January 1970. 160. World Health "Cooperation Tecnica con la Republica de Organization Zimbabwe,"34a Asamblea Mundial de la Salud, 13 de abril de 1981. 161. World Bank Social Infrastructure and Services in Zimbabwe, Washington, D.C. 1981. 162. ------ Zimbabwe Agricultural and Rural Development Sector Memorandum, February 1981, (unpublished) 163. ------ Zimbabwe Country Economic Memorandum, April 1980. 164. Zimbabwe, Govt. of "Growth With Equity," An Economic Policy Statement, February 1981. 165. ------ Report on Development Cooperation for 1981, June 1981. -128- ATTACHMENT TO ANNEX 15 Page 13 of 14 166. Zimbabwe, Govt. of European Expenditure Survey, 1978, Salisbury, 1981, Central Statistical BS/1/81/350. Office 167. - ---- Lower Income Expenditure Survey, 1976/1977 (including the weighting structure of the Lower Income Consumer Price Index), Salisbury, 1980, AD/35/80/200. 168. ------ Higher Income Expenditure Survey, 1977/1978 (including the weighting structure of the Lower Income Consumer Price Index), Salisbury, 1981, BS/1/81/340. 169. Monthly Digest of Statistics, Salisbury, March 1982. 170. ------ Supplement to Monthly Digest of Statistics, Salisbury, October 1978. 171. Zimbabwe, Govt. of Agricultural Statistics, Economics and Marketing Ministry of Agri- Branch, January 1982. culture 172. Zimbabwe, Govt. of An Inquiry into Pre-School Activities in Zimbabwe, Ministry of Education 1981. and Culture 173. ------ Social Studies Syllabus for Primary Schools, October 1980 and Environmental Science Syllabus, Environmental Science Working Party, 1980. 174. Zimbabwe, Govt. of Baby Feeding, Department of Nutrition, 1981. Ministry of Health 175. The Children's Supplementary Feeding Programme in Zimbabwe, 1982. 176. ------ Food Table, undated. 177. "Nutrition Education by Dieticians Through Trainees and Leaders," undated. 178. Report on the National Nutrition Survey of Zimbabwe, December 3, 1980. 179. ------ Health Profile, Health Planning Division, draft (undated); also "Morbidity and Mortality Statistics from all Hospitals, Ministry of Health" (undated). -129- ATTACHMENT TO ANNEX 15 Page 14 of 14 180. Report of the Secretary of Health for the Year Ended 31 December 1979, 1980. 181. Zimbabwe Medical Aid "Health Services Under the White Settler Regime in Rhodesia," undated.