Journal of Social Development in Africa (1990), 5,1,31-38 
Issues of Equity In and Access to Health Care 
in Zimbabwe * 
SAMUEL AGERE 
ABSTRACT 
The purpose of this paper is to identify and analyse, within the health care delivery system in 
Zimbabwe, certain categories of people or social groups who may or may not have access to 
health care. An attempt will also be made to give the reasons for the maldistribution of health 
resources and the implications this has for the population of Zimbabwe. Brief and appropriate 
solutions are proposed within the socioeconomic and political context of the Zimbabwean 
stage of development and its historical past. 
Introduction 
Health care is delivered within and by a hierarchically organised and structured system. The 
system includes the production, distribution and consumption of health services. Within the 
system, there areanumber of major actors suchasphysicians.nurses, paramedics, pharmacists 
and the pharmaceutical industry, insurance companies, hospitals and clinics, through which 
curative and preventive services are administered, delivered and consumed. This group of 
actors in the health care delivery system have a monopoly, and control, of the technical 
knowledge of producing and administering medicines. Within this group of actors, doctors 
dominate and control the system, from production of knowledge of medical care, distribution 
of medical services, and, more importantly, the consumption of health care. By virtue of their 
educational background, life style, and incomes, doctors form partof a class of elite in society. 
The control of health care delivery systems by doctors is facilitated by the state through 
various pieces of legislation, and regulations which apart from protecting the patients also 
protect the interests of doctors. The Health Professions'Council Act, for example, lays down 
the qualifications and experience required of the actors in the system. The doctor's task is 
made easier by the social order which reinforces their status. There are laws that determine, 
guide and protect private medical practice, pharmacies (by way of manufacturing of drugs and 
their mixtures), and medical aid societies in which doctors are also represented. 
* A revised form of a paper presented to the Workshop on Health Manpower Issues in Relation to Equity in and 
Access to Health Services in Zimbabwe, June 8/9 1989, Harare, Zimbabwe. 
+ Permanent Secretary, Ministry of the Public Service, P O Box 8080, Causeway, Harare, Zimbabwe.
32 Samuel Agere 
Equity and access in health 
A precondition for medical care is that contact is established between people needing health 
services and the persons providing these services. It must be possible for this contact to be 
realised at the time and place of need, if an optimal level of medical care is to be provided. 
Essentially, then, the requisites of accessibility are quantitative adequacy, appropriate 
geographical distribution, and the absence of cultural, economic and educational barriers to 
medical care (Babson, 1972). The quantitative adequacy refers to the ratio between medical 
personnel and technological facilities and services - for example doctors, nurses, pharmacies 
and pieces of capital equipment such as hospital beds. 
The second factor necessary for a high degree of accessibility is that health care services 
be distributed geographically in such a way as to permit their mass utilisation. Further, the 
services must be made available at times suitable for the population served. In other words 
the elementof accessibility requires only that all potential users have the opportunity toutilise 
any services, and that the point at which any specific service is rendered should not be of such 
distance as to senously endanger the health of individuals who must be transferred to receive 
such services. 
The third element of accessibility is the absence of economic, cultural and educational 
barriers to health care. Of these, economic barriers are the most obvious, and also the most 
amenable to change. If medical care is viewed as a right, as opposed to a luxury or a nonessential 
commodtty, financial barriers to health care should not exist (Babson 1972). 
Considering the three factors identified above, from all the studies that have been carried 
out in lh,s country, and from our experience, health in Zimbabwe is not adequately and 
t0 h e a l t h c a r e ' b u t ^ ** the poor and the 
T T « ^ f ^ * ^ ^ worse off than anyodter group 
This ,s despite the attempts that have been made in the last years to make health 
High quality medical care is that which utilises all the 
nal1 measures: of'health, such as life expectancy, disease patterns, 
as well as in the poorer communities ^hin J S S S T S T * "T °f ^ " " "S 
vulnerable to periods of economic crkk «JT«A ^ CSC SOCiaI g r o u p s m a lW 
housing conditions, etc. M d r ° U g h l ' u«c">Ploymcnt, inflation, poor
Equity and Acetis 33 
Reason! for the maldistribution of health care resources 
Although there are many causes for the maldistribution of health resources which result in 
their inaccessibility, discussion will only centre on a few of these, which are enumerated 
below: 
Health care is treated as a commodity. Like any other commodity it follows the general 
laws for the production and distribution of commodities. It is offered at a price on the 
market and it is purchased like food. 
The commodity view regards property relations and private capital as the determining 
factor in the distribution of services. When health is viewed as a commodity with a price, 
it tends to be differentially distributed among members of the society which in turn is also 
stratified in terms of power, wealth, education, etc. 
