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HealthTransitionFundA Multi-donor Pooled

Transition Fund for Health

in Zimbabwe

Supporting the National Health Strategy to improve access to quality health care in Zimbabwe

December 2011

ZIMBABWE

Health TransitionFundA Multi-donor Pooled Transition Fund

for Health in Zimbabwe

Supporting the National Health Strategy to improve access to quality health care in Zimbabwe

December 2011

2 Health Transition Fund

3A Multi-donor Pooled Transition Fund for Health in Zimbabwe - October 2011

Summary of Contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

1. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

2. Situation Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

3. Goal/Purpose/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

4. Planned Results and Thematic Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

5. Coordination and Cross Cutting Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

6. Feasibility and Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

7. Programme Management and Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

8. Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Annex I: HTF Logical Framework Matrix - See Separate Document . . . . . . . . . . . . . . . . . . . . . . . . . .50

Annex II: Terms of Reference - Steering Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

Annex III: Statement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Table ofContents


Country Zimbabwe

HTF Name Health Transition Fund (2011 - 2015)

Initial Donors Governments of Ireland, Sweden, Norway, and the United Kingdom as well asthe European Commission delegation to Zimbabwe

Funds Required Approximately US$ 435,336,586 - total amount over 5 years

Duration 2011 - 2015

Objective Reducing maternal and child mortality through abolishing user fees andsupporting high impact interventions and health system strengthening

Goal: to contribute to reduced maternal mortality (by 3/4) and under-5 mortality(by 2/3) (MDGs 4 and 5) and eliminate user fees for children under-5 andpregnant and lactating women by 2015.

The programme also aims to contribute to halving the prevalence of underweightin children under-5 (MDG 1c) and combat, halt and reverse trends in HIV andAIDS, Malaria and other diseases (MDG 6) by 2015.

Purpose: to improve maternal, newborn and child health by strengthening healthsystems and scaling up the implementation of high impact interventions throughsupport to the health sector.

Expected Results l National coverage of focused ANC (4 visits) increased to 90% by 2015

l National skilled birth attendance rate increased to 80% by 2015

l Access to comprehensive emergency obstetric and newborn care increasedto 80% by 2015

l National coverage of postnatal care (at least 3 visits in the first week afterdelivery) increased to 80% by 2015

l MNCH program implementation is monitored quarterly in all districts by 2015

l 80% of health centers have a fully functional health committee by 2015l Community based preventive and selected curative MNCH services are

provided for 80% of villages by 2015

Summary Of Contribution


l National full immunization coverage increased to 90% by 2015

l New vaccines (Pneumococcal and Rota-virus vaccine) introduced at thenational level by 2013

l The proportion of sick newborns and children under-5 treated appropriatelyfor common childhood illnesses (neonatal sepsis , pneumonia, diarrhoea,pediatric HIV, SAM and malaria) increased to 80% by 2015

l National coverage of exclusive breastfeeding rate increased to 50% by 2015

l The national coverage rate of timely and appropriate complementary feedingincreased to 50% by 2015

l The national coverage rate of twice a year Vitamin A supplementation forchildren 6 -59 months of age increased to 90%

l Access and compliance of routine Iron/folate supplementation for pregnantwomen increased to 80% by 2015

l The national coverage rate of Vitamin A supplementation for mothers withinthe first 42 days after delivery increased to 80% by 2015

l Availability of essential medicines (the selected package based on WHOrecommendations applicable to Zimbabwe) and health commodities ismaintained at 80% in all health facilities across Zimbabwe by 2015

l Availability of vaccines (antigens), vaccine supplies and cold chain equipmentmaintained at 100% in all health facilities across Zimbabwe by 2015

l 95% of health facilities and health management offices are staffed with theminimum standard required and qualified health professionals by 2015

l Health system capacity in policy making, planning and financing developedacross all health services delivery levels by 2015

l 80% of health facilities received financial support through the HSF to covertheir running cost

l Zero Open Defecation (ZOD) rate 100% by 2015 (output level)

Geographic Focus Area National

Focus population Women and Children (in particular pregnant and lactating women and children under-5)

UNICEF Zimbabwe l Peter Salama, UNICEF Representative,

Contact(s) Email: [email protected]

l Aboubacar Kampo, Chief of Young Child Survival and Development (Health and Nutrition)

Email: [email protected]


AU African Union

CARMMA AU Campaign on Accelerated Reduction of Maternal Mortality in Africa

CDC Centers for Disease Control and Prevention

CIFF Children's Investment Fund Foundation

CMAN Community based management of Acute Malnutrition

CCORE Collaborating Centre for Operational Research and Evaluation

CPF Child Protection Fund

CSO Country Situation Overview (WASH)

DFID Department of International Development (UK Aid)

DHET District Health Executive Teams

DHS Demographic and Health Survey

DPPME Division of Policy, Planning, Monitoring and Evaluation (MoHCW)

DPS Directorate of Pharmacy Services

DRR Disaster Risk Reduction

EPI Expanded Programme of Immunization

EU European Union

ESP Expanded Support Programme (for Immunisation)

ETF Education Transition Fund

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria (also referred to as Global Fund)

HFA Health Facilities Assessment

HIS Health Information System

HIV Human-Immuno Deficiency Virus

3 Acronyms


HMIS Health Management and Information System

HTF Health Transition Fund

INMCI Integrated Management of Maternal, Newborn and Childhood Illnesses

LATH Liverpool Associates for Tropical Health

LMIS Logistics Management Information Systems

M&E Monitoring and Evaluation

MDGs Millennium Development Goals

MICS Multiple Indicators Cluster Survey

MIMS Multiple Indicator Monitoring Survey

MLM Mid Level Management (for immunization)

MNCH Maternal, Newborn and Child Health

MoHCW Ministry of Health and Child Welfare

MPMS Maternal and Perinatal Mortality Study

NCHDs National Child Health Days

NHS National Health Strategy (2009 - 2013): Equity and Quality in Health - A People's Right

PAC Post Acute Care

PEPFAR U.S Presidents Emergency Funds for AIDS Relief

PHC Primary Health Care

PoS Programme of Support (to the National Action Plan for Orphans and OtherVulnerable Children)/Child Protection Fund

PMD Provincial Medical Director

PRP Protracted Relief Programme

RED Reach Every District (Approach)

UNAIDS Joint United Nations Programme on HIV/AIDS

UNEP United Nations Environment Programme

UNDP United Nations Development

UNICEF United Nations Children's Fund

UNFPA United Nations Population Fund

USD/US$ United States Dollars

UZ University of Zimbabwe

VHSSP Vital Health Services Support Programme

VMAHS Vital Medicines Availability and Health Facility Survey

VHWs Village Health Workers

WB World Bank

WHO World Health Organization


The Health Transition Fund (HTF) is a multi-donorpooled fund, managed by UNICEF, to support theMinistry of Health and Child Welfare (MoHCW) inZimbabwe to achieve planned progress towards'achieving the highest possible level of health andquality of life for all Zimbabweans'. Zimbabwe's recenthistory of severe deterioration in infrastructure, lack ofinvestment, low wages, decreasing motivation andcapacity of the civil service, and absolute shortage ofessential supplies and commodities, resulted in thenear-collapse of the health sector in late 2008, andearly 2009.

The HTF will support the efforts to mobilize thenecessary resources for critical interventions torevitalize the sector and increase access to carethrough eliminating the payment of fees for services formothers and children under-5 as foreseen by nationalpolicy. As such, critical, high impact interventions willreduce maternal and under-5 mortality (MDGs 4 and 5)and reduce prevalence of underweight in children lessthen 5 years old (MDG 1 c) and assist in combatingHIV, Malaria and other diseases (MDG6).

Support to key goals outlined in the Zimbabwe NationalHealth Strategy and the Health Investment Case will beprovided in a coordinated and streamlined way and willbe aligned with the MoHCW annual operating

plan/annual Performance Contracts and reviewprocesses. The pooled fund supports the continuationof national-scale health services delivery in criticalareas. The mechanism provides strengthened capacityin government to take on sector budget support shouldthe situation improve, while mitigating risks andenhancing preparedness, should humanitariansituations require response.

Based on gaps analysis, principles of aid effectiveness1

and coordination, the HTF recognizes that health MDGoutcomes cannot be achieved without adequateinvestment in the health systems that underpin healthservice delivery; that investment in health needs to beembedded in broader development planning and needslong-term predictable funding from donors as well asmechanisms to hold all partners accountable.2

The HTF initially focuses on the following four thematicareas, but according to the burden of diseases andavailable financial resources this could be extended toother areas included in The National Health Strategyfor Zimbabwe (2009-2013).

The initial first year focus areas are the three corehealth system reforms required to support the removalof user fees, and a comprehensive programmeimplementation area on maternal, newborn, and child

1 Executive Summary

1 In particular applying the Paris Declaration on Aid Effectiveness to the Health Sector to improve complementarily and coordination of funding partners to sup-port harmonization and alignment efforts at the country level.

2 Outlined in the work plan for the "Health 8" agencies: The Gates Foundation, GAVI Alliance, Global Fund to Fight AIDS, Tuberculosis and Malaria, UNAIDS,UNFPA, UNICEF, World Health Organization and the World Bank


health and nutrition to support quality of careimprovements.

The initial four core thematic areas are therefore:

1. Maternal, Newborn and Child Health andNutrition;

2. Medical Products, Vaccines and Technologies(Medicines and Commodities);

3. Human Resources for Health (including HealthWorker Management, Training and RetentionScheme); and

4. Health Policy, Planning and Finance (HealthServices Fund Scheme and Research).

Together these pillars provide comprehensive supportto the health system and provide the necessaryfoundation and recurrent revenues to alleviate thecollection of service fees from patients. The HTFincludes enhancing the health workforce, upgradingessential equipment and logistics, providing equitablefinancing solutions, ensuring quality of care, improvedhealth practices through social mobilization andintegrating community-based strategies.

The HTF will also provide integrated support tomonitoring and evaluation and technical expertise inthe roll-out of activities. The HTF requires a pooleddonor contribution of approximately US$80 million peryear over five years. The pooled mechanismsignificantly reduces overhead costs in operations,reporting and fund administration ensuring that fundingis channeled toward achieving direct programmeimpact. Further, the HTF scale will allow achievementof results against national scale indicators at the 5 yearstage and reduces potential duplication of efforts bydevelopment partners.


2.1 Brief SituationOverviewIn the 1980s and early 1990s, Zimbabwehad one of the best primary health caresystems in sub-Saharan Africa. Zimbabwewas at the forefront of regional and globalinitiatives on child survival, with thegovernment launching the first child survivalrevolution in 1988. Economic challengesfaced by the country in the last decadehowever, have led to a chronic under-investment in the health sector and asignificant deterioration in the healthindicators. This period also saw theintroduction of user fees which havepresented an additional barrier to healthcare, impacting the most vulnerable inparticular.

Maternal and Child Health Today the maternal mortality ratio is 790per 100,000 live births (compared with 390in 1990)3 and the under-5 mortality is 94per 1,000 live births (compared with 78 in1990). See figure 1.

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2 Situation Analysis

3 UN Inter-agency group for Child Mortality Estimation, 2010

This means that in Zimbabwe, eight women die every day ofpregnancy-related complications, and 100 children die every day,mainly due to preventable causes such as common newborndisorders, pediatric HIV, diarrhea, pneumonia and the underlyingcause of malnutrition (see figure 2).

Figure 1: Maternal Mortality Ratio (per 100,000 live births) adjusted figure1990 - 2010 Source: WHO/UNICEF/UNFPA/World Bank, 2010 Trends in MaternalMortality Zimbabwe: 1990 to 2008


Newborn disorders

Newborn disorders are the most important cause ofunder-5 deaths which are also intrinsically related tomaternal health and nutrition. About 75 per cent ofmaternal and neonatal deaths occur in the first weekafter delivery due to lack of basic care in the immediatepostnatal period. As such, timely identification andappropriate intervention for high risk mothers is criticalto prevent large numbers of mothers dying and toimprove neonatal outcomes and survival. Currently lessthan 30 per cent of women and their babies receiveimmediate post natal care, with the majority of motherssent home immediately after delivery. Follow uppostnatal care is delayed for approximately 10 days.4

This delay misses the critical window for maternalnewborn health and nutrition interventions, such aspromotion of exclusive breastfeeding (currently at analarmingly low coverage rate of 5.8 per cent).

AIDS related conditions Despite progress made on access to anti-retroviraltreatment (ART) for adults, AIDS-related conditionsremain the number one cause of maternal deaths andthe second major cause of child deaths.5 Currentlyonly 978 of the 7,000 HIV positive children under theage of two receive ART.6 The identification of HIVinfected infants who require treatment is a significantchallenge due to a) weak community postnatal followup for HIV positive mothers and their HIV-exposedinfants resulting in only 30 per cent receiving EarlyInfant Diagnosis (EID), b) limited health worker trainingin EID, c) a weak referral chain; only a small proportionof those who are tested and receive Polymerase ChainReaction (PCR) results being initiated on ART, and d)loss to follow up due to the centralized pediatric HIVmanagement system. Although the MoHCW is workingon decentralization, patients are referred to higher levelhealth facilities which often may be a distance away, andwhere the availability of pediatricians may be limited.

4 Current National Guidelines recommend 10 day period. Part of the HTF activities aim to support MoHCW in revising these guidelines.5 Munjanja, S. Maternal and Perinatal Mortality Study, 2007, MoHWC Zimbabwe (http://www.UNICEF.org/zimbabwe/ZMPMS_report.pdf)6 UNICEF Briefing note (Sherman and Kitabire) - Data on PMTCT/Peadiatric HIV and Maternal ART, based on 2010 National Estimates; MoHCW statistics, and

GFATM Round 10 Proposal.

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Figure 2: Causes of Under-5 Deaths in ZimbabweSource: WHO/CHERG 2010

Globally more than one third of child deaths are attributed to undernutrition


The improvement of Prevention of Mother to ChildTransmission of HIV (PMTCT) services is vital in orderfor fewer babies to be infected and should includescaled up interventions to meet the 2010 WHOPediatric HIV treatment guidelines for health facilities.While PMTCT is not a specific component of thisproposal, an integrated approach to MNCH will bepursued.

Pneumonia and Diarrhoea Pneumonia is the third leading killer disease of childrenunder-5 in Zimbabwe (after HIV and AIDS and neonataldisorders). Pneumonia contributes to 14 per cent ofunder-5 deaths. In the MIMS survey of 2009, only 16per cent of children under-5 suspected of havingpneumonia in the two weeks preceding the survey hadreceived the necessary antibiotics.

Diarrhoea is the fourth leading cause of mortality amongunder-5s in Zimbabwe, contributing to 9 per cent ofchildhood deaths. MIMS 2009 demonstrated that 11 percent of children at national level in this age group hadsuffered from diarrhoea in the last two weeks precedingthe survey, with no sex or urban and rural differentials.According to this report, 58 per cent of children under-5who had diarrhoea in the two weeks preceding thesurvey were given homemade salt and sugar solution.This rate represents a decline from 61 per cent usingsolutions reported in the 2005/6 ZDHS.

