Health has long been one of the most important social concerns of Zimbabwean people. People have just expectations to live healthy lives and to obtain a reasonable quality of care when they fall ill. Not too long ago, it seemed we were making significant progress in this respect. Major gains were achieved in the 1980s, through joint action between the health sector and communities. However, over the 1990s, the combined impact of AIDS, the structural adjustment programme, a falling health budget and declining household incomes, reversed many of these gains.
The poorest communities in rural areas were most affected by the crisis of the health care system, taking on more and more responsibility for looking after the ill, by providing home-based care, paying for their health care and dealing with their health problems, but with little role in deciding on the changes to their health services. By the late 1990s a wave of strikes amongst health workers signalled that health workers were also not happy with the situation. While a lot of attention was given to the strikes by doctors and nurses, those working at clinic level and in communities also lost wellbeing and morale. As 2000 approached, “health for all” seemed like an empty promise…
It was this situation which motivated several national civil society organisations, co-ordinated by the Zimbabwe Congress of Trade Unions, to come together in 1997 to review the current state of affairs in the health sector and look at ways in which communities could achieve greater control over their own health.
The first step was to ask communities and civil society organisations: What are your perceptions of what is happening to your health? The survey, brought up concerns about the inadequacy of public funds for health, the declining quality of public health services, the negative attitudes of providers and the weakness of current mechanisms for expressing community participation in health. These views were later also found in the national Commission of Inquiry into the Health sector.
When the report on the community research was presented at a meeting of about twenty-five national membership based organisations, the participating organisations decided to form a network organisation called the Community Working Group on Health (CWGH). The organisations developed a set of strategies to remedy the problems that were identified, and discussed these with their members, with the associations of health professionals and representatives of government, churches, the private sector, NGOs and traditional health providers. The outcome of these discussions informed the work of the network of members in the CWGH for the next few years, working with health and other authorities, and building the strength of community voices and action on health at local and national level.
Since then the organisations in the CWGH have followed the path of strengthening community voice and action in health, keeping alive consultation and involvement of people in communities, stimulating local action and tapping various institutional channels to bring these views to national level.
It is often stated that people are the centre of health systems and services. People produce inputs for health, like food, provide services for health as they care for family members, use health services and contribute money for services. Most importantly, as citizens, people guide the policies that shape health systems. Reviews from all parts of the world show that co-operation between communities and health services enhance the performance of services. Work carried out by CWGH and the Training and Research Support Centre (TARSC) through the Regional Network on Equity in Health in East and Southern Africa (EQUINET) in Zimbabwe in 2012 found, for example, that where health centre committees actively co-ordinated health workers and community members there were higher levels of knowledge and uptake of services for antenatal care and tuberculosis treatment, use of oral rehydration solution for diarrhoea and improved environmental health outcomes. Similar results have been noted in other countries of the region.
Not surprisingly the 1978 World Health Organization (WHO) Alma Ata declaration made community participation a central feature of primary health care. Yet, in fact, many people do not participate in health systems, especially those from the lowest income communities. Even where people do play roles in health systems, decisions may be made outside their communities. Even though health systems perform better when they are organised around peoples needs, roles and processes, they do not always do so. Why else would we continue to treat people and then send them back to the same conditions that made them ill?
Our work reports many aspects of the ways that the CWGH is trying to address these different aspects of exclusion by building people’s literacy, organisation, participation and voice in health systems, together with health workers, authorities and others. Our own work. such as in developing materials and capacities for health literacy and for adolescent involvement in reproductive health, in building skills for community based and participatory research, or evidence for budget debates has shown us the significant potential that exists within communities to advance health and strengthen our health services.
The CWGH is now celebrating twenty years of work in strengthening the understanding of and capacities for community roles in health. This comes at a time when our health and health system has suffered fundamental challenges and declines. Yet the understanding that we need to rebuild our health system around people’s power has never been more relevant.
Clearly Zimbabwe now needs to prioritise resources to meet people’s just expectations to live healthy lives and to obtain a reasonable quality of care when they fall ill. In the midst of economic and social difficulty, the work of the CWGH showa that people’s power and primary health care will be the best levers around which to take action to re-invigorate and revive our health system.
- Author: Itai Rusike
- Photo: CWGH Public Demonstration in Harare during ICASA 2015
- More information: www.cwgh.co.zw
- Contribution by CWGH to the Annual Report 2016 of the MMI Network