A man who is unemployed, or on minimum wage, for example, is unable to buy drugs 
from the drug store, when a prescription is given by a doctor. In some cases drugs that are 
not available in the hospital are found in the drug store where they are purchased by 
anybody with a prescription. A man who cannot afford the price of drugs has to do without 
that medicine. If he is not on medical aid he is unable to obtain treatment. To this extent 
medical treatment is determined by the purchasing power of the individual. If purchasing 
power is the determining factor, then health or medical care is not accessible to many 
people, particularly not to those that are unemployed or underemployed or those in the 
most remote parts of the country. Medical care is, therefore, differentially distributed in 
favour of those with purchasing power. 
On the contrary a man who is in a high income bracket, and on medical aid, can afford 
to purchase the drugs and claim from the medical insurance. Further he can claim rebate 
from his income tax. In reality he is reimbursed the amount of money he spent on drugs 
and on treatment by a doctor. 
If society is socially stratified in very general form into those with income and those 
without, health care can be regarded as reflecting the classes in our society. To this extent 
health is not treated as a right. Health care is not affordable, accessible nor available in 
the same manner to all social groups in our society. 
Uneven development which, as a result of colonial history and capitalist economy, 
differentiates society into urban and rural areas. The urban area has more and better 
facilities than the rural area. This differentiation in the provision of services by geographical 
regions is not only found in health services but also in housing, transportation, 
education systems and other social services. Communication patterns and facilities make 
health or medical care inaccessible. In many parts of Zimbabwe, there is still no transportation, 
nor roads leading to the nearest clinic or hospital. In some cases roads are 
available, but are impassable with the result that transport operators do not find it 
profitable to operate on such roads. In these remote parts of the country there are no private 
doctors nor pharmacies, because they are always placed in areas where there is a huge 
capital from which they can make a profit. 
About three quarters of the population live in the rural areas where clean water supplies, 
sanitation, and hygienic conditions are either non-existent or in their rudimentary forms.
34 Samuel Agere 
Major diseases that can be controlled, such as malnutrition, water borne diseases, 
diarrhoea, measles, typhoid, etc are prevalent in the rural areas. 
Another major disease group consists of the air borne diseases. This group includes 
tuberculosis, pneumonia, diphtheria, bronchitis, whooping cough, meningitis, small 
pox and chicken pox. These diseases are spread by inhaling the airborne respiratory 
secretions of affected persons (World Bank,1980). These disease groups account 
for the majority of deaths among the poorest people, particularly those resident in the rural 
areas. Life expectation is very low in the rural population, where environmental 
conditions are still very poor. 
The majority of our rural population have little, if any, access to organised health 
care or to facilities (Ushewokunze, 1981). The environmental conditions in which the 
poorest of the poor live are a testimony to the inaccessibility and unaffordability of the 
health and medical care delivery system. 
4. The rural population, though politically active and conscious, are by far the most 
politicallypowerless social groupin influencing and determining the production, distribution 
and consumption of health services. It has been argued that capital was concentrated 
where there was a rapid turnover of profits, particularly in its primary circuit, that is where 
it drew manufactured raw materials. Capital, in my view, was responsible for the 
structuring of the urban areas in such a way that the rural areas provided the required 
commodities, such as food and labour, to the so called modern sector (towns and cities). 
The capitalist mode of intervention in development was characterised by: 
a) allocation of resources where there was capital concentration 
b) the ideology and organisation of services such as health, housing and education. 
This ideology strengthened class relations in our society and consequently reinforced 
the capitalist system. In that respect services had an ideological base and therefore the 
whole question of inaccessibility to the health service by the poor or rural population is 
political and ideological. For any meaningful change to take place within the health care 
delivery system, the masses, who were disadvantaged in the past, should be involved in 
making decisions that affect their lives. The allocation of funds for health services was 
done by people who were were not directly experiencing the hardships of living in the rural 
areas. The distribution of health resources, for example doctors, nurses and pharmacies, 
is without the influence of the consumers of the services in the rural areas. 
Equally important is the production of health resources. The training of doctors and 
nurses does not take into account the recruitment of such personnel from the rural areas. 
The merit principle used in the selection of medical studentsandnurses, though important, 
does not address the specific situation of the rural population nor women, another 
oppressed social group. The training of these human resources and their location in urban 
areas still have an ideological bias against the rural people. 
Solutions 
Below I propose actions which could be considered, as they appear to contribute to the 
solutions of the problems outlined here. The solutions are by no means new.but arc repealed
Equity and Access 35 
here to extend the debate until effective tactics and strategies are identified and implemented, 
to the satisfaction of those who do not have access to health care. Health care delivery systems 
can be improved by engaging certain political and bureaucratic processes from which 
strategies and tactics can be formulated. 
