‘We thought supporting was strengthening’: re-examining the role of external assistance for health systems strengthening in Zimbabwe post-COVID-19

Abstract

Zimbabwe has received substantial external assistance for health since the early 2000s, including funding earmarked for, or framed as, health systems strengthening (HSS). This study sought to examine whether external assistance has strengthened the health system (i.e. enabled comprehensive changes to health system performance drivers) or has just supported the health system (by increasing inputs and improving service coverage in the short term). Between August and October 2022, we conducted in-depth key informant interviews with 18 individuals and reviewed documents to understand: (1) whether external funding has supported or strengthened Zimbabwe’s health system since the 2000s; (2) whether the experience of COVID-19 fosters a re-examination of what had been considered as HSS during the pre-pandemic era; and (3) areas to be reconsidered for HSS post COVID-19. Our findings suggest that external funders have supported Zimbabwe to control major epidemics and avert health system collapse. However, the COVID-19 pandemic showed that supporting the health system is not the same as strengthening it, as it became apparent at that time that the health sector is plagued with several system-wide bottlenecks. External funding is fragile and highly unsustainable, which reinforces the oft-ignored reality that HSS is a sovereign mandate of country-level authorities, and one that falls outside the core interests of external funders. The key positive lesson from the pandemic is that Zimbabwe is capable of raising domestic resources to fund HSS. However, there is no guarantee that such funding will be maintained. There is a need, then, to reconsider government’s stewardship for HSS. External funders need to re-examine whether their funding really strengthens the national health system or just supports the country to provide basic services in their areas of interest.

Introduction

External assistance towards Zimbabwe’s health sector spiralled upwards from the 2000s, particularly in response to HIV/AIDS, tuberculosis (TB) and malaria (Mhazo and Maponga, 2022b). In the aftermath of the health collapse in 2008, characterized by a mass exodus of health workers, closure of some public health facilities, severe shortage of medical supplies, escalating maternal and child deaths, and a debilitating cholera outbreak that claimed 4000 lives (Mangundu et al., 2023), a consortium of external funders created a sector-wide pooled fund known as the Health Transition Fund (HTF) (Salama et al., 2014). This consortium included the United Kingdom (UK) through the Department for International Development, now the Foreign, Commonwealth & Development Office, the European Union, the Canadian International Development Agency, Irish Aid, the Swedish International Development Agency and the Norwegian Government. The HTF, typical in fragile and conflict-affected contexts (D’Aquino et al., 2019), lasted from 2012 to 2015 and was designed to support critical interventions such as retention allowances to support the health workforce (nurses and doctors) in rural areas, as well as procurement of medicines, vaccines and commodities for maternal and child health. In parallel, the World Bank offered some funding focused on maternal and child health (Witter et al., 2020) which was conditional on using a results-based financing (RBF) mechanism (Witter et al., 2019a; 2019b). Since the end of the HTF, there were two, further multi-donor pooled funding mechanisms: the Health Development Fund (HDF) from 2016–2020 (Government of Zimbabwe, 2015) and the Health Resilience Fund (HRF), from 2022–2025. In total, between 2014 and 2020, external funders contributed over two billion United States dollars (USD) to Zimbabwe’s health sector (World Bank, 2023).