The HTF is focusing on improvement in casemanagement capacity of health workers to treatpneumonia and diarrhoea. It will also work to improvethe health care seeking behaviors of families andcommunities.

Undernutrition Global analysis confirms nutrition-related disordersincluding stunting, severe wasting, intrauterine growthrestriction and deficiencies of key micronutrients (zinc,vitamin A and iron), are responsible for about 35 percent of child deaths globally and 11 per cent of the totalglobal disease burden.7 These nutrition-relateddisorders are highly prevalent in Zimbabwe and areestimated to contribute to approximately 12,000 under-5 child deaths every year (a third of all under-5deaths).8

Child undernutrition in Zimbabwe is a result of aninteraction between poor dietary intake and disease.This interaction is driven by suboptimal feeding andcare practices, especially during the critical periods ofpregnancy, infancy and young childhood (0 to 24months), an unhealthy household environment, andlack of health and nutrition services.

The rate of exclusive breastfeeding and complementaryfeeding (the corner stone for child survival anddevelopment), is alarmingly low with less than 6 percent of infants under the age of six months exclusivelybreastfed and less than 10 per cent of those 6 - 24months accessing optimal complementary feeding.9

Child undernutrition is also partly related to maternalnutritional status. In Zimbabwe, about 10 per cent ofchildren are born with a Low Birth Weight10, indicating

7 Black et al, 2008, Maternal and child undernutrition: global and regional exposures and health consequences, The Lancet, Series, Child and MaternalUndernutrition. Though available data on nutritional status in Zimbabwe is limited mainly to stunting, wasting, low birth weight and anaemia (indicatorsfor which are all higher (worse) or similar to the global average); child and maternal undernutrition is expected to have at least similar level of effecton health and mortality. In terms of mortality this translates to one- third of 36,000 annual deaths.

8 Zimbabwe National Nutrition Survey, Food and Nutrition Council, 20109 Universal practice of exclusive breastfeeding and complementary feeding can reduce under-five mortality by 19% (The Lancet, Child Survival Series,

2003), 13% by EBF and 6% by CF. 10 DHS, 2006


intrauterine growth restriction. In addition, an estimated9 per cent of women of reproductive age are thin (BMIless than 18.5) of which 2 per cent are considered verythin (BMI less than 17). Access to and utilization of keymaternal nutrition services is very low. Regardless ofhigh attendance rates for ANC (93 per cent) and facilitylevel delivery (58 per cent)11 coverage of maternalmicronutrient supplementation (Iron/Folate duringpregnancy and vitamin A postpartum) is less than 30per cent.

User fees

After independence (and with the exception ofParienyatwa Hospital and a small number of higherlevel referral facilities) Zimbabwe did not charge userfees for health services in public facilities. User feeswere introduced and then increased during the 1990's12

as part of the Zimbabwe Economic StructuralAdjustment Program (ESAP). Generally, in the 1990sfees increased (with some exceptions in rural areas)and were collected centrally. Although designed toimprove service quality to ensure access to heath forpoor people and vulnerable groups, the application ofuser fees have not improved quality of care13 and havehad a negative impact on equitable access inZimbabwe.14 Further, the Poverty Assessment StudySurvey in 2003 showed that a lack of available moneywas the main reason for patients not seeking treatmentfor illness/injuries.

Provisions in the user fee policy have included freeaccess for children under-5, pregnant women and theelderly. Provision of ART is free but there are chargesfor consultations and laboratory tests. Despite theexemptions outlined in policy, pressures from theeconomic crisis have reduced resources to frontlineservices. Furthermore, the application of exemptionpolicies has been impacted by lack of knowledge ofindividual rights under the policy and the ad hoc

collection of informal payments. The policy is alsowidely misunderstood (one example is that fees arewidely charged for referral consultations which shouldbe exempt) and establishing eligibility for exemption offees on the basis of poverty has been difficult.

Efforts to abolish user fees for mothers and childrenunder-5 are also complicated by the limited ability tomonitor and enforce the legal implementation of thepolicy and by the different ministerial portfolios coveringhealth. Health facilities at provincial level (managed byMoHCW) are subject to the policy whereas district levelfacilities (managed by the Ministry for LocalGovernment) are not necessarily covered15.

The user fee policy includes some 'flexibility' in thaturban local authorities are not bound by fee levels inthe public sector but require ministerial approval toadopt any revised fee structures16. The implementationof the user fees policy has been erratic,administratively complicated and has lead to equity inservice use being compromised (the introduction inuser fees in 1993 resulted in a 30 per cent decline inuse of Rural Health Centres17). Even when user feeswere 'abolished,' the low capacity of the HealthServices Fund to cover running costs in facilitiesresulted in a non-standardised system of fees, levies,registration payments and incentives being charged.

For example, the provisions for women, children under-5 and the elderly are not always being realised inpractice. The Vital Medicines and Health ServicesSurveys suggest that only about 53 per cent of healthfacilities provide a full maternity service free of charge.Other facilities charge fees with prices varying from US$3 to US$50; with higher prices in urban locations.18

User fees are also charged on an ad hoc basis foremergency services (such as C-sections, for bloodtransfusion and post acute care (PAC)).

Generally, user fees present a barrier to health careand contribute to greater disparities in access,effectively excluding poorer people from the formal

11 MIMS12 http://siteresources.worldbank.org/INTPAH/Resources/Publications/Seminars/oedzimbabwe.pdf13 Johnston, T. The Impact of World Bank Support to the HNP Sector in Zimbabwe, Report No. 18141, June 1998 www.worldbank.org/htm/oed 14 Normand, C et al Resource Mobilisation for the Health Sector in Zimbabwe, December, 1996 15 The comprehensive user fee policy for public health facilities was introduced in January 2002. This policy includes: No fees to be charged at Government RCH

and RDC clinics, no fees to be charged for maternity services, free health services for children under-5, free TB treatment- public and private sector, and freetreatment for pensioners

16 See Chapter 6: health Financing (p 143) in Pauingus Lingani Ncube Sikosana in Challenges in reforming the health sector in Africa: Reforming Health Systemsunder Economic Siege, Second Edition.

17 Zigora el al 1997 personal communication in in Pauingus Lingani Ncube Sikosana, 200918 Also see www.ipsnews.net/africa/nota.asp?idnews=52272 for press comment on fees for a routine delivery.


health care system.19 20The Maternal and PerinatalMortality Study (2007)21 cited user fees as the mainreason for lack of access to ante, post-natal andinstitutional delivery services. These data also suggestthat demand for health services is higher in thosefacilities that do not charge fees.

Generally, user fee income in Zimbabwe is being usedto cover non-salary recurrent costs and is pooled andre-distributed through the Health Services Fund (seediscussion in section 4). Consensus statements suchas the Principles on Cost Sharing in Education andHealth in Sub-Saharan Africa22 stress that fees shouldbe considered at best as a stepping stone to moreequitable financing mechanisms and not for fundingroutine resource requirements.

If user fees are abolished then support for the runningcosts of facilities will be critical to ensure fees are notcharged informally. Also facilities will need to bestrengthened to effectively cope with the subsequentincreases in demand. To effectively remove user feesZimbabwe will need to:

1. Reduce and cover overhead running costs offacilities (see thematic area 4) channellingfinancial resources directly to health facility levelthrough the reactivation of the Health ServiceFund. This must be done in a timely manner asremoval of fees is likely to increase the pressureson these facilities.

2. Cover essential medicines and equipment(particularly for routine maternal and child healthinterventions).

3. Support human resources with skills in maternaland child health and ensure their retention andmotivation (see thematic area 1 and thematic area 3).

4. Develop an effective communication strategy andpublic information campaign around user fees toensure reduction in informal charges and

knowledge of rights (integrated activity in thematicarea 1).

The four thematic areas proposed in the HTF aim toadequately address these aspects and resource needsin order to effectively abolish user fees for pregnantwomen and children under-5. Further, research on thetotal cost of the package of care at different servicedelivery levels, as requested by MoHCW, will helpsupport and inform evidence-based advocacystrategies.

Health Financing

Health financing in Zimbabwe has had implications forequitable access to services. The public health sectoroperations rely mainly on tax revenues allocated by theMinistry of Finance (MoF) to the MoHCW. Morerecently sector operations rely on donor developmentaid, user fees and to some extent on health insuranceincome.

The recent improvement in the economic climate andthe significant support of the donor community havemade human resources for health, essential medicinesand medical supplies more available. However, healthfacilities are not yet functioning effectively. Facilitiesremain unable to cover costs for basic services (suchas electricity, water, communications,) as well as forregular maintenance of infrastructure and equipment.

Since mid-2009, the relative stabilization in the nationalcontext has facilitated sector recovery with a movefrom an emergency planning mode towards completionof an ambitious five year National Health Strategy(2009-2013).23 The MoHCW has recognized that themajor challenge in implementing the national strategyis a lack of resources (financial, human and material).Although the 2011 government budget for the healthsector is US$ 256 million (9 per cent of the totalbudget), the actual disbursement depends on the

19 See Zimbabwe's Association of Doctors for Human Rights Annual Report, 2009. http://www.zadhr.org/ 20 Yates, 2009 Universal health care and the removal of user fees Lancet, 2009:373:2078-81 Published online http://download.the-

lancet.com/pdfs/journals/lancet/PIIS0140673609602580.pdf?id=e16241398b8eb460:-46867125:12e76956375:4d851299071951328 21 Munjanja et al, Maternal and Perinatal Mortality Study (2007) http://www.UNICEF.org/zimbabwe/ZMPMS_report.pdf 22 1997 Addis Ababa Consensus on Principles on Cost Sharing in Education and Health in Sub-Saharan Africa 23 The National Health Strategy for Zimbabwe (2009 - 2013), Equity and Quality in Health: A People's Right, MOHCW


availability of resources. For example, in 2009 onlyUS$15 Million (10 per cent) of the originally allocatedbudget of US$150 Million was disbursed to theMoHCW for service delivery. As such, significantexternal financing is required to restore and maintainservice delivery and improve health outcomes.

If the current funding levels and weak capacity of thepublic health system persist or deteriorate, Zimbabwewill not achieve the health related MillenniumDevelopment Goals (MDGs). In this respect the 'HealthSector Investment Case' identified priority areas thatneed urgent attention over the next 3 years (2010-2012). This plan aimed to revitalize the health sectorand scale up high impact interventions that will assistthe country to 'catch up' to MDG targets. In order toachieve the MDGs, Zimbabwe should be spending atleast US$34 per capita per annum on health. This percapita amount is the minimum required to provide anessential package of health services. The 2009 revisedbudgetary allocation, including donor contributions,allocated about US$7 per capita per annum on health.

It is clear that a focused effort is required todecentralize financial resources and strengthenaccounting processes in order to better facilitate theeffective running of primary level facilities. The HTF isresponding to the findings in the Health SectorInvestment Case with a comprehensive programmethat aims to 'build back better' the health systemincluding addressing health financing needs while alsoaddressing issues of equitable access and user fees.The HTF activities and priority areas were selected asareas that will have the highest impact towardsachieving key MDG targets.

Medicines and medical suppliesThe Health Investment Case outlined the critical needfor ensuring the availability of essential medicines andmedical supplies, adequate professional staff and aneed to decentralize financial resources for day to daymanagement of primary level health facilities.

A multi-donor fund has provided support to the VitalMedicines and the Vital Health Services Support

Programme (VHSSP) to supply more than 75 per centof the country's selected package of essentialmedicines and surgical needs at primary andsecondary level facilities25.

Over the last 2 years this programme has achieved thefollowing substantial results:

l No health facilities assessed in Round Six of theVHMAS had complete stock outs of selectedessential medicines;

l Health facilities with at least 50 per cent of theselected essential medicines rose to high levels (99per cent) in Round Six from 44 per cent in RoundOne; and

l Health facilities with at least 70 per cent of theselected essential medicines in stock rose to 87.9per cent in Round Six from less than 20 per cent inRound One.

24 MoHCW, Zimbabwe. "The Health Sector Investment Case (2010 - 2012): Accelerating progress towards MDGs. Equity and Quality inHealth: A People's Right." December, 2009 (p 5) http://www.UNICEF.org/esaro/Health_Investment_Case_Report1.pdf

25 VHSSP November 2008 Mission monitoring report and the Vital Medicines Availability and Health Services Survey (VMAHS May-October 2009)

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Figure 3: Trends in availability of essential medicinesin Zimbabwe Health Facilities

Source: VHMAS, Round Six


The increase in availability and equitabledistribution of essential medicines at peripheralhealth care centres can be attributed to the pushallocation strategy introduced in 2009, in parallel tothe pull system already in place. On-going supportto the essential medicines programme is includedin the HTF under thematic area 2.

Disparities in Access

In addition to user fees and financial constraintspresenting barriers to adequate health care, otherphysical (such as distance, transport, restrictedopening hours) and socio-cultural barriers exist inZimbabwe. These barriers are more pronouncedfor people in rural areas, the poor and thosebelonging to particular religious communities.

Joint analysis conducted by Equinet and theCollaborating Centre for Operational Research(CCORE)26 in 2010 shows that disparities inmaternal health have increased in the past decade;

26 See details of the CCORE here: http://ccore-zw.org.dnpserver.com/27 Zimbabwe National Nutrition Survey, Food and Nutrition Council, 2010.

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Source: DHS 2005-6; MIMS 2009

health services, other socio-cultural barriers exist forsome religious communities, such as the Apostoliccommunities, which represent an increasing proportionof the total population. These groups exhibit pooreracceptance and coverage of health interventions (seefigure 6 overleaf).access to critical services across the

continuum of maternal health care havedeteriorated more for the poorest womenthan for women of higher socio-economicstatus. This trend is depicted in thedifferences in coverage of skilled birthattendance in Figure 4.