The processes outlined below are likely to enable citizens to have control over health 
resources and to have access to and participate in the locally available health care system, since 
they will not be constrained by a hierarchically, centralised, undemocratic and technically 
controlled system. An essential element which can facilitate these processes is the social and 
economic democracy spear headed by a political philosophy, and machinery, committed to 
change. 
It should be realised that these processes are only guidelines to help bring about 
meaningful change, and are based on the theoretical perspective advocated in this paper. They 
also form the basis on which proposed strategies and tactics outlined later are formulated. 
Incrementalism 
Some theorists and practitioners in health have proposed that the only way to solve the 
problem of access to health services is to increase the number of doctors, nurses, hospitals, 
pharmacies, etc. This proposal is based on the philosophy (or assumption) generally referred 
to as incrementalism. The proponents of this theory assume that the spread of existing 
services, by increasing the numbers of trained human resources, will saturate the market and 
consequently result in doctors and nurses placing themselves in hitherto neglected areas. In 
my view, incrementalism will not change the overall pattern of medicine and health care from 
that which existed in the colonial era. Furthermore, it does not seek to fundamentally change 
the structure of the system so that it can be based upon egalitarian principles and philosophy. 
At face value, the incrementalist approach appears to provide small material and 
numerical improvements while leaving intact the political structures which contributed to the 
inaccessibility of the health care delivery system. The approach therefore helps to preserve 
the political and economic system in its present form, rejecting any structural changes that are 
incompatible with the preservation of the system. In effect it obscures the sources of 
exploitation and structural inequalities in the health care delivery system. 
Democratisation 
It has been argued that the distribution of health services is political and that political and 
economic power is the source of the inequitable distribution of resources in general and of 
health resources in particular. As political and economic power is differentially distributed, 
health care will be differentially distributed and consumed. For health care to be fairly 
distributed, it needs to be democratised, and subjected to control by elected representatives. 
The representatives should be elected from those who work in the health sector (workers), 
those affected by the system (patients or consumers), and those chosen by the community and 
organised groups (for example youth, women and other interest groups). 
Within the process of democratisating the health care delivery system, there is a need to 
consider carefully the method of electing representatives. Such an instrument should be
36 Samuel Agere 
sharpened if there has to be meaningful and democratic representation. Avoidance of 
regionalism, tribalism and sex discrimination should always be borne in mind because 
diseases and ill health know no tribal or sex boundaries. AIDS as a disease, for example, does 
not choose an ethnic or racial group. The creation of appropriate political institutions is 
needed to guide, implement and build an egalitarian society and a fair health system. 
One of the major reasons for democratising the health institutions through citizen control 
is that it will be more likely to be in tune with the socialist goal of distributing resources in line 
with the needs of the community served. The best people to decide on their priorities would 
surely be the beneficiaries themselves. The democratisation of such institutions will help to 
replace dominance by one class and race in the main decision making bodies inside and 
outside the health sector. 
Navarro (1977), a physician, argues that when democratisation does occur, not as a token 
participation but as control, the pattern of priorities does indeed change. Actually, it is because 
of the real possibility for change that democratisation presents that there is so much resistance 
and opposition to it. Democratisation is not always smooth. It is a process in which conflicts 
and contradictions arise and are resolved. It is a process in which a majority of poor people 
struggle against exploitative ideas within the health sector. 
Decentralisation 
One of me ways of making health care more accessible is to decentralise the bureaucracy down 
to the regions, rural areas and neighbourhoods, based on the assumption that a decentralised 
health care delivery system is more responsive to local needs. The professional staff working 
at a decentralised level are more likely to be perceptive of the norms and needs of the local 
residents. 
Decentralisation is not just concerned with the equalisation of resources, but also with 
responsibilities and facilities controlled at a local level. Within the health field, facilities such 
as land, buildings, and manpower to build health centres, can be utilised. In decentralising 
health services increased use is made of paramedical personnel, who are produced in greater 
numbers. These paramedicals can be recruited locally and are not likely to have language or 
cultural barriers to thedelivery of services to the masses. A decentralised health system makes 
preventive work much more effective. If the locally recruited staff are elected by their 
communities to be trained, they are likely to be more accountable to the masses than to the 
bureaucracy. In a democratically decentralised system, the consumers are more likely to 
participate in decision making and in controlling their own health resources. 