External assistance for Zimbabwe’s health sector has targeted various areas, including through dedicated funding labelled as health system strengthening (HSS) (Storeng, 2014; Steurs et al., 2018). The World Health Organization (WHO) describes health systems in terms of six components or building blocks: (1) financing, (2) health workforce, (3) information systems, (4) medical products and technologies, (5) leadership/governance and (6) service delivery (World Health Organization, 2007). HSS, as defined by the WHO, refers to initiatives that improve the performance of one or more building blocks and that ultimately leads to better health through improvements in access, coverage, quality or efficiency (World Health Organization, 2011). Although HSS has emerged as a rallying concept in global health since the 2000s, there remains some confusion as to what it exactly entails (Shakarishvili et al., 2010; Chee et al., 2013b; Kutzin and Sparkes, 2016). The COVID-19 pandemic has been portrayed more widely as a catalytic occurrence that exposed weak health systems in low- and middle income countries (LMICs) as well as providing a window of opportunity for a ‘rethink’ or reconsideration on the need to strengthen health systems (Gebremeskel et al., 2021; Uwaezuoke, 2020; Amos et al., 2021; Kraef et al., 2020; Ndirangu and Muganda-Onyando, 2020), including the role of external resistance (Shroff et al., 2022). Despite the use of HSS as a stated aim for developmental assistance for health in Zimbabwe, it remains unclear whether donor-funded interventions have, using the language of Chee et al. (2013a), strengthened the health system (enabled comprehensive changes to health system performance drivers) or have, rather, supported it (improved service coverage through injection of inputs in the short term) (Chee et al., 2013a). This study aimed to understand: (1) whether external funding has supported or strengthened Zimbabwe’s health system since the 2000s, (2) whether the experience of COVID-19 fosters a re-examination of what had been considered as HSS during the pre-pandemic era, and (3) areas to be reconsidered for HSS post-COVID-19.

Methods

Study design

We conducted a qualitative research study. Qualitative research is well suited for understanding phenomena within their context, and uncovering links among concepts and behaviours, and is commonly used to understand diverse phenomena in health services (Shortell, 1999; Bradley et al., 2007). This suited our study because we wanted to develop an in-depth understanding of how HSS is understood and perceived in Zimbabwe. Formal ethical approval for the study was received from the Medical Research Council of Zimbabwe reference number MRCZ/11/2023.

Data collection

Our data collection methodology consisted of key informant (KI) interviews complemented by a review of relevant documents from external funders. KIs were drawn from both government and external funders. To be considered an external funder, an organization had to be the source of funds and not an implementing agent. For example, non-governmental organizations and civic society organizations funded through bilateral agencies such as The United States Agency for International Development (USAID), were not considered as external funders. This also aligns with the government of Zimbabwe’s characterization of external funders.

Document review

Based on our professional and research experience of Zimbabwe’s health system, we first purposively selected documents to review in order to map the major external funders that were actively involved in the health sector in Zimbabwe. According to the Zimbabwe Health Sector Public Expenditure Review (2022) (World Bank, 2023), three sources contributed between 86 and 96% of estimated external assistance to the health sector between 2016 and 2020, namely the Global Fund, the United States Government (USG) through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the consortium supporting the HDF. Reports and documents from these external funders were retrieved from relevant websites to capture how they portray HSS in Zimbabwe. We also reviewed the national health strategies for Zimbabwe (2009–2013, 2016–2020 and 2021–2025) to identify how the government of Zimbabwe portrays HSS. The national health strategy was chosen because it is an authoritative document that comprehensively outlines the main priorities for the government of Zimbabwe and should ideally guide external funders. That was complemented by the National Development Strategy 1 (2021–2025). Table 1 shows the list of documents reviewed.

KI interviews

We conducted KI interviews to gather in-depth knowledge on current HSS approaches, the lessons from COVID-19 and areas of reconsideration, to complete the document review. Table 2 shows the profile of KIs.

National level KIs who were involved or were previously involved in the health sector in Zimbabwe were identified through document review. We also relied on one author’s knowledge and experience with the Ministry of Health and Child Care (MoHCC) to identify other potential KIs. Overall, we sought to identify individuals who together could offer insight about donor support across all the WHO building blocks. We did not pre-define a sample size for the KIs but rather used the concept of saturation to assess sample adequacy. Saturation is reached when no new insights are generated from the KIs (Charmaz, 2006) and is an approach commonly used in qualitative inquiry (Fusch and Ness, 2015). We did not interview KIs at sub-national levels (provincial, district, community) due to feasibility constraints. However, it is important to note that all the Zimbabwean nationals (16) who were interviewed had prior work experience at the provincial and district levels or were involved in coordinating HSS-related activities at the sub-national level, including community interventions.

