Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
Morbidity and mortality in Zimbabwe's urban 
areas: policy implications for social protection 
GLADYS BINDURA-MUTANGADURA1 
ABSTRACT 
In times of tightening national budgets as a result of structural adjustment 
requirements, the need to make choices in a country's 
publicly-funded social protection programme is heightened. A greater 
understanding of the patterns and causes of morbidity and mortality 
in Zimbabwe's urban areas forms an important basis for designing an 
effective social protection policy and programmes that may have a 
positive impact on the welfare of the urban poor. This study assesses 
the prevalence of morbidity and mortality in some low-income suburbs 
of Zimbabwe. Results indicate that the reported leading causes 
of long illness and death were predominantly AIDS related. This calls 
for social policies and programmes to integrate HIV/AIDS prevention 
and improve access to treatment for the poor. The study revealed that 
households are heavily dependent on informal forms of support to 
help them cope with adult morbidity and mortality. Policies aimed at 
strengthening these informal sources of support can help foster the 
well-being of poor families. Lower-income households are less likely 
to make use of nation-wide public support programmes. The resultant 
policy implication is that public social support schemes such as health 
and education support and employment guarantee schemes should be 
intensified and expanded to generate substantial positive welfare effects 
by complementing informal resources. 
Introduction 
IN A COUNTRY where resources are scarce, information on the prevalence 
and cause of morbidity and mortality can serve as a guide in making 
1 The Carolina Population Centre, University of North Carolina at 
Chapel Hill, USA 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 5
social protection policies that target the major social protection needs 
and can help in deciding which interventions could yield the best social 
welfare benefits. In most cases this task requires a consideration of 
multiple objectives such as economic efficiency and equity. Information 
on the relative importance of various causes of death and chronic 
illnesses and the household coping responses adopted allows 
policymakers to select objective health and social support priorities 
and allocate scarce resources to yield optimal benefits to society. Unfortunately 
information on mortality and morbidity at the level of the 
household is very scarce. To date relatively little empirical work has 
been done in Zimbabwe to find out how prevalent morbidity and mortality 
is in low-income urban household settings and how households 
can be strengthened to cope with the impacts of morbidity and mortality.
The aim of this study was to find out the prevalence of morbidity and 
mortality in a randomly selected sample of households in low-income 
residential suburbs, identify household coping mechanisms and the 
formal and informal social support mechanisms currently utilized by 
households to help cope with adult morbidity and mortality and identify 
the emerging social protection policies that can be recommended to 
help households cope with adult morbidity and mortality. The aim is to 
contribute to more effective policy formulation required to support the 
existing support mechanisms through identifying new types of public 
social support interventions and policy reforms which are expected to 
have a significant positive impact on the welfare of the urban poor. 
The first section presents the background information, the second 
section reviews the data and methods, the third section presents the 
results, the fourth section presents a discussion of the results and their 
policy implications. Conclusions are presented in the last section. 
Background 
SINCE 1991 THE government has been implementing macroeconomic reforms. 
Throughout the country these reforms have resulted in very 
high inflation which has eroded the real incomes of low wage earners 
and the poor in general and severely crippled their purchasing power. 
6 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
Gross domestic product (GDP) growth has not kept up with population 
growth and the performance of GDP per capita has been poor. Economic 
growth rates have been on the decline from 8.2 percent in 1996 to 
3.7 percent in 1997,1.5 percent in 1998 and 1,2 percent in 1999 (Central 
Statistical Office 2000). The annual increase in formal employment has 
been very small. Massive retrenchment in the civil service resulted in 
many people losing their source of regular income. As part of the macroeconomic 
reforms health and education fees were increased and 
enforced, thus lowering the affordability of these services by low-income 
households (Bassett et al. 1997). The general decline in the 
economy has resulted in increased poverty and the poor performance 
of the health sector with some health indicators declining to below 1980 
levels (Mutangadura 1998). In both urban and rural areas households 
are facing rising prices of basic food because of inflation. In 1995 62% 
of the national population lived below the national total consumption 
poverty line of Z$2132.33 per person per annum and about 46% of the 
population were living below the national food poverty line, indicating 
that these households are unable to meet their basic nutritional needs 
(Ministry of Public Service, Labour and Social Welfare and United Nations 
Children Fund 1997). 