Similar disparities and trends have beennoted for prevalence of chronicundernutrition (stunting), seen in figure 5.These trends reflect low exclusivebreastfeeding rates and poorcomplementary feeding, as well as poor sanitation and poverty.27

In addition, although the majority of thepopulation is highly literate and demands

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Figure 4: Trends in Skilled Birth Attendance by WealthQuintile in Zimbabwe

Source: DHS 2005-6; MIMS 2009


Human Resources and Health Systems

The deterioration in MNCH and nutrition indicators isalso due to diminished institutional capacity due tolimited health spending, infrastructure deterioration,commodity shortages and outmigration of healthworkers. This situation has limited the health system'sability to deliver quality services and presentschallenges in enforcing user fee policies. For example,there are around 500 midwives practicing in Zimbabwetoday; it is estimated that around 2,500 midwives withenhanced training are needed to scale up necessarylife-saving services. Vacancy rates in facilities and forthose providing vocational training are high across allcadres of health workers, for example:

l Doctors - 69 per cent,

l Environmental Health Technicians - 61 per cent

l Midwives - 80 per cent

l Nursing Tutors - 62 per cent

l Medical School Lecturers - 63 per cent29

Although it is expected that the impact of vacancy rateswill be mitigated by current efforts improving the skillsof 550 Primary Care Nurses (PCNs) in midwifery andtraining of 500 environmental health assistants, most ofZimbabwe's health institutions are understaffed andoperate with a skeleton staff burdened with heavyworkloads. The shortage is most critical in rural areaswhere the staff is generally less qualified and vacancyrates are higher. Migration from rural to urban areas iscommon due to inadequate resources.30 As suchaccess to care is better in urban areas, where privatefacilities (at a cost to the patient) provide anotheralternative care option. In addition, migration of workerswithin the health system from public to private sectoroften represents a stepping stone for moving out ofZimbabwe.31

28 Estimates are based on MoHCW Administrative Report (2010) reported vacancy levels of 89 per cent midwives, 64 per cent governmentmedical offices and 59 per cent medical tutors.

29 MoHCW Administrative Report, 200830 This includes perceived lack of adequate measures for protection against HIV, combined with heavy workloads (see Chikanda 2004 for

example). 31 See Chikanda 2004 and in Connell 2008 The Migration of Health Workers From Zimbabwe in The international Migration of Health

Workers, Taylor and Francis Publishers

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Source: UNICEF Zimbabwe Countrytabulation from MIMS 2009 data (2010)


The sub-optimal availability and distribution of humanresources for health is compounded by inadequate HRmanagement systems. The staff in place are notintegrated into a system operating with adequateinfrastructure, a working information system, laboratorysystems and a functioning procurement and supplysystem for medicines and equipment. Supervision andreferrals between different levels of the health systemhave also deteriorated with need for enhancedcoordination, training and teamwork practices. Theworking conditions, leadership of health managers,salaries, benefits and career development along withnational scale workforce planning and humanresources databases need to be improved to addressfurther attrition and skill deficiencies at all levels.

Extreme shortfalls in monitoring human resources arelinked to weakened health information systems on abroader scale. Significant investment is needed inrigorous and coordinated planning, coherent policydissemination, monitoring and evaluation. Theweakened system has negatively impacted servicedelivery and otherwise effective interventions. It hasalso increased reliance on the informal health caresector due to high fees charged by private clinics andad hoc introduction of fees in public institutions.32

The Human Resources for Health Retention Scheme(HHRS) was launched at the end of 2008 in responseto the decline in health delivery services and majoroutbreaks of cholera. The situation in 2008 wascompounded by a low rate of staff turnout and a highpercentage of skilled workers seeking alternative

livelihoods and leaving the public health institutions. In response to this situation, funding partners and theMoHCW created the HRRS, as an emergencyintervention to attract public health workers back towork and to retain skilled workers by providing themwith temporary allowances.

The HHRS was successful in motivating staff to returnto work and improving attendance rates by payinghealth workers allowances. The intervention resulted in a decrease in vacancy rates, with some institutionsreporting no vacancies by September 2009. Between2008 and 2011 the HRRS has enabled the return andretention of between 16,527 to 20,555 health workers.33 34

32 See CCORE, Vital Medicines and Health Services Survey, Round 6 September 2010 33 UNDP HRRS Verification exercise report Dec 200934 Administrative data from the Human Resource Board March 2011

Key Human Resources forHealth Issues

As outlined in the National HealthStrategy (2009 - 2013 p 96)

l Failure to contain and manage brainand skills drain

l Inequitable distribution of healthprofessionals within the sector

l Unattractive retention incentivemeasures at all levels of care andmanagement

l Poor succession planning

l Low outputs from specialist trainingareas

l Absence of bilateral/internationalagreements relating to HRHrecruitment


2.2 Rationale for the HTF pooled-fund model Despite the priority given to MNCH in the Ministry ofHealth and Child Welfare's Health Investment Case,the elaboration of the new national Child SurvivalStrategy and the Reproductive Health Roadmap, thereis currently no coordinated national-scale initiative toaddress the rising maternal, neonatal and childmortality rates, to support the MoHCW in implementingthese important policy priorities and to ensure user feesare removed for key groups.

In recent years and despite a resource constrainedenvironment, health partners have been workingtogether to support the MoHCW in technical, policy andoperational areas related to maternal, newborn andchild survival and health systems as well as manyother areas. Although several donors have alreadymade commitments or are planning to increase theirefforts in these areas, and despite the increased global(such as G8 Muskoka Initiative, UN SecretaryGeneral's Initiative and the EU initiative on the healthMDGs) and regional focus on MDGs 1c, 4 and 5 (Suchas CARMMA and AU nutrition and maternal healthinitiatives), Zimbabwe will not meet any of the healthand nutrition related MDGs without a major newconcerted effort. Success on MNCH outcomes as wellas related nutrition and HIV goals is entirely dependenton the functioning of critical health system buildingblocks. These foundations include human resources forhealth (including the health worker retention scheme);reliable and adequate supplies of essential medicines;and decentralization of financial resources to the most

peripheral health facility level. However, funding forthese types of support has been inadequate andunpredictable.

A pooled fund will support government implementationof the national health sector strategy, including policydevelopment, planning and monitoring. MoHCW willlead in determining priorities, rather than coordinate amultiplicity of efforts. Pooling funds will assist inproviding coherence for existing donors under onenational initiative and set of objectives while alsoensuring gaps unable to be met by one donor arecovered by another and therefore helping to mitigaterisks. Coordinated use of resources will maximizeimpact and reduce both transaction costs, and the riskof duplication of efforts.

While the fund is a transitional mechanism aimed atbridging towards sector financing, it will also allow forcontinuity of critical health system functions under allcontingencies, including humanitarian funding shouldthe need arise. The initial focus will be on the four coreareas but the fund will be flexible enough to focus onadditional areas in the future. Other pooled funds -including ESP, ETF, Child Protection Fund (formallyProgramme of Support) and PRP - have demonstratedthat it is possible to galvanize a national scale,coordinated multi-donor response, and a similarapproach is proposed for MNCH and the health sector.Coordination across programmes, such as, sharingdirect programme support costs where possible, willensure effectiveness, accountability, transparency andbenefits from economies of scale.


3.1 Goal/Purpose/Objectives

Goal: to contribute to reduced maternal mortality (by3/4) and under-5 mortality (by 2/3) (MDGs 5 and 4) andeliminate user fees for children under-5 and pregnantand lactating women by 2015. The programme alsoaims to contribute halving the prevalence ofunderweight in children under-5 (MDG 1c) andcontribute to combating, halting and reversing trends inHIV and AIDS, Malaria and other prevalent diseases(MDG 6) by 2015.

Purpose: to improve maternal, newborn and childhealth by strengthening health systems and scaling upthe implementation of high impact MNCH interventionsthrough support to the health sector.

Objectives: (by Thematic Areas)Within the MoHCW vision and MoHCW thematic goalsof Disease and Population, Health Systems, andDeterminants of Health, the HTF covers objectives infour key thematic areas. The specific objectives andlinked MoHCW goals are provided in section 5 and inthe logical framework at Annex I (see separatedocument).

3.2 Scope of the HTF Achievement of these goals is anticipated to assistZimbabwe in reaching MDGs 1 (Target c), 4, 5 andcontribute to MDG 6 over five years. In particular, thefund aims to facilitate the delivery of a primary health

1) Maternal, Newborn and Child Health, andNutrition

* Enhance Obstetric and Newborn CareCapacity of the Health System

* Improve the Community Health ServicesSystem for MNCH and Nutrition

* Improve Child Health through Strengtheningthe EPI and Integrated Management ofNewborn and Childhood Illnesses

* Strengthen National Capacity for Maternal,Infant and Young Child Nutrition.

2) Medical Products, Vaccines and Technologies(Medicines and Commodities)

3) Human Resources for Health (including HealthWorker Management, Training and Retention)

4) Health Policy, Planning and Finance (includingsupport for the Health Services Fund)

3 Goal / PurposeObjective

The Four Key HTF Thematic Areas

care package free of charge to pregnant and lactatingwomen and children under-5 years. In the longer termother groups such as those above 65 years of age andthose with selected special conditions could beincluded, as indicated in Government policy.35

The HTF takes its design from the key objectives andstrategies outlined in the pillars of the National HealthStrategy (2009-2013): Equity and Quality in Health - APeople's Right (NHS, 2009) and the related Annual

35 See the 2011 MoHCW Performance contract and ZNHS documents for example. Planning for expansion of the fund to support these areas will be in consultation with MoHCW and funding partners


Work Plans/Performance Contracts.36 The HTF alsodraws on the Child Survival Strategy (2010-2015) andaligns to priorities identified in both the HealthInvestment Case (2010-2012) and the ReproductiveHealth Road Map (2007-2015). The HTF design,objectives and strategies stem from these MoHCWplans and will be reviewed by the HTF SteeringCommittee at critical points.

An overview of the MoHCW vision is provided in Figure 7. Those areas initially prioritized by the HTF are highlighted.

Within the MoHCW overall strategy for health there are33 specific goal areas identified. Of these 33 areas,37

(under the thematic areas of disease and population,and health systems),38 the HTF will work towardsaddressing 20-23 (directly and indirectly)39 within thefirst year of implementation (2011-2012). Although noother major national donor-funded pooled fund has anexplicit emphasis on maternal and child survival, thisfund will complement and coordinate with other existingrelated initiatives supported by the MoHCW, bilateral,multilateral, and civil society organizations.

HIV interventions are not a major focus of this pooledfund initially, because of the existing financingmechanisms in Zimbabwe (such as the HIV-Levy andGlobal Fund). However, HIV is inextricably linked tomaternal and child health and support will be given tothe MoHCW to strengthen service integration.Strengthening MNCH overall will also strengthen thecontinuum of HIV prevention, care and treatment forwomen and children. In addition it is important to notethat a complementary initiative is being developedthrough UNFPA on neglected issues on women'shealth. However, in future, the HTF could includesupport for strategic high impact HIV-related initiativesshould the need arise.

Interventions related to the water sector, particularlyinfrastructure-related programmes, are currently notsupported through the HTF. They are, rather, supportedby other sector specific financing mechanisms andincorporated in complementary programmes such asthe WASH Emergency Rehabilitation and RiskReduction initiative, with which the HTF will coordinate.

36 Focus areas of the HTF were also informed by supporting research in Zimbabwe Demographic and Health Survey 2005/6, Multiple Indicator Monitoring Survey2009 (MIMS), Maternal and Perinatal Mortality Study 2007 (MPMS).

37 MoHCW, 2009. The National Health Strategy for Zimbabwe (2009-2013) Equity and Quality in Health: A People's right p 31 38 Note that Health Promotion under determinants of health goals in the NHS focuses on WASH and school based strategies. Health promotion activities as they

relate to IYCF however, are included in the HTF in the MNCH and Nutrition thematic area. 39 This figure taken from goals relevant to the HTF thematic areas outlined in the National Health Strategy for Zimbabwe (2009-2013). It should be noted howev-

er, although aligned, these goals do not directly correlate to objectives in the MoHCW performance contract.

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Nonetheless, health promotion activitiesare included, particularly those that fallwithin the responsibilities of the VillageHealth Workers, such as demand-ledhygiene and sanitation campaigns(relevant to Zimbabwe National HealthStrategy 'Determinants of Health'goals), with an emphasis on handwashing with soap and zero opendefecation in village level interventions.


4.1 Thematic areas descriptionA broad overview of key intervention areas by thematicarea is outlined below.

4.1.1 Thematic Area 1: Maternal, Newbornand Child Health, and Nutrition

Objectives

Related National Health Strategic Plan (NHSP) Goals:40

Reduce by two-thirds, between 1990 and 2015, theunder-5 mortality rate (MDG4), Reduce by three-quarters, between 1990 and 2015, the maternalmortality ratio (MDG5), Halve the prevalence ofunderweight in children under-5 years of age by 2015 (MDG1c)

The objectives for Thematic Area 1 focus on outcomesin Obstetric and Newborn Care, Community Healthservice delivery, and strengthening the ExpandedProgramme for Immunization (EPI) and IMNCI andNutrition.41 In particular, these objectives supportMoHCW capacity to introduce, improve, implement,supervise, monitor and evaluate national evidence-based, cost effective interventions and best practices in

order to raise minimum standards of health services formothers, newborns and children. This thematic areaalso includes advocacy, communication and awarenesscampaigns that aim to increase knowledge about userfees policies and access to healthcare, particularly inrural areas.

Key Activities

A major focus is on the perinatal period where rates ofboth maternal and newborn death are highest.42

Capacity building, training, procurement anddistribution of essential equipment and supplies andsupportive supervision of critical cadres of healthworkers required for this scale-up are included.Activities for year 1 are linked to the MoHCWperformance contract43 and will continue, with review,over the five year programme period. Linked to allinterventions, including research and facilities support,this thematic area also includes advocacy forabolishing user fees at all facilities for pregnant andlactating mothers and children under-5 in particular.

Activities within the sub-sets of this thematic areainclude:44

4 Planned Results and Thematic Areas

40 Sub-objectives with targets for year one are indicated in performance contract. Related goals to Thematic Area 1 ZNHS: p. 14 41 See Annex I for full logical framework matrix, including expected results relating to these actions. 42 Munjanja, S. Maternal and Perinatal Mortality Study, 2007, MoHWC Zimbabwe (http://www.UNICEF.org/zimbabwe/ZMPMS_report.pdf) 43 The performance contract is derived from the Zimbabwe National Health Strategy and is a one year work plan signed off by the MoHWC. The HTF takes its key

strategies and areas of intervention from this document. 44 See Performance Contract for more detail on activities planned.


4.1.1.1 Enhancing Obstetric and NewbornCare Capacity of the Health System

Activities aim to significantly improve access to ANC (to90 per cent), skilled birth attendance (to 80 per cent)and relevant emergency obstetric and postnatal care.Implementation of these activities will be monitoredregularly through support to the MoHCW systems.

The programme aims to achieve a minimum standardof at least one midwife for every 5,000 people. ForZimbabwe, a total of 2,000 to 2,500 midwives wouldneed to be deployed in all health facilities includingrural health centers. Currently, there are around 500midwife nurses practicing in the country; therefore anadditional 2,000 midwives are required to fill theremaining gap. Trainees will be drawn from the pool ofRegistered Nurses currently practicing. They will berecruited nationally and enrolled into midwifery trainingschools for a period of one year.