We developed two broad sets of questions to gather the views of KIs on whether external funding has strengthened the health systems since the 2000s and the experience of COVID-19 in relation to HSS, as presented in Box 1. These questions also guided subsequent analysis.

A pilot interview with one KI was conducted. At the end of the interview, feedback was solicited from the KI, including the flow, the clarity of the questions and what could be improved. A key outcome of the feedback process was that a fourth theme was identified for inclusion in the interviews: the interaction between governmental ownership for health systems and contribution by external funders. The interviews were semi-structured, so whilst six broad questions (Box 1) guided the interview, there was some tailoring according to each KI’s experience and insights.

We gathered the views of 18 individuals (17 through in-depth KI interviews and one through a written email response) between August and October 2022 (see Table 2). All interviews—lasting between 56 and 90 minutes—were conducted in English through a publicly accessible cloud-based video conferencing facility Zoom®. Informed consent was obtained from all the KIs at the point of interview, and to protect their identity and privacy, we did not record the names of individuals and assured them that the views they expressed would be anonymized. No identifying information is provided throughout the manuscript out of respect for participants, who were deeply concerned that any identifying information would break confidentiality. With the KI’s additional expressed consent, the interviews were recorded in Zoom® for transcribing purposes. At the end of each interview, KIs were requested to suggest names of any individuals who could provide further insights. Saturation over the guiding questions domains was reached after the 13th interview, with quicker saturation achieved around the sustainability of interventions and more KIs required to reach saturation in relation to their effects.

Data transcribing

One author re-played each pre-recorded Zoom® interview and recorded handwritten notes. Subsequently, each pre-recorded oral Zoom® interview was retrieved and converted verbatim into an electronic record of written text. The electronic written text was transferred to Microsoft Word®. Both authors read the whole transcript of the Microsoft Word® document.

Interview data analysis

The authors separately read the Microsoft word transcripts. A Microsoft Word data charting matrix was used to capture the interviewer number and the institution represented. The output of each interview was deductively categorized according to whether an identified health system intervention had addressed or failed to address any of four criteria we used to assess these interventions (see Box 1). The experience from COVID-19 and areas of reconsideration were inductively categorized according to emerging themes. The authors separately analysed the interview output and met through Zoom to triangulate the notes. Areas of discordance were resolved through focused discussion during the meeting.

Results

Scope: do the interventions have cross-cutting benefits beyond a single disease or health system block?

KIs suggested that Global Fund and USG investments in procurement and supply chain management (PSM) contribute to HSS by cutting across building blocks and tackling more than one disease. As highlighted by one KI:

‘When Global Fund invests in PSM … let’s say delivery trucks, warehousing or logistics information, or renovation of pharmacy stores, that does not only benefit TB, HIV/AIDS and malaria; every disease benefits’.

However, KIs noted that USG scope in PSM is hindered by restrictions or non-prioritization for other areas, such as infrastructure. Nonetheless, other informants highlighted positive spillover effects between harmonized commodity distribution and efficiencies in human resources (HR) since it frees up health workers from doing repetitive work. Whilst these spillover effects were noted in the request for funding from the Global Fund (2021–2023) (Global Fund, 2021), this request also highlighted the reality of parallel procurement systems and fragmented laboratory sample transportation systems.