Against this backdrop of an economic downturn has come the unparalleled 
crisis of HIV/AIDS that is now threatening the productive sector 
and seriously affecting the health of women and children. Zimbabwe 
has one of the highest AIDS infection rates in the world, with the adult 
HIV rate estimated to be 25.8% (Joint United Nations Programme on HIV/ 
AIDS (UNAIDS) 2000). At least 700 people die from AIDS every week 
(National AIDS Co-ordinating Programme (NACP) 1999). Zimbabwe's 
last sentinel surveillance survey was undertaken in 1997. The reported 
adult HIV percentage rates among antenatal women in rural areas ranged 
from 28% in Harare to a high of 37.7% in Mutare. The data also show a 
typical upward trend in the sero-prevalence in all areas over the years 
covered by the surveillance study. Anti-retroviral therapy costs more 
than Z$20 000 per month, which is more than the average formal wage 
earned by an average civil servant professional with tertiary training; 
hence it is beyond the reach of many, HIV/AIDS has already reversed 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 7
hard-won national health gains and continues to threaten the major 
health indicators. Life expectancy, which had improved to 62 years by 
1994, had fallen to 49 in 1997. Discounting the AIDS epidemic, adult 
deaths in the age range 15-50 in Africa is very low - about six deaths 
per 1000 persons aged 15-50 peryear(Over 1995, Adetunji 1997). But 
including the AIDS epidemic the total death rate in Zimbabwe, which had 
fallen to 9 per 1000 in 1994, rose to 13 per 1000 in 1997 (UNAIDS 1999). 
Recent research indicates that mv/AiDS-related morbidity and mortality 
has the greatest impact at household level (Kwaramba 1998, World 
Bank 1997). The household is forced to bear the costs of medication, 
funerals, loss of income, loss of labour and management skills as well as 
severe emotional and psychological costs. Theoretical insights into 
the socio-economic impact of aids on households suggest that the 
premature death of an adult results in direct and indirect costs (Barnett 
and Blaikie 1992, World Bank 1997, Tibaijuka 1997) where direct costs 
are the medical costs prior to death and the costs of the funeral and 
indirect costs are costs related to the income lost due to death of the 
adult and the impact on other welfare measures such as household 
food security status, child schooling, and loss of assets. The degree of 
vulnerability of households to the impact of the death of an adult and 
the subsequent risk management strategy adopted by a household 
depends on 
• the household's socio-economic setting (internal factors peculiar to 
the household, such as the asset base, the household's access to 
resources, household size and demographic composition), 
• the availability and accessibility of informal social support mechanisms, 
• the availability and accessibility of formal social support mechanisms 
(Moser 1998, Webb et al. 1992, Barnett et al. 1992). 
The ability of the household to manage the impact of the loss of an 
adult female in the household depends on its economic asset base. 
The availability and accessibility of informal social support mechanisms 
is crucial for successful recovery from a death of an adult female 
in the household. Informal social support mechanisms refer to the interhousehold 
relationships between the household and community 
8 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
members, friends, relatives and neighbours. In times of stress, households 
usually resort to these relationships for help on the basis of trust 
and reciprocity. The role of communities in mitigating the impact of 
adult illness and death depends on the socio-economic status of the 
community and the stage of the epidemic. The poorer the community 
and the more advanced the stage of the AIDS epidemic, the less likely the 
community is to be able to cope with the increase in the number of 
deaths (McKerrow 1998). Urbanization and the economic and social 
hardship resulting from structural adjustment programmes and HIV/AIDS 
are weakening community and family support structures (Ledward 1997). 
With this background, the thrust of this study was to find out the 
prevalence of adult morbidity and mortality in a randomly selected sample 
of households in low-income residential suburbs, identify the main 
causes of adult morbidity and mortality, identify household coping 
mechanisms and the formal and informal social support mechanisms 
currently utilized by households and identify the emerging social protection 
policies. 
Data and Methods 
THE STUDY WAS conducted in three low-income suburbs of three major 
cities; Harare, Bulawayo and Mutare. A total sample of 598 households 
was selected (Harare (n=200), Bulawayo (n=200) and Mutare (n=198)). 