Initially the capacity of midwifery training schools will bestrengthened to enable the schools to providecompetency-based midwifery training. This will beachieved through:

l Revising the current midwifery training curriculum(for RGNs and PCNs) to provide competencybased comprehensive midwifery education thatproduces fully qualified midwives;

l Increasing the number of fully functional midwiferyschools from 13 to 20. The existing 13 midwiferyschools that are functional are seriouslyunderstaffed, with only two to three midwifery tutorsin each school. There are an additional sevenpotential schools which can provide fully fledgedcompetency based training if support is provided inselected areas, such as human resources, teachingmaterials and supplies. Therefore the HTF willsupport a total of 20 midwifery schools whichrequire varying levels of support in different areas ofcapacity in order to render them fully functional.Each school is expected to produce around 25

midwives per year;

l Ensuring availability of five midwifery tutors for eachmidwifery school; that is 100 tutors. There are 30midwifery school tutors currently in practice whorequire only on-the-job type refresher training. Theremaining 70 new tutors will be recruited primarilyfrom the pool of current practicing midwives andfrom outside the country. Where necessary, they willreceive training on teaching methodology andselected refresher trainings;45

l Provision of regular refresher training on maternaland newborn life-saving skills, including neonatalresuscitation for all currently practicing midwives;and

l Strengthening policies for retention of midwives.After graduation, midwifery nurses will be bonded toan equivalent year of service for each year oftraining received. Together with the national healthworker retention scheme and improving the skills ofother health workers (such as PCNs, PGNs andVHW), this plan is expected to support a conduciveworking environment for health workers to keepthem motivated to work for longer periods,especially in rural health centers.

Conducting regular supportive supervision is critical toreinforce the skills of already deployed midwives andPCNs. The supervision will also assess overall clientsatisfaction and identify problems related to stock-outsof essential supplies and consumables. Clientsatisfaction will be measured through exit interviews ofwomen attending care with their infant(s) to assesstheir level of satisfaction with the service.

Regular supportive supervision will remain one of themost important mechanisms for quality assurance forthe provision of standard MNCH services. Currentefforts to improve supportive supervision will bestreamlined and an integrated and standardized tool forsupportive supervision will be developed in consultation

45 There is a global shortage of midwifery tutors. This strategy helps to produce more midwifes with the capacity to tutor. Other schemes and potential partners inZimbabwe and the region working to increase the available pool of tutors will be explored by the HTF, this will include teamwork training, twining and regionalpartnership arrangements, improving access to training and teaching (such as those outlined in the Scaling Up, Saving Lives Task force for Scaling UpEducation and Training for Health Workers (Global Health Alliance, WHO, GHWA 2008) Report.


Based on priorities and gap analysis, the HTF will consider support to revitalize the Maternity(Mother/Baby) Waiting Homes (MWHs), to make themfully functional. These homes are vital to ensureincreased access to Emergency Obstetric andNeonatal Care (EmONC). This strategy will also ensureall high risk mothers are in contact with health facilitiesbefore and after delivery to address problems related tothe 'three delays' in order to allow for earlyidentification of and intervention for life threateningcomplications for both the mother and the newborn. Asmost mothers stay an average of three to four weeks inMWHs, the MWHs provide an excellent opportunity tointroduce key maternal and newborn health practices,such as early initiation and exclusive breast feeding,thermal care, hygiene, family planning and early careseeking behaviors for danger signs for her and thenewborn. Postnatal care will also be strengthenedthrough training and supportive supervision of all health workers.

It is widely recognized that family planning contributesto reducing maternal mortality by reducing the numberof births and, thus, the number of times a woman isexposed to the risk of mortality. Family planningreduces maternal mortality directly through reducingexposure to unintended pregnancy and indirectly,through reducing high-risk births as a consequence of

timing, spacing, and parity.46 Recognizing the significantrole of family planning in reducing maternal mortality, ifrequired the HTF will complement other support in thisarea to improve the national contraceptive prevalencerate over the next five years.

Advocating for the enforcement of the existing userfees policy is imperative to mitigate demand sidebottlenecks and barriers that impact equitable access.A comprehensive advocacy strategy and awarenesscampaign that explains the costs of healthcare,promotes transparent understanding of investments inthe health system through the HTF and promotes rightsto health care will increase demand for abolishment ofuser fees for vulnerable groups at all levels.

There is also a need to address barriers to maternal,neonatal and child health for specific groups of thecommunity such as Apostolic sects, for whom theproblem goes beyond financial and geographicalbarriers. There will be a need to design specialimplementation approaches to address issues ofmaternal and neonatal health with these communities.

The HTF will complement ongoing essential equipmentand supplies for maternal and newborn healthinitiatives with special emphasis on providing supplies,equipment and consumables to all primary healthcentres. This includes upgrading operation rooms,

46 John Stover and John Ross: Maternal Child Health J DOI 10.1007/s10995-009-0505-y, 2009

with the MoHCW and other partnersfor roll out within the HTFintervention period. In addition,supportive supervision will becomplemented with regular annualreview meetings to assess the statusof programme implementation. Thematernal and newborn audit systemwill also be revitalized. Thisapproach will be further supportedthrough integrated education andtraining strategies and strengthenedmanagement information systemsfor the health workforce.


laboratories and blood banks as well as training andrecruitment of key health professionals.

In addition, in order to strengthen the key referralsystems the HTF will support:

l Review, standardization and introduction of referralguidelines and tools for facility and communityMNCH and nutrition; and

l Procurement and distribution of ambulances to all district hospitals as well as communicationequipment for health facilities.

4.1.1.2 Strengthening the communityhealth service delivery system forMNCH and Nutrition

The HTF will support activities that will revitalize healthcommittees in all districts and strengthen community-based and targeted case management services. Toensure the continuum of care from the household levelto the health facility, empower families to take care oftheir own health and strengthen the health careseeking behavior of the community, the HTF will focuson the following activities:

l A Village Health Worker (VHW) situation analysiswill be conducted to assess the geographicaldistribution of VHWs and their scope of work;

l VHW training materials on MNCH and Nutrition andutility kits will be revised, updated and standardized.In-service and pre-service training for approximately17,000 VHWs will be provided in line with theupdated materials. Community-based casemanagement training for VHWs on selected MNCHproblems will also be included;

l Revitalization of health centre health committees;

l Social mobilization efforts to engage Apostoliccommunities and other religious groups usingpurposefully designed programmes andapproaches;

l Social mobilization and community basedawareness campaigns on user fees policy and rightto health care; and

l Capacity development of VHWs to promote hygieneand sanitation in order to increase hand washingwith soap at critical times from 10 per cent to 80 percent and to achieve Zero Open Defecation (ZOD) inall villages (100 per cent).

4.1.1.3 Improving Child Health ThroughStrengthened EPI and IntegratedManagement of Newborn andChildhood Illnesses.

Activities in this area contribute to an increase in fullimmunization coverage (including new vaccines). Theyalso aim to increase the proportion of newborns andchildren treated for key neonatal and childhoodillnesses.

Building on existing WHO and UNICEF support to EPI,activities to strengthen routine EPI services include:

l Revise, update and standardize training materialsfor Reach Every District (RED) approach and forMid Level Management for immunization (MLM),such as microplanning and cold chain managementetc. and conduct associated training with relevanthealth personnel and managers;

l All EPI vaccines (antigens), injection supplies andrelated consumables will be procured anddistributed, with logistics and financial support forregular monthly outreach services;

l Support the development of a proposal to GAVI forthe inclusion of new vaccines (pneumococcal androtavirus) into the routine EPI system; and

l Support the MoHCW in the prepartion to introduceand roll out new vaccines according to the GAVIrecommendations for new vaccines.

In order to build health workers capacity to assess andmanage common childhood illnesses (including HIV,neonatal sepsis, pneumonia, diarrhea, severe acutemalnutrition and malaria) the following activities will beundertaken:

l Revising and standardizing the Integratedmanagement of newborn and childhood illnesses(IMNCI) training material (integrated with updated


management of early newborn problems, Ped-ARTand management of acute malnutrition);

l Training on IMNCI (facilitators, course directors,clinical facilitators and health workers) at primaryhealth centre level;

l Incorporation of the updated IMNCI trainingpackage into pre-service training of the PrimaryClinical Nurses (PCNs) and Registered GeneralNurses (RGN); and

l Training on 'follow up after training' to district andprovincial health managers and master trainers(supervisory skills); and development anddistribution of IMNCI drug kits.

4.1.1.4 Strengthen National Capacity (at alllevels) in Maternal, Infant and YoungChild Nutrition

In order to expand high impact nutrition interventions47

(that give priority to increasing exclusive breastfeeding,complementary feeding, micronutrientssupplementation and treatment) at facility andcommunity level, nutrition activities supported by theHTF will focus on integration of these interventions intoMNCH services, by strengthening the capacity ofnutrition managers and implementers throughknowledge transfer, skills development, supportivesupervision, provision of policy, strategies andguidelines and evidence based advocacy.

Activities supported by the HTF will include:

l Comprehensive analysis of gaps and developmentand dissemination of key policy and relatedstrategies/guidelines including the national food andnutrition policy,48 comprehensive national nutritionstrategy and national nutrition communicationstrategy;

l Ensure improved and integrated materials and toolsfor scaling-up effective interventions on optimalbreastfeeding and complementary feeding -

practices for use at all levels of health professionals;

l Conduct relevant training to all facility andcommunity health workers;

l Review, update and standardize the national growthmonitoring system and standards (using most recentWHO recommendations) and conduct the relevanttrainings;

l Assess gaps, update guidelines/tools and conductrefresher training on micro-nutrition supplementationto health workers in all health facilities (prioritizingprenatal and postnatal Vitamin A supplementation towomen, Vitamin A supplementation to children 6 to59 months and supplementation of Zinc duringdiarrhea);

47 Including: Maternal Iron/folate supplementation, immediate breastfeeding, Exclusive breastfeeding, timely introduction of appropriate complementaryfoods, zinc in treatment of diarrhea, vitamin A supplementation, treatment of acute malnutrition, deworming of children

48 The development of the national food and nutrition policy is being supported by UNICEF, WFP, WHO and FAO, and WHO.


l Further adapt and finalize guidelines and protocolfor treatment of acute malnutrition and ensure thattreatment of Severe Acute Malnutrition is routinelyprovided in all facilities;

l Integrate IYCF counseling, supplementation ofmicronutrients and treatment of severe acutemalnutrition into routine child and maternal healthservices, including ANC, PNC, PMTCT, IMNCI,Pediatric HIV and others; and

l Strengthen capacity of the nutrition systemnationally to ensure integration and supportivesupervision of direct nutrition interventions (mainlythough the health sector) as well as intersectorallinkages/indirect interventions (such as throughAgriculture, WASH).

The HTF also includes a comprehensive review of thestatus of high impact nutrition interventions to date aswell as formative research to define barriers andfacilitators of optimal breastfeeding, complementaryfeeding and maternal nutrition practices. Acomprehensive assessment of the national nutritionsystem's ability to support direct interventions (mainlythough the health sector) and inter-sectoral linkageswill also be conducted. Furthermore, where gaps doexist, capacity development of key nutrition personnelwill be pursued at all levels.

4.1.2 Thematic Area 2: Medical Products,Vaccines and technologies(Medicines and Commodities)

Objectives

Related NHSP Goal:49 Increase access to andutilisation of quality primary health care services andreferral facilities through health systems strengtheningand ensuring availability of essential healthcommodities

The objective for Thematic Area 2 is to maintain theavailability of 80 % of essential medicines andcommodities (the selected package based on the WHO

recommendations applicable to Zimbabwe) and 100 %of vaccines and injection equipment, cold chainequipment and nutrition commodities in all healthfacilities across Zimbabwe by 2015 . In particular thosesupplies required to scale-up interventions foraccelerating MDGs 1, 4 and 5 are included.

Key Activities

Key activities within this thematic area include theprovision of selected essential medicines and medicalsupplies, the procurement of vaccines, injectionmaterials and cold chain equipment for immunization,emergency obstetric care equipment, newborn caresupplies, including early infant HIV diagnosis, ready touse therapeutic and supplementary nutritioncommodities, and potentially micronutrient sprinklesand lipid-based supplements50.

Reproductive health commodities may also eventuallybe included as well as essential supplies for NationalChild Health Days (NCHDs) and for tertiary facilities.

Provision of essential capital equipment for MNCH andnutrition activities covered in this area includes:

l Comprehensive inventory of needs for capital healthfacility equipment at all levels through the IntegratedHealth Facility Assessment;

l Procurement and distribution of capital healthfacility equipment as needed;

l The maintenance and repair of equipment; and

l Annual reviews of capital equipment functionality.

The HTF will finance the strengthening of NatPharmand MoHCW counterparts in integrated management ofessential medicines and health and nutritioncommodities to increase access, use and quality ofprimary health care services across Zimbabwe. Therecent NatPharm System Assessment noted thatNatPharm capacity for distribution of essentialmedicines is limited and continued support for theharmonisation of distribution resources would make themost efficient use of available resources and ensure

49 Sub-objectives with targets for year one are indicated in performance contract. Related goals to Thematic Area 2 ZNHS: p 18 50 There is an estimated 40 per cent gap in Dried Blood Spot and PCR supplies for 2012 and 2013, with larger gaps in subsequent years up to 2015.


equitable distribution. The HTF will work together withstakeholders within the existing HarmonizationTaskforce to support capacity building efforts.

The national Vital Medicines Programme currentlymanaged by UNICEF is included in this thematic area.The Vital Medicines Programme works withgovernment to provide all health care facilities with at least 80 per cent stocks requirements of agreedselected essential medicines and supplies and tostrengthen supply chain management.

The HTF will also provide support to the quarterly VitalMedicines Availability and Health Services Survey(VMAHSS) that has proved essential in ensuringsufficient monitoring coverage for a programme of thismagnitude. Spot checks will also be carried out. A DrugInformation System which will focus on collectinginformation on stock at hand, consumption and anylosses or adjustments to the system will be set up aswell as support provided to Logistics ManagementInformation Systems.

To ensure that availability is not affected by irrationalprescribing or dispensing habits, the HTF plans tosupport the MoHCW DPS drug management trainingexercises for district pharmacy managers and ruralhealth worker staff as well as to continue to distributethe 2010 revised Standard Treatment Guidelines(EDLIZ) to health workers for reference.

Training of rural health workers is a key step intransitioning from the push to the pull system fordetermining medicine requirements at the decentralizedlevel. The curricula focuses on calculation of minimumand maximum medicine stock levels, calculation of re-order levels and how to place requisitions. The trainingstrategy, with support to the DPS supervisory activities,will promote good drug management practices such asthe use of stock cards to manage stock, determinationof average monthly consumption for quantificationpurposes and minimum and maximum stock levels atfacilities to avoid expiry of commodities and to makeeffective use of resources.