Similar to investments in PSM, Global Fund investments towards information systems were viewed to have a positive influence on Human Resources for Health through replacement of manual and cumbersome data entries with digital platforms. Donor funding intended to strengthen data systems for specific disease programmes was viewed to have benefits across other diseases over time. KIs mentioned that the ‘Making Sense of TB data program’ funded by USG capacitated health workers to collect, analyse and utilize the data for decision making. They also mentioned that the approach emerged as an exemplar that was adopted by other programmes within Zimbabwe and exported to other countries. The success of the concept within Zimbabwe concurs with the USAID/Zimbabwe Tuberculosis Support Performance Evaluation report (USAID, 2021). Some donor-initiated projects, such as the RBF were considered to have expanded in scope over time. As remarked by one KI:

‘in terms of scope, whilst RBF started off as a maternal and child health focus intervention, it is basically right now, I think since 2013, 2014 …a package that is really looking at integrating various disease programmes—so you actually have HIV, TB, malaria, non-communicable diseases (NCDs), all in that whole package’.

In terms of funding modalities, the HTF and HDF were considered to meet the criteria for scope in terms of HSS, by addressing several pillars of the health system:

‘… what stands out for me is the HDF, which tries to cut across human resources, infrastructure and the barriers … that effort for me is to ensure that we have a better system’.

This interview comment aligned with the 2016 independent evaluation of the HTF (2016) (Pyone et al., 2016) and HDF (2018) (UNICEF, 2018).

However, although the Global Fund interventions in PSM and data systems were viewed to contribute to HSS in terms of their scope, KIs confirmed that, overall, the Global Fund provides intensive inputs (particularly health commodities) within a generally weak health system.

‘So, while you can spend ten years somebody getting their anti-retroviral medicines—if they are involved in a road traffic accident and they are bleeding, they can die from lack of resources to treat that condition, that acute emergency.’

As a result, donor-supported interventions often do meet the criterion of scope as we have defined it. For example, KIs pointed out that whilst external funders report high availability of commodities for their areas of interest such as malaria, TB, HIV, and maternal, new born and child health (MNCH), there remained major gaps in general essential medicines. The government itself also highlighted severe medicines shortages for areas that receive peripheral attention from external agencies such as non-communicable diseases (NCDs), including mental health (Government of Zimbabwe, 2021).

Sustainability: will the interventions produce permanent systemic impact beyond the term of the project?

KIs concurred that external funding was highly unsustainable, and this was the only criterion for which there was such consensus. As put forward by one respondent, discussing the HDF mechanism specifically, the unpredictability of external funding poses a threat to the whole health sector:

‘As we speak, there is not really any support from HDF… there is still some discussion, but there is no support. You may need to know that the village health worker and other staff in the MoHCC were supported by HDF. They are no longer supported, and because of that, there is a lot of attrition from Zimbabwe’.

Uncertainty in external support for HR and its implications for the health system was also raised during the HTF end-term evaluation (van den Broek et al., 2016). KIs echoed similar effects in relation to the Global Fund support for health care worker retention in the mid to late 2000s. However, according to one KI, this initiative collapsed because the government failed to match its co-financing and domestic transition commitments.

External funders also acknowledge broad sustainability concerns in relation to their funding. The HDF mid-term review cited lack of a clear transition roadmap as a major risk; a concern that was also highlighted in the HTF end-term evaluation. In an apparent sign that the consortium of donors who had been supporting the pooled mechanism are either reducing their funding or near exit, the amount allocated to the HRF in 2023 (USD 90 mn over 4 years) is much less than for HTF in 2011 (actual budget of USD 235 mn over 4 years) and HDF in 2016 (USD 682 mn over 5 years). In its 2022–2025 business case for the HRF, the UK government, which contributed 44% to the HRF, envisaged Zimbabwe to have a more resilient health system to enable a smoother and ‘more sustainable exit from the sector by 2025’ (Foreign, Commonwealth & Development Office, 2023). Similarly, the 2021 PEPFAR Sustainability Index and Dashboard for Zimbabwe also raised broad sustainability challenges, such as the low national budget allocation to health, heavy reliance on donor funding and significant HR shortages (PEPFAR, 2021).