Cities have a high incidence of poverty with the percentage of poor and 
very poor people estimated to be 35%, 37% and 50% for Harare, 
Bulawayo and Mutare respectively (MPSLSW and UNICEF1997). The 
adult HIV prevalence is also high in cities. According to the 1997 sentinel 
surveillance study, the HIV prevalence rate was estimated to be 28%, 
30%, and 38% in Harare, Bulawayo and Mutare respectively (NACP, 
1998). In all the three cities the oldest low-income residential suburb 
was selected (Mbare in Harare, Mzilikazi in Bulawayo, and Sakubva in 
Mutare). With the exception of Mzilikazi the residential suburbs are 
located close to a centre of informal trade and the travel centre (Mbare 
musika [market] in Harare and Sakubva musika in Mutare). In some 
parts of Mbare and Sakubva some people live in wood and plastic cabins 
and have poor access to clean water sanitation and health facilities. In 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 9
Table I. Demographic characteristics of sampled households 
by site 
Mutare All areas 
(n=200) 
Bulawayo 
(n=198) (n=598) 
Harare 
(n=200) 
Sex of head of household (% households) 
75 69 86 
Female 15 25 31 
75 66 64 59 
30
7
4 
8 
10
8 
19
9
6 
18 
13
6 
Male 71 
29 
Marital status of head of household (% households) 
Married 
Deceased 
Single 
Divorced 
Average age of head of household 
49 38 43 42 
Average household size 
5 6 5 5 
some areas of Sakubva and Mbare, households share common toilets, 
water collection and laundry facilities. Unlike Sakubva and Mbare, most 
of the people in Mzilikazi have access to better facilities (water, health 
and accommodation). 
The study used two sampling procedures, cluster sampling and systematic 
sampling. Both qualitative and quantitative research methods 
were used. The former involved three focus group discussions with 
communities in each site. The latter methods involved administering a 
household questionnaire on the randomly selected sample. 
Results 
The socio-economic characteristics of sampled households 
THE SOCIO-ECONOMIC characteristics of households in the different sites 
are presented in Table I. The Mutare and Bulawayo samples have higher 
proportion of female-headed households. The marital status of the sample 
differed across the three sites. In Harare married household heads 
dominated whereas in Bulawayo a large number of household heads 
10 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
had a deceased spouse. In Mutare, although married household heads 
dominated, there was a higher proportions of household heads with 
deceased spouse and those who were single. The average household 
size was five, which conforms to the national mean of 4.6, but is higher 
than the urban average of 4.1. 
On average households had low average monthly incomes. Fiftytwo 
percent (311 households) of the households indicated monthly 
incomes of the head of household of less than Z$2000. The main source 
of income was higher from formal sources (53%, 317 households), followed 
by informal sources (42%, 251 households), pensions (3%, 18 
households), and gifts and transfers (2%, 12 households). The forms of 
household head's formal employment were permanent formal job, casual 
or temporary and self-employed. The main informal business activities 
include food, urban agriculture and clothes vending, knitting and sewing. 
The 1995 poverty datum line, calculated as Z$2132.33 per person 
per year, translates to ZS817 per household per month using a national 
average household size of 4.6 persons (Raftopolous et al. 1998). 
Adjusting for inflation, which averaged 21 %, 19%, 32% and 57% in 
1996,1997,1998, and 1999 respectively, these results indicate that more 
than half of the households sampled live below the inflation-adjusted 
national total consumption poverty line. Recent studies of poverty in 
two low-income suburbs of Harare also revealed a high incidence of 
households whose average monthly income is below the national total 
consumption poverty line (Matshalaga 1997a and b). 
Long illness and death in households and households: coping and 
preventive strategies 
THE PREVALENCE OF households with chronically ill patients in the sample 
was 24 percent (see Table II). This figure is higher than a morbidity 
of 12% found by the author in a similar study in Zambia's low-income 
suburb of Kafue town (Mutangadura et al. 1999). The definition of a 
chronically ill patient (CIP) in both surveys was "ill for the last 30 days". 
The difference may be because of the difference in the stages of the 
epidemic that the two countries are experiencing, where Zimbabwe has 
now a higher mv rate than Zambia. The prevalence of CIPs was higher 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 11
in Harare and Bulawayo than in Mutare. The breakdown of CIPs by 
gender revealed that in Harare and Bulawayo, more than half the CIPs 
were female whereas in Mutare more CIPs were male than female. The 
most common type of relationship of the CIP to the head of household 
was a son or daughter, spouse and household head. 
More than fifty per cent of the CIPs have been ill for more than three 
months, indicating that affected households had experienced an income 
shock for an equivalent length of time. The overall mean age of a 
CIP for males was 33.9, for females it was 34.7. A salient feature that 
comes out of the age distribution of the CIP by gender is that female 
morbidity was higher in the economically active age group when compared 
with male morbidity, which was higher at the younger and older 
ages. The leading causes of morbidity in order of importance were: high • 
blood pressure, coughing or TB and diabetes. Other common types of 
illness were fever, malaria, sores, wasting, cancer, witchcraft, diarrhea, 
STD/HIV and mental illness. The conditions were self-reported with no 
medical diagnosis as confirmation. 