4.1.3 Thematic Area 3: Human Resourcesfor Health (including Health WorkerManagement, Training and Retention)

Objectives

Related NHSP Goal:51 To reduce the vacancy levelsacross all staff categories by 50%

The objective for Thematic Area 4 is to ensure that95% of health management offices and health facilitiesare staffed with the minimum standard of qualifiedhealth professionals by 2015.52

Key Activities

This thematic area will also support MoHCW in HumanResources management and planning. Activities in thisthematic area ensure the Health Worker RetentionScheme (HWRS) is resourced, coordinated andeffectively administered within a framework thatenables an affordable harmonized national retentionallowance that complements government salaries andhelps retain critical health sector workers. The HWRS(direct cash transfers to workers) will be administeredby an appropriate contractor to support key strategicpositions within the MoHCW, approved by the HSFSteering Committee, through 'top-up' salary payments.Support for Human Resources for Health is linked to allsystem strengthening work supported by the HTF andsits across the four thematic pillars (see Figure 8).

51 Sub-objectives with targets for year one are indicated in performance contract. Related goals to Thematic Area 4 ZNHS: p 18 52 This objective links to the ZNHS goal: To ensure that the health system based on PHC has appropriate numbers and categories of Human Resources for

Health for efficient and effective implementation of the National Health Strategy (Goal 23 NHS).


Further, considering these areas of support for HumanResources across the HTF pillars, the relationshipbetween scaling up support for the health workforceand MDG health outcomes is described in Figure 9.

The diagram shows how immediate steps can lay thefoundation for longer term outcomes and achieving theMDGs within the 5 year programme. For example, therapid scale up of large numbers of community healthworkers and supervisors in a well managed healthsystem can significantly improve access to preventativeand curative interventions for child health andcommunicable diseases (MDG 1c, 4 and 6). Increasesin mid-level cadres including midwives and midwiferytutors/assistants, will also help reduce maternalmortality (MDG 5).53 The HTF focuses on medium termand quick win interventions as the foundation forcomprehensive support. Further, the focus on HumanResources will help counter the increased workload forstaff as demand for services increases with therealization of the user fee policy.

The HTF's support to human resources under thematicarea 3 (the health worker retention scheme andtechnical assistance) are outlined in figure 9.

53 See Global Health Workforce Alliance, 2008. Scaling Up, Saving Lives Task force for scaling up Education and Training for Health Workers

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4.1.3.1 Health Worker Retention Scheme(cash payments to workers)

The Health Worker Retention Scheme aims to ensurethat the health system, based on Primary Health Careprinciples, has appropriate numbers and categories ofHuman Resources for Health for effective and efficientimplementation of the National Health Strategy.54 Inparticular, the scheme aims to provide salary incentivesthat reduce clinical and managerial turn-over andvacancy rates of essential staff nationwide, targetingareas and levels of critical need. Priorities for supportinclude the Human Resources Directorate (with view toimproving capacity in overall data analysis to betterinform policy decisions) as well as front lineprofessionals and village health workers.

The HWRS has been successful in returning healthworkers to facilities and improving vacancy rates. Sinceits inception the scheme has steadily increased thenumber of workers receiving top-up payments (seeFigure 10).

The HTF support to the HWRS aims to complementand work with existing initiatives supporting HumanResources for Health, with a view to coordinating,aligning and where possible streamlining other fundingmechanisms, such as the Expanded SupportProgramme, bilateral donor institutions and GlobalFund Round 8 commitments.

Over the next five years the scheme will be co-financedby the HTF contributions from donors and thegovernment with a phased-down approach. The HTFcommitment will initially support 94 per cent of thescheme’s costs in the second half of 2011 with aphased out approach to zero per cent in 2015 asgovernment resources become increasingly available.Over the five years government will increase wages forhealth workers as well as take on full payment ofsalaries by 2015. Table 1 shows the tentative schemearrangements and exit strategy. Although the HTF and

government current commitments will fund the majority,a seven per cent shortfall currently remains unfunded.

The scheme aims to support a projected quota of22,065 workers in the public system over the next fiveyears. Any additional health workers will be fullysupported by government (rather than the HTF).

The allowances will be paid in line with the grades andconditions set out in the MoHCW Reviewed Short-TermHuman Resources Retention Policy (April 2009) and2011 MoHCW projections. These costs, presented inTable 1, include all positions C5 and above55 as well asadjustments for rural workers incentives. Ruralincentive payments are critical to retain and attract staffin areas where vacancy rates are higher and healthcare coverage is lower.

Payments of HTF funds to health workers will be madedirectly into employees' bank accounts through acontracted service provider. The terms of reference forthis contract will be agreed within the HTF SteeringCommittee.

54 Zimbabwe National Health Strategy page 96 - 10155 C5,D1,D2,D3,D4,E1,E2,E3,E4,E5 (1), E5(2), F and F+. Deployed workers (Cuban) do not come under the scheme, however are

included for rural incentive adjustments.

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Source: MoHCW, 2011


4.1.3.2 Technical Support for HumanResources Planning and Management

In addition to the details outlined in the Health WorkerRetention Policy the HTF proposes to also support keystrategic positions within the MoHCW. These positionswill be proposed by the Human Resources Taskforceand other MoHCW stakeholders including the Directorof HR and the MoHCW finance team. Support to thesepositions will be co-financed from the MoHCW and theHuman Resources for Health phased commitmentsfrom the HTF. These key staff will support timely and

accountable financial liquidation, monitoring of healthtransition progress and outcomes, and resourcemanagement, particularly at the district level.

The communication and planning processes in the HTFwill ensure that posts supported by donors and fundingmechanisms are coordinated and harmonized acrossthe MoHCW. This harmonization will occur at variouslevels of implementation, ensuring no duplication orgaps in key roles.

56 Government will also introduce additional wage increases to ensure incremental salary increases for employees over the five years. 57 This plan assumes additional health workers (beyond the assumed fixed number of 22,065 minimum standard) will be supported by government and not HTF

funding.

Health Worker Retention Scheme Commitments (2011 - 2015)

(6 mths) Total (4.5 Year 1 Year 2 Year 3 Year 4 Year 5 years)

Government commitment (% of the scheme that will be covered by government).56

Government's increasing commitment to scheme in US$ (excluding additional payincreases) Support required for the

Retention Scheme(unfunded by governmentUS$)

HTF's decreasing commitment to the Scheme in US$

HTF commitment (% ofscheme costs that will becovered by HTF)

Total cost of Scheme(22,065 workers)57

Gap (shortfall not fundedby HTF or government current commitments) US$

0% 25 % 50% 75 % 100 % -

- 8,512,254 17,022,497 25,532,740 34,042,983 85,110,474

17,021,491 25,530,729 17,020,486 8,510,243 (funded by 68,082,949 government)

16,000,000 19,000,000 14,100,000 8,510,243 (funded by 57,610,243government)

94% 56% 41% 25% 0%

17,021,491 34,042,983 34,042,983 34,042,983 34,042,983 153,193,423

10,472,706 1,021,491 6,530,729 2,920,486 0 0 (7%)

Table 1: Health Worker Retention Scheme Commitments (2011 - 2015)


In addition to incentive 'top-up' payments through theHWRS, the MoHCW will be supported with technicalassistance in health workforce planning anddevelopment and implementation of a staged NationalHuman Resources Strategy and strengthenedmanagement capacity.

The development and implementation of the humanresources strategy will include the followingconsiderations:

l Review and develop bi-lateral agreements based onthe 2010 WHO code of practice on internationalrecruitment of health personnel and best practicerecommendations for scaling up education andretention of health workers (particularly midwives).58

l Strategic targeting for scaling up education andtraining for health workers, including considerationof 'institution twinning' and regional partnershipsarrangements.

l Use of health information systems for modelingcurrent and future health needs and health workerrequirements as a basis for developing strategicplans.

l Indicators and targets relating to health workforceplanning and development including monitoring ofhealth labour market absorption capacity (such asconsidering quantitative indicators on deploymentand retention).

l A sub-strategy on communication that helps toattract and retain health workers (considering theimpacts of migration of workers within the sector).

The HWRS will be a key component of the HumanResources Strategy, including monitoring progresstowards the phased-down approach in HTF funding.

In addition to the Human Resources Strategy andrelated plans, management systems will also bestrengthened through provision of technical support.Such work will include improving ethics policies,appraisal systems and clinical audits. Technicalsupport will also assist in future planning for the HWRS.

4.1.4 Thematic Area 4: Healthpolicy, planning and finance(Health Services Fund andResearch)

Objectives

Related NHSP Goal:59 Increase access to andutilisation of quality primary health care services andreferral facilities through health systems strengthening

The objective for Thematic Area 4 is to improvenational capacity for policy, planning and financingacross all health service delivery levels,60 with specialemphasis on the most peripheral health facilities by2015 .

Key Activities

Interventions in health policy, planning and financeinclude financial support to peripheral health facilitiesthrough the Health Services Fund and externalMonitoring and Evaluation and Operational Researchand provision of Technical Assistance.

58 See for example Task Force for Scaling up Education and Training for Health workers, Global Health Workforce Alliance recommendations in Scaling UP,Saving Lives Task Force for Scaling up Education and Training for Health workers, Global Health Workforce Alliance, 2008

59 Sub-objectives with targets for year one are indicated in performance contract. Related goals to Thematic Area 3 ZNHS: p 12960 This objective links to the ZNHS goals: to increase the levels of sustainable and predictable financial resources to ensure provision of high quality services to

the population (Goal 29 NHS), and to strengthen capacity to formulate, develop and implement health policies and regulations (Goal 31 NHS).


Evidence from other countries show that three healthsystems reforms are required to facilitate the removalof user fees - namely adequate essential medicines,motivated and equipped personnel, and funding formaintenance and running costs of health facilities. The International Health Partnership, for example,recommends that funds be set aside for monitoringperformance, evaluation, operational research andstrengthening health system information systems.61

Human resources, routine activity and outputmonitoring and essential medicines are addressedthrough other HTF thematic areas. Complementingother system reforms included in the HTF design,activities under this thematic area will support vitalhealth facility maintenance costs through support forthe Health Services Fund and a robust monitoring,evaluation and research framework.

4.1.4.1 Revitalising the HealthServices Fund The Health Services Fund was initially established inSeptember 1996 to expand and improve servicedelivery through decentralized funding to DistrictHospitals (DHs) and Rural Health Clinics (RHCs). The HTF aims to revitalise the existing financingmechanism to cover selected running costs andmaintenance expenses of health facilities. In particular,through increasing and decentralising financialresources using the Service Fund procedures it isenvisaged that the support from the HTF will facilitatethe delivery of a primary care health package free ofcharge for all children under-5 years, pregnant women,people over 65 years of age and a few selectedadditional groups, as indicated in government policy.

The types of costs covered by the Health ServicesFund are primarily non-capital investments and includeutilities (such as water, electricity, communication,transport), basic commodities and maintenance (suchas soap and cleaning products, electrical bulbs, bedsheets and blankets, fuel, minor repairs) and funding tosupport community based interventions (such as healthoutreach activities).

A 2010 World Bank mission confirmed that theServices Fund structure and system are used by theDistrict Health Executive Teams (DHET) for thefinancial management of the user fees revenues underthe supervision of the Provincial Medical Directorates(PMDs).62 The assessment found the system andstructure to be sound and relevant for decentralisedhealth financing. However, because of the low incomebase, facility maintenance has been constrained. Theincreased revenue for the HSF aims to provide theincome necessary to enable MoHCW to enforce theuser fees policy, mitigating motivations to charge fees.

Impact on User Fees

The 'Access to Health Care Services Study'63 providesinsight into the issue of user fees in Zimbabwe. Thestudy found that the majority of communities in thestudy (59 per cent) paid to access health care servicesespecially in the urban areas, commercial farmingareas and mines. In rural areas, people paid user feesat the district hospital level and in most rural healthcentres. The study also found that most people (66 percent) said they could afford to pay the fees chargedand 36 per cent said they could not. However, 62 percent of respondents did not believe that they shouldhave to pay for basic health services.

Those key informants in the study that perceived thefees to be affordable strongly believed that patient feeswere necessary to enable health institutions toreplenish stocks and maintain facilities and equipment.They also argued that since the government could nolonger afford to adequately finance health services,patients should pay; otherwise the whole system wouldcollapse. As such, motivated by the need to coverrecurrent costs, health facility managers are chargingfor services that would normally be free.

The impact of re-introducing user fees has affected theuse rate of health services. The "Assessment ofPrimary Health Care Study in Zimbabwe" (2009)recommends that a package of essential services andresources be defined and costed at primary level and

61 A common framework for monitoring performance and evaluation of the scale up for better health. International Health Partnership concept note. Health 8Meeting, January, 2008

62 PMD is the provincial office of the health system, which major task is to provide technical assistance and supportive supervision for the correct implementationof national health policy, strategies, technical and administrative procedures.

63 See Access to Health Care Services Study' (2008) http://www.mohcw.gov.zw/index.php?option=com_content&view=article&id=36&Itemid=79


that this basic level of service provision is funded anduniversally delivered by primary care clinics (central,local government, mission and other private). Thecosting of the primary health package is beingsupported as one of the advocacy and planningstrategies in the HTF.

The HTF aims to provide the support necessary toensure this primary health package is availablenationally over the next 5 years; government supportincludes all costs not covered by the HSF as well asincremental support to the Health Worker RetentionScheme. The HTF support to the Health Service Fundaddresses those recurrent costs that are directly linkedto facility-based rationale for charging user fees. Alongwith a tailored advocacy strategy, the revitalised HSFwill enable MoHCW to enforce the user fee exemptionsin MoHCW policy and increase the population's accessto health care.

As part of the final programme evaluation, theprocesses contributing to the success of user feeremoval will be reviewed. The medium term economicprospect of the country is optimistic and therefore thegovernment’s fiscal revenues will increase modestly inthe medium term. The HTF will advocate for pro-healthbudget allocations, with a view towards achieving fiscalself-sufficiency while also acknowledging limitedeconomic growth, competing demands for socialservices, and aid dependency.

HTF support to the Health Service Fund

Funds will be allocated to peripheral health facilitiesaccording to the "HSF Financial and AccountingProcedures Manual" which contains procedural andaccounting information specific to government hospitaloperations. The manual will be revised to outlineadapted modalities such as the disbursement of fundsdirectly to RHC and DH bank accounts. The fundstransfer will be coordinated by MoHCW and facilitatedby a service provider contracted by UNICEF.

Lessons learnt from the two 'front runner' districts(Marondera Rural and Zvishavane) as part of the 2011World Bank Results Based Financing programme willbe taken into account in yearly review and coordinationmeetings and future programme design. DHETs areexpected to aggregate and approve health facilities'plans/reports and provide supportive supervision and

technical guidance where necessary. These officers willalso be responsible for reporting on funds utilization toboth the MoHCW and the HTF contracted serviceprovider. The terms of reference for the contractedservice provider for this component of the HTF will beagreed by the HTF Steering Committee.