External funders have also openly highlighted the need to review the sustainability implications resulting from COVID-19. Speaking at the inaugural High-Level Policy Dialogue on Health Financing in Zimbabwe in late 2021, the Director for the Foreign, Commonwealth & Development Office (UK Embassy), who doubled as Chair of the HDF, singled out pandemic-induced fiscal pressures amongst external funders as a threat to future aid (UNICEF, 2022). This aligns with the narrative of the major funders of the health sector in Zimbabwe such as the USG (USAID, 2022).

Finally, KIs highlighted lack of local ownership for donor-funded projects as an underlying driver for unsustainability. Specifically speaking in relation to infrastructure and equipment:

‘the problem is that there is no in-built sustainability to ensure that the investment made (equipment and infrastructure) is serviced and maintained—this thinking that as long as the donor is still there, the donor should continue supporting is what needs to be get rid out of people’s minds so that the ownership translates to real ownership’.

Nonetheless, some interventions were considered to be sustainable in diverse ways. In relation to sustainability as government ownership of donor-initiated projects, the institutionalization of RBF within the MoHCC and transition to governmental funding has been described as a key sustainability milestone. Regarding the pillars of the health system, reports from current (USAID, 2023) and former USG-funded PSM projects (USAID, 2016b), showed that the USG-funded investments for PSM contributed to sustainability through local capacity building, particularly for commodity quantification and logistics management information systems.

Tailored to national needs: are the interventions tailored to country-specific constraints and opportunities, with clearly defined roles for country institutions?

The HTF was singled out as one donor-funded intervention that was pragmatically tailored to support rather than strengthen the health system at its point of inception:

‘It was not going to make sense in 2008 to say we are strengthening the health system when there was nothing and people were dying’.

However, over time, the HTF’s preoccupation with supporting the health system limited HSS by overshadowing the role of national institutions in key health system functions. For example, according to the HTF evaluation report, the HTF heavily relied on external mechanisms for procurement of commodities at the expense of capacitating the national pharmaceutical company (Nat Pharm). In an apparent display of the inherent tension that may arise between supporting or strengthening the health system, the same report justified lack of local capacity building for ‘legitimate reasons’ related to prioritizing results rather than capacity building during a crisis period. However, some KIs raised issues regarding how the government itself prioritizes interventions that are not effectively attuned to address pertinent country-specific constraints. One KI shared the following view regarding the prioritization of specialist care services at the apparent neglect of primary health care:

‘I don’t even understand how the ‘quinary’ [super specialist] hospital became prioritized as part of the National Health Strategy, when primary health care is on its knees … I think it’s meant to sort of impress a certain audience that we are doing very well when we are not’.

Effects (impacting on health outcomes, equity, financial risk protection, and responsiveness)

The documents we reviewed suggest that donor funding has immensely contributed to health outcomes. The Global Fund funding request for 2024 to 2027 cited that, largely through the contribution of the Global Fund and PEPFAR, particularly towards access to anti-retroviral therapy, HIV-AIDS-related deaths declined by 60% (from 54 200 to 21 800) between 2010 and 2018, and 260 000 lives were saved between 2015 and 2018 (Global Fund, 2023). The Global Fund data explorer web page https://data.theglobalfund.org/location/ZWE/overview, cites that the Global Fund has also contributed to a steady decline in new TB infections and related deaths since 2011, while malaria deaths have fallen by 75% since the 2000s (Global Fund, 2023). An independent review of the HTF argued that the mechanism positively contributed to MNCH and mitigating against general health collapse (van den Broek et al., 2016). RBF reports from the World Bank also demonstrate its contribution to effects, particularly for improving MNCH outcomes (World Bank, 2023).