The health facility most frequently utilized by chronically ill patients 
was the clinic or hospital, followed by private clinic or doctor. In Mutare 
clinics and hospitals were the main health facilities utilized, followed by 
modern faith healers. Overall, 12 CIPs indicated that they did not use 
any health facility. The main reasons forthis were reported to be lack of 
funds and religious reasons. The average total medical costs per illness 
episode were ZS865 for the clinic and hospital, Z$2858 for the private 
clinic or doctor, Z$474 forthe traditional healer and Z$681 forthe modern 
faith healer. As expected, the costs were highest for the private 
clinic or doctor. The main sources of money to meet medical costs 
included wage earnings, relatives, savings and the Ministry of Public 
Service, Labour and Social Welfare's Social Dimensions Fund (SDF) 
(see Table III). This shows that long illness is indeed a form of an 
income shock that diverts wage income and depletes household savings. 
Relatives and the SDF formed the major social support mechanisms 
to help households meet medical costs. The main insurance support 
adopted by households was medical aid. However, high membership 
costs makes this mechanism inaccessible to poor households. 
12 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
Table II. Profile of chronically ill patients 
n=200 
% Households without a CIP 
Mutare JMl areas 
n=598 
76 
Harare Bulawayo 
n=200 
67 
n=198 
86 
24 14 33 
27 158 66 
42 59 32 
58 
28 21 
Spouse 24 35 
32 Son/daughter 23 
41 68 
Relation of CIP to head of household (% households) 
67 
% Households with a CIP33 
Number of CIPs 65 
%ofmaleCIPs 35 
% of female CIPs 65 
(n=158) (n=65) 
Household head 
(n=66) 
36 
22 
32 
(n=27) 
27
0 
50
8 Parent of head 0 
Other relation 21 
2
9 
2 
14 
100 Total (%) 
15 
100 100 100 
(n=158) (n=27) (n=66) 
33 26 7 
12 14 8 
55 >3 months 60 85 
Total (%) 100 100 100 
1-2 months 
Length of illness (% of CIPs) 
(n=65) 
51 
2-3 months 11 
38 
100 
Coping with illness-related decrease in income 
AFFECTED HOUSEHOLDS were asked whether the illness had affected 
household income. Seventy percent of the 158 households with CIPs 
indicated that they had experienced a decrease in income as a result of 
the ill adult not being able to perform normal income-generating activities. 
In order to cope with the decline in income, households adopted 
different strategies. The main strategies adopted were remittance from 
relatives (27%, 30 households), use of savings (19%, 21 households), 
informal borrowing (16%, 18 households) and informal business activi- 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 13
Table 111. The main source of money to pay for 
medical costs (% households) 
Harare 
n>65 
Bulawayo 
n=66 
25 
All areas 
n=158
27 
Mutare 
n=27 
23 
Formal Sources 
Wage earnings 32 
5 7 4 Medical aid 4 
12 15 SDF 7 12 
15 
14
2
5 
13 
13
0
3 
23 
15
4
4 
6 
Informal Sources 
Relatives 16 
Savings 18 
Sold assets 4 
Borrowed 7 
Proceeds from own business 
0 
Not reporting 14 14 
10 
14 
8
8 
ties (11%, 12 households). Other household coping strategies reported 
included the sale of assets, subletting, taking on a second job and 
borrowing from a bank. These household coping strategies are similar 
those found in other studies, Kwaramba in rural Zimbabwe and 
Rugalema in Tanzania. 
Prevalence of death in the sample households 
TWENTY ONE percent of the households reported a death within the 
previous 12 months. There were a total of 126 deaths from the total of 
598 households. About 15 households experienced more than one death. 
Some points stand out. Seventy four percent or 93 of all the deaths were 
of adults aged 19 to 50 years. The most common death to occur overall 
was that of the household head or spouse. Also noticeable was the fact 
that the vast majority of deaths (over 70 per cent) were of the immediate 
nuclear family (the head, spouse, the son, daughter and the parent of 
head or spouse) possibly indicating that each death is likely to have a
Table IV. Profile of deceased persons and household's coping 
responses to a death 
All areas 
(n=598) 
126 
Mutare 
(n=198) 
41 
Harare 
(n=200) 
Number of deaths 36 
Bulawayo 
(n=200) 
49 
46 53 
% of female deaths 50 54 47 
(n=49) (n=36) 
Household head 0 
Spouse 28 
% of male deaths 50 50 
50 
Deceased's relation to head of household (% households) 
(n=126) 
7 
28 
26 
2 
44 
15 
(n=47) 
21
3 
46 Son/daughter 22 
Parent of head/spouse
16 g 
Other relation 34 
13 
26 
13 
24 21 
greater overall impact on the welfare of the household. In addition, the 
low average age at death of 35 indicates that those who died were likely 
to be productive and involved in supporting other household members. 