In addition to monitoring the removal of user fees by2015, other key results to be outlined in the ToRinclude:

l Consolidation and revision of the Health ServicesFund procedures including exploration andconsideration of Result Based Financing modelsimplemented in World Bank 'front runner' districts.This may involve participatory workshops with keystakeholders and reorientation/training of MoHCWaccountants and financial officers directly involved inthe management of the HSF at central andperipheral levels.

l Each health facility has a prioritized and costedAnnual Plan of Action approved and monitored byDHETs as well as a sound information systemrecording data on services provided and available.

l HSF financial resources are readily available ineach peripheral health facility and are usedeffectively according to agreed criteria.

The service provider will transfer funds on a regularbasis to each peripheral health facility across eightprovinces (excluding Harare and Bulawayo cities)according to the MoHCW list of countrywide healthfacilities. As presented in Table 2, the HTF will supportthe Health Services Fund over the next five yearsaccording to the estimated indicative amount in thefollowing table. Government will continue toincrementally support the Health Worker Retentionscheme and facility costs not covered by the HSF.

The service provider will report to UNICEF and theHTF Steering Committee in order to monitorimplementation and to ensure effective coordinationamong the different stakeholders. The service providerwill provide relevant information on implemented HSFprocedures, funds disbursement and utilization, and willimplement any recommended improvement measures.The service provider will also provide an annual auditof MoHCW expenditures at different levels and designand implement relevant visibility activities that arecoordinated with related HTF advocacy strategies.


4.1.4.2 Operational Research,Evaluation and MonitoringFramework The HTF monitoring and evaluation framework willprovide the basis for tracking progress and addressingchallenges in implementation. This framework will relyon MoHCW systems, structures and processes that willbe strengthened through various HTF interventions.Accountability for outcomes in the HTF will bemeasured against indicators outlined in the MoHCWyearly Performance Contracts (AWPs) and the HTFlogframe, which outlines tools to track progress atvarious levels. This initial monitoring and evaluationframework (to be developed at the outset ofprogramme action) is presented in the logicalframework matrix (Annex I).

Three distinctive elements are considered in thissection. These are:

a) Routine monitoring

b) Impact evaluation

c) Operational research

Routine monitoring of HTF activities have beenintegrated within descriptions of HTF thematic areas.Routine monitoring will be based on existing nationalsystems, particularly the Health ManagementInformation System (HMIS). Further, tools andprocedures, such as UNICEF's Field MonitoringSystem that captures outcomes of monitoring trips andthe Vital Medicines and Health Services Surveys(VMAHSS) will complement the MoHCW HealthInformation System. The comprehensive quantitative

and qualitative Integrated Health Facility Assessmentplanned for 2011 along with other government datacollection will be used to confirm baselines and informprogramme planning. Other key sources of informationinclude the DHS/MICS Administrative Report and datacollected by ZimStats (formally CSO).

Specific activities included within routine monitoring of the HTF include:l Routine monitoring reportsl Periodic surveysl MOHCW/health sector quarterly administrative

reports

l Regular supportive supervision; an importantmechanism for quality assurance in the provision ofstandard MNCH services and the management ofhealth commodities. Current efforts to improvesupportive supervision will be streamlined in theHTF and an integrated and standardized tool forsupportive supervision will be developed inconsultation with different programmes within theMoHCW.

l Regular review meetings to assess the status ofprogramme implementation will also bestrengthened, focusing on particular technicalcomponents of MNCH and Nutrition

l Quarterly and annual review meetings that provideupdates on programme progress and planningneeds.

The HTF will seek to strengthen national monitoringsystems including the HMIS. Specifically, the HTF willstrengthen national health information through the useof new information technologies, revitalizing systems

64 Excluding Harare and Bulawayo health facilities

Table 2: Support to the Health Services Fund over five years

Clinic/Rural Centres 1,25264 750 5,634,000 11,268,000 11,268,000 11,268,000 11,268,000District and Mission Hospitals 181 1,500 1,629,000 3,258,000 3,258,000 3,258,000 3,258,000DHEs Office 62 1,500 558,000 1,116,000 1,116,000 1,116,000 1,116,000Total Required for Health Services Fund (funded by HTF) 1,495 7,821,000 15,642,000 15,642,000 15,642,000 15,642,000

Type of facility Number offacilities

Monthlycost per

facility US$

Year 1 (6 mths)

costs US$Year 2

costs US$Year 3

costs US$Year 4

costs US$Year 5

costs US$


such as the logistics management system that willenhance reporting on key health commodityconsumption rates and the maternal and newborndeaths audit system. Ongoing routine programmemonitoring will further develop institutional capacitywithin various levels of the MoHCW by strengtheningthe current information collection and reporting systemsfor the selected core indicators included in the nationalHMIS. Registration books will be standardized, printedand distributed for coherent data collection andreporting. Supportive supervision and in service trainingon the new HMIS will be conducted in all healthfacilities, targeting staff and health mangers at all levels.

Monitoring data will be analysed to generateconclusions and recommendations aimed at adjustingand improving programme implementation. Theprogramme manager will ensure that conclusions andrecommendations from routine monitoring are followedup effectively.

b) Impact Evaluation of the HTF

Impact evaluation activities will be managedindependently from the implementation of the HTF,although the independent contractor will work closelywith the HTF Steering Committee. Independence ofsuch evaluations is considered as part of OECD DAC'skey norms and standards for evaluating developmentassistance65. Four aspects of independence66 areconsidered here:

1. Organizational independence - given the size ofthe HTF and the involvement of multiple funders,it is proposed that the impact evaluation elementsbe managed by an independent evaluationcontractor. It is also proposed that this contractorreport to the HTF Steering Committee through anevaluation sub-committee established specificallyfor this purpose. It is proposed that this sub-committee be formed of three to five independentprofessionals drawn from academic institutions,civil society organisations and the private sector.This work is provided for as a separate,earmarked line within the overall HTF budget. The evaluation contractor would have free accessto all information that they consider relevant.

2. Behavioural independence - items for inclusion in

to be approved by all individual members of theSteering Committee. The evaluation contractor willbe encouraged to produce candid,uncompromising, high quality reports, containingwell-evidenced findings and clear conclusions andrecommendations. These reports will be submittedto the Evaluation Sub-Committee of the HTFSteering Committee. Evaluation findings will bemade freely and proactively available to all HTFstakeholders, including beneficiaries and thegeneral public.

3. Protection from outside influence - theindependent evaluation contractor will be recruitedthrough an open and transparent process, basedon agreed recruitment criteria. The independentevaluation contractor and the evaluation sub-committee of the HTF Steering Committee will beresponsible for the design and execution of allelements of the impact evaluation. This willinclude design of a suitable evaluation framework.The independent evaluation contractor will beresponsible for all reports generated from theimpact evaluation. Comments from stakeholders,including the HTF Steering Committee will bewelcomed but the evaluation contractor will beresponsible for determining how these commentsshould be addressed in terms of revising thereport. The evaluation sub-committee willdetermine whether or not the report submitted bythe contractor meets required quality standards.

65 OECD DAC Network on Development Evaluation - Evaluating Development Cooperation: Summary of Key Norms and Standards66 See Picciotto, R. (2008) Evaluation Independence at DFID: An Independent Assessment Prepared for IACDI

elements of theimpact evaluationwill be selected bythe evaluationcontractor and theevaluation sub-committee of theHTF SteeringCommittee. Althoughthese items - anddetailed terms ofreference - may bediscussed with thefull HTF SteeringCommittee, they donot necessarily need


4. Avoidance of conflicts of interest67- the evaluationcontractor will operate a conflicts of interest policywhich will ensure that no individual involved in theevaluation have a conflict of interest relating to theHTF.

Elements of the impact evaluation include:

l A baseline assessment that considers and reviewspotential indicators for assessment of indicators,selects those to be used and identifies baselinelevels for them.

l Annual reviews that assess programmeachievement, challenges and opportunities. Theseannual reviews will feed into68 the programmaticreviews and planning processes described aboveand will produce annual reports which will feed intothe Mid-Term Review (MTR) and final evaluation.

l A Mid-Term Review (MTR) of technical programmeachievement and the effectiveness of HTFmanagement arrangements will be undertaken. The MTR will inform all stakeholders on progress,challenges and opportunities. It also provides anopportunity to reorient priorities if required in orderto achieve key programme goals.

l A final impact evaluation will be undertaken in thefinal year of the HTF linked to regular MDG statusreporting for 2015 and following the guidelines setforth in ‘UNICEF Evaluation Report Standards’.Existing data collection efforts in line withgovernment and global MDG monitoring will beused. The Multiple Indicators Cluster Survey(MICS/MIMS) planned for 2013 will provide mid-programme results and the next round ofDemographic Health Survey (DHS) will also provideresult data at the end of the HTF funding period.

The Independent Evaluation Contractor and theEvaluation Sub-Committee of the HTF SteeringCommittee will determine the timing, terms of referenceand composition of annual review missions, the MTRand final evaluation. The timing of the annual reviewswill be coordinated carefully with the governmentplanning cycles to ensure that the information is ofmaximum benefit to the MOHCW.

c) Operational Research

Based on the current situational analysis on health andprogramme roll out, health information gaps will beidentified. Accordingly, an operational research agendawill be developed for approval by the HTF steeringcommittee. Subsequently, suitable institutions andindividual candidates will be identified. The CCORE(Collaborating Centre for Operational Research) and allother relevant academic and research institutions willbe considered according to their comparativeadvantage. UNICEF, supported by the HTF monitoringteam, will ensure that findings are well disseminated toall stakeholders and used to inform decision makingand future programme direction.

4.1.5 Technical Support andIndirect Outcomes through HTFPlanning and ApproachA subsidiary objective in each thematic area is to assistdonor harmonization and alignment as interest grows inscaling-up actions for MDGs 1c, 4, 5 and 6. Aprogramme of technical assistance will be developedwith the MoHCW and relevant para-statal institutions inrelation to all thematic areas of support under this fund.The HTF includes technical assistance in areas ofgovernance, management, HMIS, and policydevelopment as well as technical assistance for itsprioritized thematic health care areas. Providers oftechnical assistance will be identified according to thecriteria of comparative advantage and value for money.

The management and governance arrangements of theHTF will work to strengthen and support governmentprocesses, systems and accountability in healthprogramming. The design of the HTF as a sector wideapproach helps prepare government structures forfuture receipt and direct management of donor funds. Italso assists in disaster risk reduction and preparationfor humanitarian action should the situation deteriorateor in the event of complex disasters.

67 Potential conflicts of interest include:l Official, professional, personal or financial relationships that might cause an evaluator to limit the extent of an inquiry, limit disclosure, or weaken or slant

findings l Preconceived ideas, prejudices or social/political biases that could affect evaluation findings l Current or previous involvement with a programme, activity or entity being evaluated at a decision-making level, or in a financial management or

accounting role; or seeking employment with such a programme, activity or entity while conducting the evaluationl Financial interest in the programme, activity or entity being evaluated l Immediate or close family member is involved in or is in a position to exert direct and significant influence over the programme,

activity or entity being evaluated68 Options to be considered include (i) holding these annual reviews prior to the annual programmatic review so that findings and conclusions can be con-

sidered in that process (ii) the external evaluation contractor contributing personnel to the annual programmatic review.


The strategies presented in the table below will bemainstreamed in various aspects of the HealthTransition Fund. The programme will develop analyticaltools, programming guidelines and standards to informthe choice of appropriate interventions and appropriateinstruments to monitor the extent to which theprogramme adequately addresses cross-cutting issues.

The specific issues and considerations in theprogramme are presented below. The issues aredivided into those that will be fully mainstreamed intoHTF-supported programmes and those with whichlinkages with HTF-supported programmes will bemade.

5 Coordination and Cross cutting Issues

69 Based on OHCHR and WHO The Right to Health (Fact sheet No. 31) www.ohchr.org/Documents/Publications/Factsheet31.pdf70 Article 25 of the Declaration of Human Rights includes: 1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of

his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness,disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. 2) Motherhood and childhood are entitled to special care andassistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Cross cutting issue(mainstreamed)

Mainstreaming (across the explicit activities outlined in the HTF logframe andproposal)

Gender and HumanRights69

Realization of the 'Right to Health' is inherent in the HTF programme goals. The pro-gramme goal to eliminate user fees, in particular, is a key challenge in ensuring uni-versal access to health care protected under Article 25 of the Declaration of HumanRights, with particular reference to motherhood and childhood70 as well as specificChildren's Rights (the Convention of the Rights of the Child, article 24).

The entitlements in the Right to Health are advocated, provided for and supported inthe HTF including:

l The right to a system of health protection providing equality of opportunity foreveryone to enjoy the highest attainable level of health;

l The right to prevention, treatment and control of diseases;

l Access to essential medicines;

l Maternal, child and reproductive health;

l Equal and timely access to basic health services ;

l The provision of health-related education and information; and

l Participation of the population in health-related decision making at the national andcommunity levels.


71 UNICEF DRAFT Operational Guidance on Gender Analysis and Programming for Young Child Survival and Development, Version 1 April 201072 See http://www.oecd.org/dataoecd/11/41/34428351.pdf



HIV and AIDS

Communication

Governance

The HTF also recognizes and aims to prevent issues related to disability, ensuringequitable access to health care without discrimination. Gender considerations in maternal and young child survival and development includethe issue that maternal health and survival is socially determined, women's status andaccess to resources and services powerfully affect child health outcomes, the genderdivision of labour, and the role of boys and men in sustaining young child andwomen's development.71

The HTF includes a focus on:

l Promoting gender equality and women and girls' empowerment through a nationalscale programme that alleviates barriers (including fees) to health care in pregnan-cy as a critical factor in girls' vulnerability and inequality in society;

l Men's role in MNCH (such as through male champions) is emphasized;

l Gender sensitive training for male and female community health workers includingskills to tackle social issues facing women and communication skills to supportgood maternal nutrition and exclusive breastfeeding;

l Gender-based violence and sexual violence are recognised as public health issuesand a child protection priority affecting girls, boys and women, requiring support forforensic examination recognised by the courts, access to treatment for HIV, emer-gency contraception and referral for welfare and legal services; and

l Ensuring age and sex disaggregated data in all stages of the programme cycle(analysis, implementation, monitoring, evaluation) wherever required.

l Integration of HIV across the life cycle of health care and across all health servicedelivery; and

l Reducing HIV associated stigma through national scale and holistic programmes.For example, exclusive breastfeeding programmes will focus on all mothers, andwill reduce the problematic association of HIV with exclusive breastfeeding prevailing in parts of Zimbabwe.

l Integrated communication, awareness and advocacy strategies (especially arounduser-fees) cut across all interventions, especially at community-based levels:

l Operational research will inform evidence-based advocacy and special socialmobilization efforts, particularly related to behavior change such as householdlevel promotion of exclusive breastfeeding and engagement with religious groups;and

l Interventions involving a number of strategies including face to face motivation,posters and IEC material, focus group discussions and private/public partnerships.

The focus of the HTF is on health system strengthening and support for the MoHCWto ensure financial systems and accountability are improved, within the working con-text and safeguards of the Cotonou Agreement Article 96, the MDGs as well as theParis Declaration on Aid Effectiveness and the Accra Agenda for Action72.