Our document analysis also showed that equity is embedded in the design of donor-funded interventions For example, the HTF’s initial implementation approach was tailored towards disadvantaged population groups—women and children—and marginalized, rural communities (van den Broek et al., 2016). Additionally, direct treatment is designed to be provided free of change under donor-funded programmes, which fosters financial risk protection. At its launch in 2012, the HTF aimed to scrap user fees for MNCH services by 2015 (van den Broek et al., 2016). Similarly, treatments for HIV/AIDS, TB and malaria are provided free of charge in the public sector. However, the design features for financial risk protection appear to be partially effective at the point of implementation, either as a result of policy-implementation gaps or due to the circumscribed nature of the interventions. For example, although the application of user fees was reduced under HTF/RBF, the practice persisted across certain services, particularly for antenatal care, post-natal care and family planning (van den Broek et al., 2016). Similarly, as of 2022, TB patients were incurring catastrophic and impoverishing costs in seeking care (Ministry of Health and Child Care, 2022).

Responsiveness also remains a key component of donor-funded programmes. For example, the Global Fund has supported differentiated models of care for HIV/AIDS, including multi-month-dispensing of anti-retroviral medicines for eligible patients. The Global Fund also prioritizes user informed responsiveness through community-led monitoring, a process in which people affected by HIV, TB and malaria systematically monitor services and generate solutions to address service-delivery bottlenecks. On the other hand, the World Bank projects operate a mandatory grievance redress mechanism, a formal platform under which individuals and communities lodge complaints regarding service delivery and seek relevant remedies. Nevertheless, KIs raised concern over the effectiveness of these mechanisms, including limited funding for community-led monitoring.

‘Rethinking’ HSS post COVID-19

During COVID-19, a number of external funders, including the Global Fund, USG and HDF either redirected fund towards COVID-19 or created new streams of funding towards the pandemic, which was key in sustaining essential services. The Global Fund in particular created specific COVID-19-related grants that departed from the norm of focusing on TB, HIV/AIDS and malaria to cater for other areas such as emergency response and clinical operations. However, more broadly KIs suggested that experience during the COVID-19 pandemic showed that whereas external assistance had been discussed as HSS over the years, in reality it might have been only health system support:

‘We thought supporting was strengthening, when actually it was not. And as a result (of COVID-19), we really felt the shock. But some people might also look at it differently… they might think that support is also strengthening. There could be a confusion of understanding’.

Similarly, the UK government asserts that the COVID-19 pandemic revealed that past support, and its effects, had masked the inherent weaknesses in the health sector. As captured in the UK government’s business case summary for the HRF (2022–2025):

‘In the last 10 years Zimbabwe has seen some significant improvements in maternal and child mortality and wider health outcomes, in part due to the UK’s longstanding support in this sector. However, this progress has masked serious vulnerabilities in the health system. The 2019 drought and economic crisis followed by COVID-19 has halted progress, exposed those vulnerabilities and threatens to reverse hard won progress for women and girls’ (Foreign, Commonwealth & Development Office, 2023).

To this end, for the period 2022 to 2025, the UK government envisages a broad shift from a focus on basic service delivery (support) to an increased focus on investing in health systems and policies that will make the sector more resilient, sustainable and accountable in the medium term (HSS).

The COVID-19 pandemic also fostered a re-examination of the relative role of external funding in relation to government. In particular, KIs emphasized the need to move away from the expectation that external funding can sustainably strengthen health systems—and, instead, to reduce donor reliance and expect more of government. As put across by one KI:

‘I think it would be madness on our part to expect them (external funders) to do that (HSS) … you hear people complaining that Global Fund gave country X more money but you don’t see the same energy directed towards government. Our whole concept of who does what in health systems needs to change’.

Others opined that COVID-19 clearly showed the unpredictability and unsustainability of external funding, since ‘Once things cross to the other side (high-income countries) people try to put fires out that side of the border before they look at others’.

‘…I think it’s also a wake up for developing nations to say, you need to put, all these things in place for your own people. Depending on outsiders coming, they first look after their own people. We saw that with vaccine nationalism’

KIs judged that during global emergencies, the domestic interests of donor countries come clearly to the fore and can lead to action that directly weakens the health systems they purport to support.