The reported cause of death was dominated by coughing/TB (32%, 
40 of the deaths), followed by hypertension (13%, 16 of the deaths), 
boils (8%, 10 of the deaths), HIV/AIDS (8%, 10 of the deaths), sores (7%, 
9 of the deaths) and witchcraft (6%, 8 of the deaths). Other reported 
causes of death were malaria, meningitis, accident, cancer and old age. 
In general the mortality profile was similar to the morbidity profile. 
The coping strategies adopted by households in response to a 
household death also follow closely those adopted for morbidity. Households 
rely heavily on support from family members, utilization of savings 
and borrowing from informal networks. The main coping responses 
adopted by households included remittances from family members (30%, 
37 of the deaths), use of savings (26%, 33 of the deaths), borrowing 
from informal institutions (16%, 20 of the deaths), informal business 
activities (11%, 14 of the deaths), subletting (9%, 11 of the deaths), sale 
of assets (4%, 5 of the deaths) and government transfers (3%, 4 of the
deaths). The most commonly sold assets were furniture, cattle, radio, 
televisions, goats, beds and bicycles. In Zimbabwe's rural areas, 
Kwaramba (1998) found that households sold agricultural implements 
such as hoes and ploughs and livestock. The majority of the household 
coping strategies adopted are reversible, indicating that households 
had not yet reached the point of destitution. 
The existing local informal social support mechanisms 
THE MAIN INFORMAL support mechanisms cited by the surveyed households 
and focus group discussions include burial societies, savings 
club, church clubs, women groups, informal borrowing and chimbadzwa 
(high interest loan clubs). The informal mechanisms where the households 
have been receiving benefits for a long time include burial societies, 
church, women's group and chimbadzwa. The benefits of the latter 
accrue mostly in the form of funeral assistance, food support, clothing, 
counselling and spiritual support. The inadequacy of benefits was cited 
as the most severe type of constraint in all types of informal social 
support mechanisms. Burial society and savings clubs were ranked the 
most effective type of informal support mechanisms by affected households. 
Other support mechanisms perceived as highly effective are 
women's groups and church organizations. 
The existing formal social support mechanisms 
THE MAIN PUBLIC social support mechanisms include the Social Development 
Fund for Fees, Social Development Fund for Health, Department 
of Social Welfare public assistance and medical aid. Only four households 
reported that they had benefited from the education and health 
assistance programmes. The main constraint experienced in accessing 
the public mechanisms was the inadequacy of the benefits and the long 
vetting procedure. Other constraints identified include ill-defined selection 
criteria, bureaucracy and corruption. Affected households also 
reported receiving support from non governmental organizations such 
as Plan International, FACT and the Red Cross in the form of microcredit, 
boreholes, food and school fees. 
16 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
The main private social support mechanisms on the other hand include 
financial insurance and funeral insurance. For private social support 
mechanisms, "membership" and "joining fee" were identified as the 
main criteria needed by the household before benefits could be accessed. 
The lack of collateral, high interest rates and prohibitive joining fees 
were the main constraints cited by households to accessing support 
from micro-credit schemes. Funeral insurance and financial services 
were rated to be the most effective formal support mechanisms. With 
the current economic hardships the country is experiencing it is very 
difficult to get a loan and be able to repay it due to very high interest 
rates. A general observation is that the public formal support mechanisms 
are less effective than private formal support mechanisms. 
Discussion and emerging social protection policy implications 
IN THIS STUDY WE sought to expand our understanding of the prevalence 
of morbidity and mortality in a randomly selected sample of households 
in low-income residential suburbs, identify household coping mechanisms 
and the formal and informal social support mechanisms currently 
utilized by households to help cope with adult morbidity and mortality 
and identify the emerging social protection policy implications. The 
study revealed the prevalence of households experiencing adult morbidity 
to be 24% and households experiencing adult mortality to be 
21%. The leading causes of long illness and death were reportedly 
similar, dominated by coughing or TB followed by hypertension, diabetes, 
fever, boils, sores and witchcraft. Coughing or TB, boils, fever and 
diarrhea are the primary manifestations of AIDS, while meningitis and 
malaria mortality can be AIDS related also. These findings suggest that 
the leading cause of long illness and death in adults in these lowincome 
urban areas is AIDS related. This calls for the government to 
promote strategies that can help prevent the spread of HIV/AIDS and 
improve access to treatment for those who are ill. In terms of social 
protection, HIV/AIDS prevention and mitigation programmes should be 
integrated with the social assistance programmes in order to prevent 
future illnesses, deaths and increased poverty. This means that some 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 17
programmes can include prevention messages. Certain mitigation strategies, 
such as micro-credit, can be specifically targeted at women and 
youths, who appear to be the worst affected by the epidemic, yet typically 
have limited access to productive resources and employment 
opportunities. 
