Neonatal Mortality, Infant Mortality, and Under-Five Mortality Rates in the Provinces of Zimbabwe: A Geostatistical and Spatial Analysis of Public Health Policy Provisions

The aim of this research is to present a disaggregated geostatistical analysis of the subnational provincial trends of child mortality variation in Zimbabwe from a child health policy perspective. Soon after gaining independence in 1980, the government embarked on efforts towards promoting equitable health care, namely through the provision of primary health care. Government intervention programmes brought hope and promise, but achieving equity in primary health care coverage was hindered by previous existing disparities in maternal health care disproportionately concentrated in urban settings to the detriment of rural communities. The article highlights policies and programs adopted by the government during the Millennium Development Goals period between 1990-2015 as a response to the inequities that characterised the country’s maternal health care. A longitudinal comparative method for spatial variation on child mortality rates across provinces is developed based on geostatistical analysis. Cross-sectional and time-series data was extracted from the World Health Organisation (WHO) Global Health Observatory data repository, Demographic Health Surveys reports, and previous academic and technical publications. Results suggest that although health care policy was uniform across provinces, not all provinces received the same antenatal and perinatal services. Accordingly, provincial rates of child mortality growth between 1994 and 2015 varied significantly. Evidence on the trends of child mortality rates and maternal health policies in Zimbabwe can be valuable for public child health policy planning, and public service delivery design both in Zimbabwe and across developing countries pursuing the Sustainable Development Agenda.

A potential caveat in the national child and maternal health initiatives in Zimbabwe is related to the fact that a uniform policy was designed and implemented for different regions with potentially significant distinct needs, as the heterogeneous evidence on the outcomes of child mortality rates across the country demonstrates. The factors that inhibited equity in maternal care in Zimbabwe are many and they vary from province to province. According to the Demographic and Health Survey conducted in Zimbabwe in 1994, educated mothers have greater knowledge of nutrition, hygiene and other practices relating to childcare and are more likely to utilise health facilities at their disposal. The survey also established that under-five mortality rate was higher in rural areas than in urban areas. However, in cases where there was a decline in mortality rates, the decline was not significant enough to meet the MDG4 target. Our results provide updated evidence supporting this association.

Zimbabwe’s health policy soon after independence revolved around access to health services regardless of geographical location. The central concern of government was extending health facilities and services to every province.  Some district hospitals were selected for both expansion and upgrading purposes. The strategy was aimed at alleviating pressure on central hospitals and make modern health facilities accessible to more people, particularly in rural provinces. Central hospitals became referral hospitals to which more complex and uncommon cases would be referred to by the district hospitals (Sanders, 1992). Training of health personnel was invigorated to meet the expansion of the health sector. The government also introduced the village health workers (VHW) program which entailed training of a suitable local community member on health issues (Sanders, 1992). The VHWs would serve the local community there by improving accessibility to health care.

 Similarly, the government introduced combined programmes to address the challenges of malnutrition, family planning, and immunization, with the aim of both improving children nutrition standards and fighting the spread of infectious diseases. Trained personnel from the Ministry of Health and Child Welfare would visit schools and vaccinate school children, while Child Supplementary Feeding Programmes were implemented as early as 1992-93 (Munro, 2002). Such strategies adopted in post-colonial Zimbabwe were meant to prevent neonatal mortality, infant mortality, and under-five mortality rates through antenatal and perinatal care, family planning knowledge and HIV/AIDS awareness. According to Sanders (1992), as a result of these nutritional and vaccination strategies, the rural-urban differential in antenatal care was significantly lowered, given that high quality prenatal care enhances the survival prospects of infants.

However, when assessing the impact of the country’s public health policy and strategies for inclusive primary health care, it is importance to also look at the historical context. The worsening economic conditions resulted in frequent shortages of drugs and medical supplies. The declining economic activities particularly among rural communities somehow altered household decisions on the use of health services and facilities. Survival rates became much higher in urban than in rural communities. It has been noted that through resignations, health personnel eventually became overloaded and demotivated. Thus, institutional deficiencies and the critical shortage of skilled personnel also contributed to the provincial variations in childhood mortality rates.

Geographical location of households is also suggested to play an important role in explaining the changes and differences in percentages of the infant mortality, neonatal mortality, and under-five mortality rates in Zimbabwe. Women in urban provinces such as Harare and Bulawayo are more likely to have received antenatal care from medical doctors while women from predominantly rural provinces relied mostly on nurses. According to the Demographic and health Survey (1994), the primary difference in the provision of antenatal care in rural and urban areas lies in the use of physicians. Lack of transport from district hospitals to referral hospitals could be another challenge experienced by rural communities (Karra et al. 2017).

Furthermore, cultural and religious beliefs can be a source of the variance in child mortality rates in Zimbabwe. According to Chitura and Manyanhaire (2013), some women continue to deliver birth at home or delay seeking maternal health care due to religious and cultural factors. However, although underreporting of early childhood mortality is a risk as some traditional communities are not willing to use health facilities on religious grounds, the lack of equipment, inadequate staffing and poor communication remain the main obstacles to the provision of high-quality maternal care in Zimbabwe (Chitura and Manyanhaire, 2013).

Based on current evidence, we can conclude that most of the factors that account for child mortality in Zimbabwe are within the government’s reach, and can therefore be improved by public health programs. The lessons learned with data from the MDG period could be used to reassess the policy planning for the Zimbabwean Sustainable Development Goals agenda regarding child health. Knowledge about the trends and varying mortality rates in Zimbabwe’s provinces is essential for public health policy making, planning purposes, and measuring strides made towards the realization of the country’s human development.