73 Medical waste includes (but is not limited to) sharps (needles, scalpels, etc.), laboratory cultures and stocks, blood and blood products, bodyfluids, bandages, dressings, and pathological wastes, as well as solid waste.



Environment

Support to the MoHCW systems and processes, particularly in human resources andhealth sector financing, will strengthen sector governance, financial monitoring andcoordination. The emphasis on integrated and supportive supervision also aims toimprove performance, accountability and governance within key areas of MoHCW,particularly maternal, newborn and child health as well as the MoHCW financial direc-torate.

Interventions in the HTF pooled funding arrangement aim to bridge towards sectorfinancing by strengthening government accounting and financial monitoring process-es. The pooled mechanism allows for continuity and improvements in critical healthsystem functions under all contingencies, including preparations in the scenario ofhumanitarian funding channels becoming dominant once more. Finally decentralizedflow of resources, client satisfaction surveys and support to community level healthcommittees aim to increase community ownership and ultimately accountability ofhealth services to those whom they intend to serve.

l Impacts of WASH activities on young child survival and maternal health are con-sidered in the context of MDG 7 (environmental sustainability). Impacts on climatechange are monitored by UNICEF globally. UNICEF is a party to new UNEP globalagreements to monitor the environmental footprint in programming, and whereverpossible will reduce the impact and increase efficiency in resource use includingthrough innovative new technologies.

l Behavior change promoted in the HTF within the VHW programme, for example,addresses water conservation and efficiency in use.

l Funding to health facilities will facilitate safe disposal of medical waste73 accordingto MoHCW protocols. The handling of all medical waste will utilize universal pre-cautions, treating all blood and other potentially infectious materials (OPIM) aspotentially infectious. At minimum, rubber gloves shall be worn when there is thepotential for the hands to have direct skin contact with blood or OPIM. All medicalwaste shall be collected, stored and shipped in leak-proof bags or containers andlabeled as medical waste. Disposable syringes, needles, scalpel blades or othersharp items shall be placed in puncture-resistant containers for disposal.


74 Based on Minimum Agency Standards for incorporating Protection into Health Programmes (Physical, Mental and Social Aspects of Health)

Key related issues(for linkages)

Consideration of key linkages with the programme themes

Disaster Risk Reduction (DRR)

Protection74

l DRR is embedded within all HTF activities. Focus is on reducing vulnerabilitiesand mitigating the impacts of disasters and related disease outbreaks. Particularlyvulnerable groups are targeted to ensure reduced exposure to risks. The HTF willsupport institutional and community capacity to: - identify, assess and monitor disaster risks and enhance early warning;- use knowledge, innovation and education to build a culture of safety and

resilience at all levels; and - reduce underlying risk factors and strengthen disaster preparedness for effec-

tive response at all levels.

l Linkages with services working to improve birth registration (such as throughhealth facility based registration facilities) so that appropriate legal, civil status andhealth documents are provided to vulnerable women and children (especially chil-dren under-5) in particular. This includes strengthening the maternal death auditsystem.

l Mechanisms for monitoring and reporting instances of abuse and exploitation arein place and health staff are trained to refer patients to, or directly provide (if capa-ble) appropriate care services and gender-sensitive counseling, particularly forpeople who have experienced rape, domestic violence, sexual exploitation, forcedor child marriage, forced prostitution, trafficking and those suffering psychologicaltrauma. Such referral mechanisms and staff capacity will be strengthened throughactivities in HTF.

l Efforts to discourage or eliminate harmful traditional practices are done in a cultur-ally sensitive way (those practices that are helpful for healing will be researchedand respected and interventions will be supported at all levels).

l Linkages to health insurance schemes and social protection programmes (cashtransfer etc)


A summary matrix of the risk management strategy isprovided below. Risks and assumptions are alsoincluded in Annex I, specific risks (such as those thatrelate to the Retention Scheme, impact of increaseddemand due to user fees advocacy etc will be outlinedseparately in workplans). The existing strengths of theZimbabwe health system should be noted as importantfoundations for the feasibility of the HTF. Suchstrengths include:

l Key government planning documents and strategiesare comprehensive and in place;

l A strong network of partners exists in Zimbabweworking to improve health;

l The MoHCW has working groups for technical

components, aid coordination and planning withwhich the HTF will interact;

l Key research has been completed such as theMaternal and Perinatal Mortality Study, 2007; and

l Importantly, with the exception of certain religiousgroups, demand for a quality health system is stillhigh. People in Zimbabwe remember when thehealthcare system was functioning well andcontinue to demand health services; the challengeis improving utilization and the quality of services.

Risks and assumptions will be addressed by the HTFpartners and UNICEF.

6 Feasibility and Risks

Risks and Assumptions

Planned Risk Response

l Political and economic situationdoes not worsen to civil conflict orcollapse of service sectors.

UN security phase does not rise tolevel 3 or above

UNICEF and other UN agencies are working closely with governmentMinistries responsible for social service sectors to ensure goodrelations and delivery. UNICEF was able to support the provision ofservices through various mechanisms over the past years and doesnot anticipate this changing in the near future. The UN system has riskmitigation strategies to continue support should security phaseincrease.


Risks and Assumptions

Planned Risk Response

l UNICEF is able to effectively workwith all partners, includingGovernment, as well as havingfull access to implement andmonitor its programmes. UNICEFis able to maintain programmefocus on intended strategic out-comes for women and children.

UNICEF is cluster lead for WASH, Nutrition and Education as well asfully engaged with other sectors. It maintains close links withgovernment structures and the donor community, ensuring closecoordination and consultation. In particular, UNICEF engages with keyministries to advocate for separation of politics from provision of socialservices and conducts regular field monitoring of programme activitiesto report operating risks and programme activities.

l UNICEF's internal procurementand contracting systems are ableto effectively expedite and man-age large scale programmes.

HTF donors and UNICEF are to agree on the realistic in-countrytechnical and operational capacity required to effectively implementand monitor the programme's progress.

l Overall costs of procurement ofgoods and services do not escalate beyond reasonable levels

UNICEF has a comprehensive procurement process which aims atsupplying the best services and goods at the best cost and can accessglobal markets to ensure economies of scale where necessary.Nevertheless as a principle local procurement is encouraged todevelop the local economy wherever possible - but not at the risk ofcompromising implementation or quality.

l Collaboration between implement-ing organisations and councils willbe problem free and devoid ofpolitics.

MOUs between implementing partners should emphasize the need towork together, commit to a transparent process free of politicisation.Interventions are designed to support national strategic plans,coordinated by Government and implemented through governmentsystems whenever possible.

l Government has capacity to facilitate policy reform quickly andcontribute adequate domesticfinancial resources, especially forhealth worker payments.

The HTF pooled-fund mechanism will allow government appropriateflexibility in implementation across different components of the healthperformance contract (including the health worker retention scheme).Policy and strategic planning support and technical assistance willassist in strengthening government capacity.

l All 4 thematic areas are indivisible/interdependent and need to besupported in order to achieve theoverall objective of the HealthTransition Fund

The HTF provides realistic funding projections and a pooledmechanism with reduced transaction costs to encourage all fourinterdependent pillars to be pursued. An integrated proposal has beenpresented to donors.


The Health Transition Fund is a multi-donor pooledfund with UNICEF serving as a common programmeand fund manager. The roles and responsibilities forprogramme management and coordination of the HTFare outlined below, and further detailed in Annex II

(Terms of Reference, HTF Steering Committee.) Adetailed operations manual for the fund is also beingdeveloped. The management structure of the HTF ispresented in Figure 11 below.

7 Programme Management and Coordination

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7.1 Ministry of Health and ChildWelfare (MoHCW)It is the role of the MoHCW to take leadership indirecting the health sector through national planningand review processes which articulate nationalpriorities, strategies and operational objectives. TheDirectorate of Policy, Planning, Programming,Monitoring and Evaluation (PPPME) within the MoHCWconvenes a consultative meeting each December thatinvolves all Departments, with national and provincialhealth staff, and funding and technical partners. Theparticipants review the status of health for allZimbabweans and determine a set of prioritised actionsfor the following year. These actions are detailed andcosted in a Performance Contract that the MoHCWsigns with the Office of the Prime Minister and theMinistry of Finance. The Performance Contract isotherwise known as the MoHCW Annual Plan.

Broad policy dialogue and aid coordination areaddressed within the Health Sector Review andPlanning Group, chaired by the Minister of Health andChild Welfare, with a funding partner as Vice Chair.The Health Sector Review and Planning Group iscomposed of senior-level representatives from bi-lateraland multi-lateral agencies and development banks. TheGroup's mandate is to (i) support MoHCW ownershipand leadership in the health sector, and encouragestrong MoHCW-led coordination of funding partners; (ii)promote coordinated sector-wide policy dialogue andtechnical support on strategic issues in health; and (iii)ensure that the support of funding partners to health isprovided to MoHCW in a regular, predictable,harmonised and coordinated manner.

In regards to the HTF, the MoHCW Directorate forPolicy and Planning will provide leadership in thedevelopment of annual implementation plans. An HTFCoordinator position will be established based in theMoHCW Directorate for Policy and Planning, withresponsibility to ensure that the programme is fullyimplemented, and to assist in coordination andcommunication with HTF partners. The implementationof the HTF will be further supported by the NationalMaternal, Newborn and Child Health SteeringCommittee (MNCHSC), chaired by the HonorableMinister of Health and Child Welfare. The MNCHSCwill be technically supported by the national

Reproductive Health Steering Committee (RHSC) andthe Child Survival Technical Working Group (CSTWG).The RHSC and CSTWG are comprised of Governmentministries, development partners, civic society, andresearch and training institutions.

7.2 HTF Steering CommitteeThe HTF Steering Committee will be responsible for theoversight and decision making of the HTF. The HTFSteering Committee will be composed of MoHCW,funding partners to the HTF, a representativeorganisation from Civil Society, UNICEF, WHO andUNFPA. The latter three agencies will also serve astechnical advisors and UNICEF will serve as theSecretariat. The steering committee may inviteindividuals or representatives of other organisations toparticipate in discussions. All efforts will be made toreach decisions through consensus. If agreementcannot be reached by consensus and a vote isrequired, only the MOHCW and the major financialstakeholders (donors to HTF and the fund manager)will be eligible to vote.

Funding partners to the HTF will provide pooledfinancial support, with the exception of financialresources already allocated in 2010/2011, necessary tofully implement the coordinated interventions set out inthe HTF Programme Document, and make timelytransfers of funds through the agreed-upon pooledfunding mechanisms. Funding partners will strive toensure the predictability of their financial support byinforming the MoHCW and other partners of thesupport they anticipate providing.

The Steering Committee will be co-chaired by thePermanent Secretary of the MoHCW and a FundingPartner. Funding partners will select, annually, afunding partner which will serve as Co-Chair of the HTFSteering Committee. The HTF Steering Committee willinitially meet monthly (this could be changed to everyother month or quarterly as implementationprogresses).

The role of the HTF Steering Committee includes, butwill not be limited to:

l Approving funding allocations to thematic areas andrelated activities in accordance with the frameworkof the agreed HTF objectives


l Ensuring alignment of HTF allocations with theMoHCW Performance Contract/Annual Plan withinthe thematic areas agreed upon in the ProgrammeDocument

l Approving terms of reference for implementingpartners

l Participating in tender review committees andapproving selection of implementing partners inaccordance with UNICEF rules and regulations

l Reviewing and approving annual, mid-term andend-of-programme programmatic and financialprogress reports submitted by UNICEF. Theprogramme report will present results-basedprogress against the log frame indicators

l Appointing an evaluation sub-committee consistingof three to five independent professionals who willhave responsibility for managing all aspects of theimpact evaluation conducted by the independentevaluation contractor. These elements include thebaseline assessment, joint annual reviews, mid-termreview and final evaluation. This management rolewill include determining areas of enquiry, agreeingterms of reference, and approving reports and otherproducts in terms of meeting quality standards.

7.3 UNICEF UNICEF will have two distinct roles in the HTF- as fundholder and programme manager, and as a potentialimplementing partner in areas in which it has acomparative advantage as determined by the SteeringCommittee. A number of safe-guards will be put intoplace to ensure transparency and segregation of dutiesas necessary.

As fund manager and programme manager of the HTF,UNICEF, under the oversight of the Steering Committeeand supported by the HTF Coordinator, will beresponsible for ensuring overall financial managementand attainment of programme results across allthematic areas. This role will include legal responsibilityfor the appropriate use of funds as well as theperformance of contractors and HTF implementingpartners. Using the in-country management HTFbudget line, UNICEF will ensure sufficient technical and

operations capacity exists to manage risk, supervisecontractors and ensure accountability for the HTFresources and results. UNICEF will also support theMoHCW with the minimum level of technical andimplementation capacity in each thematic area asrequired and in building capacity for overall financialand programme management of such fundingmechanisms. The HTF Coordinator will be aZimbabwean national based in the MoHCW who willplay a key liaison role between the MoHCW, theSteering Committee and UNICEF. He/she will assist incoordination, trouble shooting and in real time updatesand communication. An HTF financial officer will assistboth UNICEF and MoHCW with overall financialmanagement of the programme.'

UNICEF will sign a Contract or Memorandum ofUnderstanding with each funding partner setting out theterms and conditions governing the receipt andadministration of contributions, and will report on theuse of funds pursuant to parameters established withinthe Contract or Memorandum of Understanding signedwith each funding partner. UNICEF will prepare andmaintain a treasury plan to ensure timely replenishmentof the HTF account, showing likely cash-flow require-ments for the programme over the course of the year.

As part of the consolidated report and as an annex tothe narrative report, UNICEF will submit to Donors by31 March an annual financial utilisation report, showingfunds received from all sources and expended for theHTF. The financial utilisation report will follow theformat set out by the contributing donors and will be inline with key institutional agreements such as the


Financial and Administrative Framework Agreement(FAFA) with the EC. It will cover the period, in any oneyear, up to 31 December. In addition, UNICEF willprovide quarterly and six monthly budget andprogrammatic updates for in-country review anddiscussion by the HTF Steering Committee. A certifiedfinancial statement will be produced by 30 June.

Annual Reviews, a Mid-Term Review in year 3, and aFinal Evaluation of the HTF programme will beconducted as detailed in the Programme Documentand as agreed by the HTF Steering Committee. Thefindings of the reviews will inform GoZ, Donors, andUNICEF on progress, challenges and opportunities,including recommendations to reorient priorities ifrequired in order to achieve key programme goals andobjectives.

UNICEF will arrange for its financial records to beaudited in accordance with the established proceduresand appropriate provisions of the financial regulationsand rules of the United Nations and UNICEF.Procurement of goods and services under the HTFprogramme will be in accordance with UNICEF'sProcurement Rules and Regulations. The HTF SteeringCommittee will be invited to participate in tender reviewcommittees and to approve selection of implementingpartners in accordance with UNICEF's ProcurementRules.

