Reducing Maternal and Neonatal Mortality Rates in Underserved Urban Areas of Zimbabwe

Six months pregnant and stressed about her financial situation, Shorai Sande delicately made her way around her community in Dzirasekwa, a high-density suburb in Harare, Zimbabwe, wondering how she could deliver her child. Like other high-density areas, the Dzivarasekwa community faces challenges such as limited access to public services, lack of infrastructure, and high unemployment. Shorai was late into her pregnancy and had yet to register at a clinic as she was unemployed. 

Shorai is among the over 80,000 women who were provided with essential antenatal care through the Urban Voucher Program, a component of the Health Sector Development Support Project (HSDSP), which ensured healthier pregnancies and safer childbirth. The program ensured 35,000 safe deliveries and reduced maternal and neonatal mortality rates in underserved urban areas. The program mitigated the risks associated with home births by redirecting deliveries to clinics, saving lives in vulnerable communities.

Collaboration with the government and support to the Ministry of Health and Child Care (MoHCC) began in 2011 with the support of the World Bank through the Health Innovation Results Trust Fund, later renamed the Global Financing Facility (GFF). The HSDSP aimed to increase the availability, accessibility, and utilization of maternal, newborn, and child health care services and improve quality. The project focused on improving health facility performance and management and promoting a results orientation, potentially contributing to improved health system performance.

Increasing quality of care in central and provincial hospitals

During the life cycle of the project, it was noted that declining quality of care in central and provincial hospitals was contributing to 57% of maternal deaths recorded in the country. To mitigate this situation, the project in 2022 introduced a quality-focused, results-based financing (RBF) pilot to enhance quality at provincial and central hospitals.

RBF is a health systems management tool intended to improve the efficiency of health system inputs and the coverage and quality of health services. As applied in Zimbabwe, the approach linked subsidy payments to health facilities based on their performance (quantity and quality of maternal and child health services). Subsidies earned by health facilities are used to re-invest in priorities identified locally by the facility teams, and a portion (up to 25%) is allocated to the health workers as incentives.   

“In 2023, a year after the hospital joined the project, we had seven maternal deaths, down from 11 and 32 neo-natal deaths as compared to 51 from the previous year. This was a testament to the improvement in care that our patients were receiving. We procured equipment, consumables, and sundries through project subsidies to save pregnant women and children. This has helped us to manage conditions and monitor key health indicators of our patients, such as post-partum hemorrhage, eclampsia, pre-term babies, deliveries, and prolonged rupture of newborns,” says Mrs. Choruma, Matron, Marondera Hospital.

Another hospital that received similar support is Sally Mugabe Hospital, the busiest hospital in obstetrics in Harare. The hospital also procured equipment and made improvements to its infrastructure. “As facilities were able to determine what they wanted to procure, we decided to procure Intensive Care and Theatre equipment, including ultrasounds for our fetal medicine unit, which is our busiest department at the hospital,” says Dr. Munyaradzi Nyakanda, Head of Obstetrics, Sally Mugabe Central Hospital.  

Community and Rural RBF

In rural areas the RBF approach began as a pilot in 18 districts. It was later scaled up to the remaining 42 districts by the government and other development partners (namely the Health Transition Fund, which later became the Health Development Fund). In rural districts, project funds were used to refurbish facilities, provide electricity and sustainable water sources, and improve service delivery. Community participation was sought, and the decision-making and operational planning at the facility level were improved. Village Health Workers (VHWs) were trained and provided with tools to assist community members, which led to a boost in demand and increased coverage and use of healthcare services in the districts. This included the rollout of an integrated register for all services, which sought to harmonize different programs and lessen the paperwork burden. In Mutare District, it was noted that new skills of the VHWs led to an increase in early booking of pregnancies and the use of long-acting reversible contraceptive methods. 

“As a trained Village Health Worker, I advise pregnant women in our community on the importance of registering their pregnancies early to ensure that their babies are adequately catered for. We educate them on the importance of getting tested for HIV,” says Irene Goba, VHW Dora District, Mutare. HIV testing of mothers is key to ensuring those with positive results are provided with medicine to prevent the transfer of HIV to their babies.

As part of the sustainability plans, the Government of Zimbabwe has institutionalized RBF in all rural districts and adopted the RBF approach as one of the health financing mechanisms for strategic purchasing of health services. Efforts are being made to sustain the program to ensure gains made over the years are not reversed.