Findings on what households do to cope with morbidity and mortality 
revealed that they have become increasingly dependent on family 
support and informal sources of income to cope with the morbidity and 
mortality-related loss of income. One of the mechanisms adopted by 
households was informal business activity. There is need to explore 
ways of strengthening informal activities that have been reported to be 
most frequently used by households such as vending, agriculture, crafts 
and sewing and knitting. Increased informal sector activity can be a 
major route to fostering the informal mutual assistance schemes found 
in the communities. The level of output and earnings in the informal 
sector can be increased by enhancing its supply potential through 
policies aimed at improving access to financing, supportive regulatory 
policies, supportive infrastructure, the removal of prohibitive by-laws 
hindering the operations of this informal sector and training and disseminating 
information about appropriate technologies (Raftopolous 
etal. 1998; Kanji and Jazdowska 1993). 
The main form of income or food transfer was from extended families 
and informal networks. This dense network of exchange does help a 
household overcome the impacts of the long illness or death of an adult 
member. However, during an economic crisis it is more difficult to ask 
for help from anyone as they are also experiencing a decline in income 
and the poorer the community, the less the support and the greater the 
need for outside intervention. It is therefore necessary that public assistance 
programmes play a more active role in sustaining the livelihood 
of the poorest families. This calls for the improved allocation of funds 
to social welfare and the improved targeting of the transfers to needy 
households. In sub Saharan African countries public transfers are often 
not well targeted and fail to reduce income inequality (Moser 1998, 
Castro-Leal et al. 1999). Improvements in the targeting of social assistance 
to the poor not only involves rearranging the flow of the public 
18 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
transfers but also addressing the constraints that prevent the poor 
from accessing these services, such as improved access to health, education 
and sanitation services and the way that the transfer is 
administered. How can targeting government transfers from the SDF be 
improved in the urban areas? Should the SDF change its targeting mechanism 
from means testing (where programme eligibility is determined by 
household income)? According to Baker and Grosh (1994), means testing, 
used in combination with geographical targeting greatly improves 
the efficiency of a transfer programme. It is important that the SDF 
explores means of incorporating geographical targeting in their programmes, 
using the high-density suburbs as units of analysis. As shown 
in the study, more than half of the households in the randomly selected 
sample earn an income that is lower than the inflation-adjusted poverty 
datum line. Thus primarily targeting transfers to low-income suburbs 
can improve targeting of social assistance. However, given that there 
are many low-income suburbs, targeted suburbs should be prioritized 
using other indicators such as the availability of clean water, sanitation, 
health and education services. 
Improvement in the management and administration of the social 
protection programmes can greatly improve the efficiency of what might 
be small social safety nets. Such improvements can be achieved through 
tackling the major constraints raised by the communities, which include 
minimizing bureaucracy and political influence and eliminating corruption. 
The process of getting exemptions for school and health fees has 
been reported in one study to be difficult (Bassett et al. 1997). It is 
therefore important that the Social Development Fund improves the 
handling of beneficiary applications so as to avoid any unnecessary 
decline in human welfare development. This can be achieved through 
the decentralization of activities and sub-contacting activities to locallevel 
organizations such as municipalities. Such schemes have the 
advantage of low administration costs and encourage the local participation 
of communities in project design and implementation. 
Burial societies were reported in this study to be an effective informal 
mechanism helping to cushion households against death-related 
income shock. It is important that the government formulate policies 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 19
and incentives that strengthen this informal institution and promote it 
in areas where it is non-existent. There is a need for policymakers to 
explore how similar voluntary societies such as burial societies can 
operate to help cushion the impact of long illness-related income shock. 
Such a social support mechanism at community level could be a healthfees 
insurance club or a prepayment scheme. There is a growing body 
of literature on voluntary community health insurance and prepayment 
schemes in which such schemes have been reviewed and evaluated 
(Atim 1999, Ron 1999, Bloom et al. 1999, McPake et al. 1993, Noterman 
et al. 1995, Sauerborn et al. 1996). One of the major findings of these 
reviews is that community initiatives to generate funds to meet health 
costs through risk-sharing schemes proved efficient in protecting the 
community from the negative effects of fees and is a promising tool in 
shouldering the economic burden of income shock. This helps the poor 
beat the high joining fees and membership subscriptions often required 
by formal medical organizations (Atim 1999). However the schemes 
should be strongly based on community participation, accountability 
and autonomy. Such schemes can also benefit from government or 
NGO assistance in their design and monitoring (Ron 1999). 