7.4 Implementing Partners

Non-UN Partners

Although the majority of the HTF activities will beimplemented by the MoHCW, specific components maybe delivered by academic or research institutions,private sector companies, UN agencies, or non-governmental organizations using UNICEF tender orpartnership cooperation agreement procedures. TheTerms of Reference for subcontractors will be approved

Ensuring Transparent Governance inthe Health Transition Fund

l The HTF programme is developedthrough a highly consultative process(including MoHCW planning and reviews,aid coordination unit discussions andcollaborative work planning).

l Donor and UNICEF Agreements outlinecommitment to logframe and budgetallocations within the programme budgetallotment (PBA) and correspondingproposal.

l Only the Steering Committee has theauthority to make changes to the logframe and budget allocations.

l UNICEF will recuse itself from SteeringCommittee decisions regarding selectionof implementing partners in whichUNICEF is a potential partner.

l An HTF co-coordinator based at MoHCWwill ensure alignment with MoHCW plansand assist in sharing information with allpartners.

l Contractors will be selected through atransparent and competitive tenderprocess. Terms of Reference will beapproved by the Steering Committee, andMoHCW and donor representatives willparticipate on the review committee.

l Independent reviews will occurthroughout implementation, including:Regular joint annual reviews, a mid-termreview, a final evaluation

l Transparent communications strategy will ensure public availability of keydocuments, including web-basedmaterials.


by the HTF Steering Committee, with contractsawarded based on comparative advantage, ability todeliver results and value for money. Key comparativeadvantages will be considered in areas where anational programme and provider are already engagedand performing successfully. Partnerships andoutsourced contracts will be subject to a capped costrecovery rate of seven per cent.

UNICEF will sign a Contract Agreement withimplementing partners and contractors will providestandard quarterly, semiannual and end of yearnarrative and financial reports. Implementing partnerswill submit their final financial report no later than sixmonths following the financial closing of programmeactivities. Rules and guidelines for contracting partnerswill be detailed in the HTF Operations Manual.

UN Partners

Should the Steering Committee select UN agenciesother than UNICEF as implementing partners, provisionwill be made for pass-through or bilateral agreements,

with consideration for funding agency requirements. Inboth cases standard UN agreements between UNpartner agencies or between donors and UN agencieswill be utilised.75

7.5 Financial Assurance Policies and procedures for making and accounting forpayments to implementing partners will be detailed inthe HTF operations manual, currently being drafted.

7.6 Statement of Intent Guidingthe HTF PartnershipMoHCW, the HTF funding partners, UNICEF, and otherrelevant agencies will be governed by a Statement ofIntent to guide the partnership for the Health TransitionFund in Zimbabwe (see Annex III).

Please see separate document forHTF Budget

8 Resources

75 In the pass-through mechanism, UNICEF would charge 1% administration fee for administering funds and UN agencies receiving funds would charge a 7%recovery rate. Should the funding to UN partners exceed a to-be-determined amount, then a bilateral arrangement between the donor partner and UN partnerwould ensue with recovery rates based on UN partners' agreements with donor governments.


ANNEX 1: HTF Logical FrameworkMatrixThe logical framework is provided as Annex I in aseparate document. Please contact UNICEF for a copyof the matrix.

ANNEX II: Terms of Reference -Steering CommitteHealth Transition Fund Steering Committee: Terms ofReference

BackgroundThe Health Transition Fund (HTF) is a multi-donorpooled fund aimed to support the Ministry of Healthand Child Welfare (MoHCW) in Zimbabwe to achieveplanned progress towards 'achieving the highestpossible level of health and quality of life for allZimbabweans'. These Terms of Reference serve toguide the management of the HTF through a HTFSteering Committee.

PurposeThe HTF Steering Committee will be responsible fordefinition of priority interventions within the fourselected thematic areas and allocation of relatedfinancial resources.

Guiding PrinciplesThe Steering Committee will be guided by theprinciples laid out in the Statement of Intent to Guidethe Partnership for the Health Transition Fund inZimbabwe.

Specific Roles and Responsibilities

The Steering Committee's specific roles andresponsibilities include the following:

l Approving funding allocations to thematic areas andrelated activities in accordance with the frameworkof the agreed HTF objectives

l Ensuring alignment of HTF allocations with theMoHCW Performance Contract/Annual Plan within

the thematic areas agreed upon in the ProgrammeDocument

l Approving terms of reference for implementingpartners

l Participating in tender review committees andapproving selection of implementing partners inaccordance with the UNICEF rules and regulations

l Reviewing and approving annual, mid-term andend-of-programme programmatic and financialprogress reports submitted by UNICEF. Theprogramme report will present results-basedprogress against the log frame indicators

l Appointing an evaluation sub-committee consistingof three to five independent professionals who willhave responsibility for managing all aspects of theimpact evaluation conducted by the independentevaluation contractor. These elements include thebaseline assessment, joint annual reviews, mid-termreview and final evaluation. This management rolewill include determining areas of enquiry, agreeingterms of reference, and approving reports and otherproducts in terms of meeting quality standards.

MembershipThe HTF Steering Committee will be composed ofMoHCW, funding partners to the HTF, a representativeorganisation from Civil Society, UNICEF, WHO andUNFPA. The latter three agencies will also serve astechnical advisors and UNICEF will serve as theSecretariat. The steering committee may inviteindividuals or representatives of other organisations toparticipate in discussions. The agreed quorum formeetings is over 50 per cent of membership. All effortswill be made to reach decisions through consensus. Ifagreement cannot be reached by consensus and avote is required, only the MOHCW and the majorfinancial stakeholders (donors to HTF and the fundmanager) will be eligible to vote.

ChairThe steering committee will be co-chaired by thePermanent Secretary of the MoHCW and an HTFfunding partner. The HTF funding partners will select,annually, a funding partner which will serve as co-chairon an annual rotation basis.


Secretariat

UNICEF as the programme and fund manager willserve as the Secretariat to the steering committee.The Secretariat will convene meetings of the steeringcommittee; prepare and circulate the meeting minutes;and perform other functions necessary to ensure thesmooth functioning of the steering committee.

Frequency of meetings

The HTF steering committee will meet initially on amonthly basis, unless otherwise determined by aconsensus of the steering committee. The agenda andminutes of previous meetings will be circulated by theSecretariat one week prior to the meeting.

ANNEX III: Statement of IntentA Statement of Intent to Guide the Partnership for theHealth Transition Fund in Zimbabwe

1 IntroductionThis Health Transition Fund (HTF) Statement of Intent(hereinafter the SI) provides a specific framework ofcollaboration, cooperation and coordination betweenthe Government of Zimbabwe (hereinafter the GoZ),the Donors and UNICEF in the implementation of theHTF. The SI provides a Code of Conduct andinformation on the programme management,administration and reporting of the HTF.

2 GoalTo harmonise, align and coordinate support by GoZand donors in the implementation of the UNICEF-managed HTF.

3 PurposeThe GoZ, Donors and UNICEF recognize theimportance of addressing the needs of the

Zimbabwean people in the field of health and committhemselves to the goals and objectives articulated in anumber of key policy papers, including the GoZNational Medium Term Plan (2010-2015), the HealthSector Investment Case (2010), and the NationalHealth Strategy for Zimbabwe: Equity and Quality inHealth - A People's Right (2009-2013). This SI definesthe principles and mechanisms to guide, coordinateand facilitate productive relations between the GoZ,Donors and UNICEF in the pursuit of those goals andobjectives, and to deliver an effective framework ofsupport, under a set of guiding principles, utilisingstandardised operational procedures.

4 BackgroundThe HTF is a multi-donor pooled fund aiming to supportthe Ministry of Health and Child Welfare (MoHCW) inZimbabwe to achieve planned progress towards'achieving the highest possible level of health andquality of life for all Zimbabweans.'76 The HTF willsupport efforts to mobilize the necessary resources forcritical interventions to revitalize the health sector andincrease access to care through eliminating thepayment of fees for services for mothers and childrenunder-5. As such, critical, high impact interventions willreduce maternal and under-5 mortality; reduceprevalence of underweight in children less than 5 yearsold, and assist in combating HIV, malaria and otherdiseases.

Support to key goals outlined in the Zimbabwe NationalHealth Strategy and the Health Investment Case will beprovided in a coordinated and streamlined way and willbe aligned with the MoHCW annual review processesand operating plans (performance contracts.) The HTFwill initially focus on the following four thematic areas,but could be extended to other areas in accordance todisease burden and available financial resources.

The four core thematic areas are:

1. Maternal, Newborn and Child Health and Nutrition

2. Medical Products, Vaccines and Technologies(Medicines and Commodities)

76 National Health Strategy (2009-2013)


3. Human Resources for Health

4. Health Policy, Planning and Finance

The pooled funding mechanism will significantly reduceoverhead costs in operations, reporting and fundadministration, ensuring that funding is channelledtowards achieving direct programme impact. Further,the HTF scale will allow achievement of results againstnational scale indicators at the five-year stage, andreduce potential duplication of efforts by developmentpartners.

This SI represents a common understanding betweenthe GoZ, Donors and UNICEF, and does not constitutean international treaty, a legally binding instrument, oran obligation on the part of the signatories to commitfunds. This SI does not supersede any legally bindingContribution Agreement between Donors and UNICEF.Where there is a conflict between this SI and a legallybinding agreement, the terms of the legally bindingagreement shall govern.

The signatories agree to the principles of transparency,openness and accountability, including the observanceof universal respect for human rights and the principlesof gender equity. Any suspected breach of theseprinciples during implementation of HTF will be subjectto thorough investigation and review.

5 PartnersThe initiating partners to this SI are the Government ofZimbabwe; UNICEF; the Governments of the UnitedKingdom of Great Britain and Northern Ireland ("theUnited Kingdom") represented by the Department forInternational Development (DFID); the Government ofIreland represented by Irish Aid; the Government ofSweden; the Government of Norway; and theEuropean Commission represented by the Delegationof the European Union to Zimbabwe. These partnerswill be collectively referred to as Signatories. Any newfunding partner wishing to participate in the HealthTransition Fund should do so in accordance of theprovisions of this SI.

6 Code of Conduct

6.1 The Code of Conduct takes into considerationregional and international policies, strategies andcommitments such as the Millennium DevelopmentGoals and the 2005 Paris Declaration on AidEffectiveness. The GoZ, Donors and UNICEFrecognize this Code of Conduct as a mechanismfor facilitating donor harmonisation, allowing forgreater government ownership and leadership,aligning donor activities with sector programmesand budgets, and linking sector support to nationalpolicies and poverty reduction support.

The GoZ, Donors and UNICEF recognize that the GoZhas the leadership role in directing the health sector.The GoZ should co-ordinate all health care providers,funding and implementation partners, includingcommunities, to ensure that health services areefficient, effective and equitable.

The GoZ, donors and UNICEF understand thatprogress towards achieving the goals laid forth in theNational Health Strategy is largely dependent upon theassurance and effective and efficient utilisation of bothnational and international resources. For this reason,the GoZ, Donors and UNICEF agree that a pooledfunding approach is an important mechanism to:

a) Promote a common vision for health development;

b) Establish priorities and improve the allocation ofresources to achieve those priorities;

c) Improve the efficiency and accountability ofutilisation of resources; and

d) Rationalise and maximize the efficient use ofresources in the health sector.

6.2The Code of Conduct will be guided bythe following principles:

i. The need to raise the health status of allZimbabweans through an efficient and effectivehealth delivery system;

ii. The commitment to national ownership andleadership with the Government setting health


priorities, using national planning and budgetingprocesses;

iii. A climate of transparency, openness andaccountability. All parties bear the responsibilityto share relevant information and to keep otherparties informed so as to ensure full and equalopportunity to participate in and contribute tohealth development in Zimbabwe throughestablished institutions;

iv. The observance of health-related resolutionsentered into by the Government at bothregional and international levels; and

v. The observance of universal respect for humanrights, including reproductive and health rights,and the respect for principles of gender equity,democracy, transparency, rule of law, goodgovernance and protection of the environment.

6.3The Government agrees to:

i. Maintain and steadily augment contributions tothe health sector; and

ii. Undertake a joint annual review and planningprocess that is decentralized and collaborative.The process will produce a PerformanceContract that will present priorities andresources, including allocations from the StateBudget.

6.4Donors agree to:

i. Align funding support to MoHCW priorities;

ii. Communicate with the GoZ regarding theirannual and multi-annual commitments in orderthat the GoZ can plan and provide servicesaccordingly;

iii. Recognize the importance of timelydisbursement of funds and work towardsensuring that financial disbursements are made

according to a schedule agreed with the GoZ;

iv. One system for technical reporting,procurement, financial accounting, and auditingof programme expenditure;

v. Build the capacity of MoHCW personnel in theareas of project planning, design, budgeting,implementation, monitoring and evaluation, andreporting;

vi. Conduct joint missions related to the HTF inorder to minimise the burden on MoHCW; and

vii. Review and approve annual budgets andworkplans by end of December each year forimplementation the following year.

7 Programme Management,Administration and Reporting

7.1 The HTF is a pooled fund in which donorcontributions are allocated according to theProgramme Document and annual work plansapproved by the HTF Steering Committee.

7.2 UNICEF is prepared to receive and administercontributions of varying amounts from Donors forthe implementation of the HTF.

7.3 As part of the consolidated report and as an annexto the narrative report, UNICEF will submit toDonors by 31 March an annual financial utilisationreport, showing funds received from all sources and expended for the HTF. The financial utilisationreport will follow the format set out by thecontributing donors and will be in line with keyinstitutional agreements such as the Financial andAdministrative Framework Agreement (FAFA) withthe EC. It will cover the period, in any one year, upto 31 December. In addition, UNICEF will providequarterly and six monthly budget andprogrammatic updates for in-country review anddiscussion by the HTF steering committee. Acertified financial statement will be produced by 30 June.


7.4 Annual Reviews, a Mid-Term Review, and a FinalEvaluation of the HTF programme will beconducted as detailed in the Programme Documentand as agreed by the HTF Steering Committee.The findings of the reviews will inform GoZ,Donors, and UNICEF on progress, challenges andopportunities, including recommendations toreorient priorities if required in order to achieve keyprogramme goals and objectives.

7.5 The Signatories will meet at minimum quarterlywithin the HTF Steering Committee to reviewprogress of on-going activities and to plan for thenext phase in the programme, as further detailed inthe Steering Committee Terms of Reference.

7.6 UNICEF will arrange for its financial records to beaudited in accordance with the establishedprocedures and appropriate provisions of thefinancial regulations and rules of the United Nationsand UNICEF.

7.7 Procurement of goods and services under the HTF will be done in accordance with UNICEF'sProcurement Rules and Regulations. The HTFSteering Committee will be invited to participate intender review committees and to approve selectionof implementing partners in accordance withUNICEF's Procurement Rules.