‘Because of COVID their gaps were exposed in terms of HR capacity and they went on then to recruit from developing countries… So, once you do that, you are also disrupting a lot of development in the country which you are supposedly providing support’

However, the influence of domestic interests even before the pandemic was also noted. One KI remarked that ‘taxpayer’s money from Europe or from America cannot be used to pay salaries for a sovereign government’. Other respondents suggested that donor countries prefer to offer support to a health system because it produces quicker results that can be showcased to their own electorate, unlike HSS which is a long-term developmental strategy that falls outside electoral cycles.

To remedy the pitfalls of donor reliance, KIs underscored the need for Zimbabwe to leverage its own resources to strengthen its health system. Thus, whilst external funders and government alike normally attribute limited domestic fiscal space as a critical constraint for domestic funding, the KIs in our study were ambivalent about this judgement. They consistently asserted that ‘Zimbabwe is rich’. As put forward by one respondent:

‘there’s lots of money. Zimbabwe is rich. Politicians always talk about how sovereign we are. So why doesn’t that translate to the prosperity of the common men on the streets, which should be demonstrated by the strength of our social protection systems and safety nets’.

Indeed, during COVID, despite the option for vaccine donations through mechanisms such as the COVID-19 Vaccines Global Access, the country decided to fund the immunization programme using domestic resources. According to the KIs, this demonstrated that ‘the money is there’ to strengthen the health system. The government also allocated resources to fund village health workers’ salaries and provided COVID-19 allowances to health workers.

Another broad area identified as needing review was the role of leadership and governance in mediating HSS efforts. KIs proposed strengthening the government’s stewardship role, in particular to ensure stability in the bureaucracy and expansion of their decision-making space:

‘… in 2020 the health system underwent a very serious political metamorphosis in which there was like purging of MoHCC staffers … the institutional memory was generally lost … there have been people who have been in acting capacity who seem not to have the voice to implement things in the manner they were moving’.

Trust between government and external funders also needs to be strengthened. Respondents felt that in recent years the top MoHCC leadership has become less trusting towards external funders. According to KIs, the heightened distrust has resulted in extra scrutiny and suspicion over what external funders do to the detriment of effective collaboration and execution of donor-funded activities.

Discussion

This is one of the few studies to examine whether external assistance has merely supported or, more fundamentally, strengthened Zimbabwe’s health system over time. This study demonstrates that whilst external funding has significantly contributed to the health sector, its main effect has been through the provision of critical inputs, particularly specific life-saving commodities (so, supporting the health system). Strengthening of the health system has, however, been limited. The main constraints to HSS in Zimbabwe seem to be the limited scope and sustainability of external investments. This experience aligns with previous literature which has pointed out that external agencies only partially achieve HSS by directing support to the limited set of health system functions necessary for the delivery of their own activities (Marchal et al., 2009).

In this way, the study draws attention to the limitations of conflating external support for health systems with strengthening health systems. For example, in relation to HR—withdrawal of health worker retention allowances under HDF in 2022 (which has long been framed as HSS in Zimbabwe) resulted in immediate negative effects for the whole system. The COVID-19 pandemic also appears to have fostered a rethink on the role of external assistance towards HSS, including amongst the external funders themselves. Whilst sustainability of donor-funded programmes has been a global concern over the years (Nonvignon et al., 2024), the pandemic brought to the fore the pitfalls of approaches that have limited scope (akin to vertical funding of programmes) in Zimbabwe. It revealed to external funders that, due to limited scope, their cumulative investments labelled as HSS had created the semblance of a strengthened system whilst masking underlying weaknesses.

Looking forward, therefore, the government of Zimbabwe needs to take the issue of sustainability seriously, particularly as the pooled funding mechanisms that have been the anchor of the health system for the past decade are nearing an end amidst planned donor exit. It is also important to reconsider how sustainability can be maintained in areas that have been strengthened but incur heavy operational costs, such as commodity distribution costs for PSM systems.