All in all, although policies that strengthen household's coping strategies 
should be encouraged, such policies should be seen as a 
complement to and not a substitute for efficient and equitable macroeconomic 
policies and sustained growth in the formal sector of the 
economy. It is important that macroeconomic policies securely embeds 
the need to sustain the welfare of the most vulnerable in society, by 
addressing inflation and ensuring that expenditure on social capital 
does not fall. It is important that the government prioritize the welfare of 
the poor and allocate resources towards it if progress in the country's 
human development is to be achieved. Social protection strategies can 
be successful only where the macroeconomic policies support the social 
policies (Raftopolous et al. 1998). High nominal and real interest 
rates and stagnant per capita incomes have created a hostile environment 
in which the new small-scale enterprises have to operate 
(Raftopolous et al. 1998). The study has shown that inflation is weakening 
the informal support network, the main form of support to 
20 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
households. The macro-economic policies that are required include those 
that foster economic growth and price stability, create an environment 
that promotes savings, investment and employment creation, improve 
the purchasing power of the poor, reduce unproductive spending (such 
as military spending) and promote efficient spending on the social sectors; 
health and education. 
Conclusion 
THIS STUDY HAS revealed that low-income households have been under 
severe stress from adult morbidity and mortality. Social services budget 
cuts, real decline in wages, massive retrenchments, real increases in 
food and other non-food items, health cost recovery and increases in 
HIV/AIDS and other epidemics have seemed to have worked against the 
poor. The study's findings suggest that households and communities 
have adopted innovative strategies to try and cope with the income 
loss-related morbidity and mortality. It revealed that households are 
heavily dependent on informal forms of support ranging from informal 
borrowing, remittance from family members to informal business activities. 
Policies aimed at strengthening these informal sources of support 
can help foster the well being of poor families and reduce the burden of 
the negative impact of morbidity and mortality. If informal employment 
or self-employment is to be a viable development strategy, the necessary 
innovative enabling environment must be created. Policies such 
as improving the regulatory framework of the informal business activities, 
technical training, technology promotion and financing can help 
ensure that poor households have a reliable source of income to help 
them maintain consumption when they experience an income shock. 
The study has suggested that the SDF needs to improve the targeting 
of public assistance by localizing the administration of the fund. 
Granting financial grants to local area administration or grassroots organizations 
involved in education, housing, health and sanitation can 
help ease the costs of administering the programme at the same time as 
ensuring that the transfers reach the people who are most in need. If the 
aim of national economic development is not simply to increase output 
but also to improve human welfare, government must redirect its policy 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 21
towards meeting this goal. What is needed is improvement in government 
resource allocation to social services and employment generation; 
a modified cost recovery mechanism, intensified HIV/AIDS prevention 
and mitigation strategies and targeted social assistance for the vulnerable, 
in order to protect the poor from falling deeper into poverty. 
References 
Adetunji, J. 1997. Assessing the mortality impact of HIV/AIDS relative to 
other causes of adult deaths in sub-Saharan Africa. Paper presented at 
the Conference on Socio-demographic Impact of AIDS in Africa at Durban, 
South Africa. 
Atim, C. 1999. Social movements and health insurance: a critical evaluation 
of voluntary, non-profit insurance schemes with case studies from 
Ghana and Cameroon. Social Science Medicine, 48,881-896. 
Barnett, T. Blaikie, P. 1992. AIDS in Africa: Its present andfuture impact, 
Chichester, John Wiley & Sons. 
Bassett, M.T, Bijlmakers, L.A., Sanders, D.M. 1997. Professionalism, 
patient satisfaction and quality of health care: Experience during Zimbabwe's 
Structural Adjustment Programme. Social Science Medicine, 
45,12,845-1852. 
Baker, J. Grosh, M. 1994. Poverty reduction through geographic targeting: 
How well does itwork? World Development, 22,7,983-995. 
Bloom, G. Shenglan, T. 1999. Rural health prepayment schemes in China: 
Towards a more active role for government. Social Science Medicine, 
48,951-960. 
Castro-Leal, Dayton, F.J. Demery, L. Mehra, K. 1999. Public social spending 
in Africa: Do the poor benefit? World Bank Research Observer, 14, 
1,49-72. 
Central Statistical Office. 2000. Quarterly Digest of Statistics, Harare. 
22 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001
Bindura-Mutangadura/MORBIDITY AND MORTALITY IN URBAN AREAS 
KanjiN. Jazdowska,N. 1993. Structural adjustment and women in Zimbabwe. 