Debureaucratisation 
Asalready discussed, health care is deUvered to hierarchically designed bureaucracies. These 
bureaucracies are part of a larger political economy, a macro social and historical formation 
in which a given mode of production tends towards dominance over others. These 
bureaucracies are loyal and accountable to those who control resources and not those who 
consume them. A bureaucratic organisation according to Heyderbrand (1977) is created by 
the need of the employer or owner to structure and control the process of woik. The
Equity and Access 3 7 
characteristic of this structure is that decision making has to be organised from the highest 
level to the lowest level, according to the vertical order of the hierarchy. The controllers have 
apicture of the processes of delivering the service and the technologies employed, which must 
replicate the hierarchical division of labour. 
The health care delivery system, which is hierarchically organised according to class and 
degree of expertise, is likely to distribute health resources differentially and selectively. For 
these reasons there is a need to reduce the bureaucracy to a level where services, as well as 
consumers, play a part in decision making and delivery of service. Debureaucratisation not 
only reduces over centralisation of the control of services but also increases the chances of 
local representatives controlling the health resources. 
Strategies 
Based on the processes discussed above the proposed strategies for a new health care 
paradigm focus on health as a fundamental right, concomitant with economic and social 
development A few of the strategies which I have elaborated elsewhere in more detail 
(Agere, 1986) are briefly discussed here: 
Preventive measures of public health 
Preventive measures are based on the assumptions that: 
1. they are redistributive in that they play a role in minimising the gross inequalities in 
the availability and consumption of health resources. 
2. they are cheaper than hospital based curative services which cater only to a small 
minority of the total population with access to them. 
3. they are based on social justice - it is just and fair that all citizens receive the benefits 
of development, and that benefits be fairly distributed. 
Environmental sanitation 
Many of the diseases that account for a major number of deaths among the people are those 
that are faecally transmitted. Food and water can be contaminated with human waste leading 
to such diseases as diarrhoea and dysentery. To reduce these water borne and faecally 
transmitted diseases it is necessary to attack the cause by designing strategies and simple 
techniques of waste and water treatment 
Nutrition 
vlany deaths, particularly among children, have resulted from malnutrition. It is a major 
contributing factor in infectious disease because it impairs the body's responses to disease and 
'educes immunity. To eradicate malnutrition it is necessary to provide adequate quantities of 
bod, of the right type and quality, which can bring about a change in the nutritional status of 
be population. To produce enough food requires the equitable distribution of suitable land.
38 Samuel Agere 
Unity of traditional and scientific medicines 
The need to combine both the scientific and traditional medicine worlds emanates from two 
assumptions: 
1. Some traditional medicine is effective while the majority is not. 
2. Eighty percent of the population, mostly in the rural areas, still use traditional 
medicines outside the health sector. The use of traditional medicine is part and 
parcel of their culture, and the sooner those medicines which do not work are exposed 
the better. 
Planning for health care 
The present government inherited a health care delivery system that essentially served settler 
interests, and that was biased in favour of curative services as opposed to preventive services. 
The health care delivery system was highly oriented towards specialised, hospital based 
medicine as opposed to community medicine, urban technologically intensive medicine in 
contrast to rural labour intensive medicine, and personal health services as opposed to 
environment health services. 
The first goal of restructuring such a health system is to set priorities, and to make 
maximum use of the present health resources, particularly for those in greatest need. Several 
techniques designed for maximum utilisation of availableresources, such as rational planning, 
cost benefit analysis and emphasis on primary health care, could be used in planning for a 
better health care delivery system. Planning for health care not only involves primary care 
and medical education but also appropriate technology without which the proposed health 
care paradigm cannot function. 
The strategies discussed above are simple, participatory and inexpensive. They enable the 
health care delivery system to be more available to the people, especially to the underprivileged, 
the majority of whom are in the rural areas. These strategies, if implemented with 
commitment and seriousness of purpose, are likely to make health care more equitable, and 
more accessible, acceptable and available to the majority of the people. These strategies avoid 
the competition, conflict and confusion brought about by the inherited colonial system and by 
hierarchically organised structures. 
References 
Agere ST (1986) "Progress and Problems in Health Care" in Mandaza I (ed) Zimbabwe. 
The Political Economy of Transition 1980-1986, CODESRIA, Dakar. 
BabsonJ (1972) Health Care Delivery Systems: A Multinational Survey,Pitman Medical. 
Gilmurray J, Riddell R and Sanders D (1980) The Struggle for Health: From Rhodesia 
to Zimbabwe, Catholic Institute for International Relations, London. 
HyderbrandW (1977) "Organisational Contradictions in Public Bureaucracies: Toward a 
Marxism Theory of Organisation", in Sociological Quarterly, 18, Winter. 
NavarroV (1977) Medicine Under Capitalism, Prodist, New York. 
UshewokunzeH (1981) Equity in Health, Government Printer, Harare. 
World Bank (1980) Health Sector Policy, Washington.