Review of African Political Economy, 56, 11-26. 
Kwaramba, P. 1998. The socio-economic impact of MV/AIDS on communal 
agricultural systems in Zimbabwe. Zimbabwe Farmers Union, Friedrich 
Ebert Stiftung Economic Advisory Project, Working Paper 19, Harare. 
Ledward, A. 1997. Age, gender and sexual coercion: Their role in creating 
pathways of vulnerability to HIV infection. Masters thesis submitted 
to University College of London. 
Matshalaga, N.R. 1997 (a). The Gender Dimensions of Urban Poverty: 
The Case of Dzivarasekwa, Institute of Development Studies, Harare. 
University of Zimbabwe. 
Matshalaga, N.R. 1997 (b). The Gender Dimensions of Urban Poverty: 
The Case ofTafara, Institute of Development Studies, Harare. University 
of Zimbabwe. 
McKerrow, N.H.I 998. The vulnerability of the southern African family. 
Paper presented at the Conference on Raising the Orphan Generation, 
Pietermaritzburg, (June 9-12). 
McPake, B. Hanson, K. and Mills, A. 1993. Community financing of 
health care in Africa: An evaluation of the Bamako initiative. Social 
Science Medicine, 36,11,1383-1395. 
Ministry of Health and Child Welfare, 1998. HIV, AIDS, STD and TB Fact 
Sheet. Quarterly Report November 1998, Harare, Monitoring and Evaluation 
Unit and National AIDS Coordination Programme. 
Ministry of Public Service, Labour and Social Welfare and UNICEF1997. 
1995 Poverty Assessment Study Survey: Main Report, Harare. 
Moser, C.O.N. 1998. The asset vulnerability framework: Reassessing 
urban poverty reduction strategies. World Development 26,1, 1-19. 
Mutangadura, G. and Webb, D. 1999. The Socio-Economic Impact of 
Adult Morbidity and Mortality on Households in Kafue District, Zambia, 
Harare, SAFAIDS. 
Mutangadura, G. 1998. Macroeconomic policies and the health sector in 
Zimbabwe: Past experience and lessons for the future. Paper presented 
at the Zimbabwe: Macroeconomic Policy Management and Performance 
VOL 16 NO 1 JANUARY 2001 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 23
since Independence (1980-1998): Lessons for the 21 st Century Conference 
held at the Harare Sheraton Hotel, 19-21 August, 1998. 
National Aids Coordination Programme, 1999. HIV/AIDS in Zimbabwe: 
background, projections, impact and intervention. Ministry of Health 
and Child Welfare, Harare. 
Noterman, J.P. Criel, B. Kegels, G. and Isu, K. 1995. A prepayment scheme 
for hospital care in the Masisi district in Zaire: A critical evaluation. 
Social Science Medicine, 40,7,919-930. 
Over, M. 1995. Kagera health and development project: Report from a 
consultation on the socio-economic impact ofmv/AiDS on households. 
UN AIDS, World Health Organization. 
Raftopolous, B. Hawkins, T. Amanor Wilks, D. 1998. Zimbabwe Human 
Development Report 1998. Report by the United Nations Development 
Programme, Poverty Reduction Forum and Zimbabwe Institute of 
Development Studies, Harare. 
Ron, A. 1999. NGOs in community health insurance schemes: Examples 
from Guatemala and the Philippines. Social Science Medicine, 48,939— 
950. 
Rugalema, G. 1998. It is not only the loss of labour: HIV/AIDS, loss of 
household assets and household livelihood in Bukoba district, Tanzania. 
In AIDS and African Smallholder Agriculture, G. Mutangadura, H. 
Jackson and D. Mukurazita. (eds.) SAfAIDS, Harare. 
Sauerborn, R. Adams, A. Hien, M. 1996. Household strategies to cope 
with the economic costs of illness. Social Science Medicine, 43, 11, 
291-301. 
Tibaijuka, A.K. 1997. AIDS and economic welfare in peasant agriculture: 
Case Studies from Kagabiro Village, Kagera Region, Tanzania. World 
Development, 25,6,963-975. 
UNAids 2000. AIDS Epidemic Update: June 2000, Geneva. 
Webb, P. Reardon, T. 1992. Drought impact and household response in 
East and West Africa. Quarterly Journal of International Agriculture, 
31,3,230-246. 
World Bank 1997. Confronting AIDS: Public Priorities in a Global Epidemic. 
A World Bank Policy Research Report, Oxford University Press, 
New York. 
24 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 16 NO 1 JANUARY 2001