The study, therefore, underscores the role of the government as the steward of HSS. The government of Zimbabwe itself considers over-reliance on external funders for health as unsustainable (Ministry of Health and Child Care, 2022), including framing it as a national security threat (Herald, 2013). Whilst self-reliance for health has been recently bolstered by the national ethos of ‘nyika inovakwa nevene vayo’ (a nation is built by its owners) (Herald, 2023), there is a need to move from rhetoric to action. The domestic financing of COVID-19 vaccines reinforced a previously acknowledged observation that under certain conditions, countries that are normally portrayed as under-resourced, such as Zimbabwe, can nonetheless raise domestic resources for health (Bhat et al., 2016). This challenges the dominant narrative that lack of funding is the major constraint for government-led HSS. In order to comprehensively understand the drivers of government-led HSS interventions, and to devise appropriate approaches to enhance the feasibility of intended reforms, it is important to look beyond material explanations for sub-optimal HSS investments by government and to consider the political dynamics of policy reform processes (Mukuru et al., 2020; Mhazo and Maponga, 2022a).

From a discursive standpoint, the understanding of HSS in Zimbabwe, and its conflation with health system support, appears to be heavily influenced by the unprecedented collapse of the health sector in the late 2000s as a result of a protracted socio-economic meltdown (Mhazo and Maponga, 2022b). Since the injection of donor funds was instrumental in aiding health system recovery after that time, there is a tendency to label any performance improvement relative to the crisis period as HSS, even when the funding is tilted towards the provision of basic services or injection of inputs (support). That was apparent from the KI interviews and review of documents. KIs from external funders were more upbeat about their contribution towards HSS, with specific reference to how their investments stimulated service delivery at the height of the health crisis in 2008. In contrast, KIs from government and civic society organizations had mixed feelings. They viewed HSS within a wider perspective that compared the state of the health system to earlier periods, such as the 1980s when Zimbabwe’s health system was vibrant, with strong domestic ownership.

It is important to acknowledge, then, that context matters, and that supporting the health system is not always inferior to HSS. However, external funders should refrain from portraying any form of external support as strengthening health systems as this portrayal may serve to undermine rather than bolster their efforts. If activities fail to produce improvements in system performance because they were incorrectly labelled as system strengthening, the value of HSS investments could quickly be discredited (Chee et al., 2013a). Not distinguishing supportive activities from strengthening ones will lead to unmet expectations of stronger health systems, as well as neglect of critical system-strengthening activities.

The study had some limitations. First, it was mainly based on qualitative interviews and respondents’ views could have been biased. However, since we gathered views from stakeholders who represent diverse interests, we were able to triangulate data and identified both positive and negative views. Second, the political aspects of the interview focus could have censored some sentiments. We sought to address this concern by assuring the respondents that their views would be anonymized. Third, the views expressed may not be applicable to all external funders or funding approaches in Zimbabwe—although we took care to focus on those funders providing the vast majority of external funding in the country and funding mechanisms supported by multiple funders, such as the HTF and HDF.

Conclusion

External funders have substantially supported the health system in Zimbabwe, with mixed contribution to HSS. The pandemic demonstrated that Zimbabwe is capable of raising domestic resources to fund its own HSS efforts. However, there is no guarantee that such momentum can be maintained, since COVID-19 was a crisis that demanded radical policies, a very different environment to routine policy making. This study suggests that there is a need to restore domestic ownership of HSS by strengthening government’s stewardship role for HSS. Research is required to understand the conditions, including COVID-19, under which external and domestic funding can be effectively synergized for HSS.

Funding

None received.

Acknowledgements

We acknowledge all key informants who provided their views and insights.

Author contributions

Conception or design of the work, data analysis and interpretation, critical revision of the article and final approval of the version to be submitted: A.T.M. and C.C.M.

Data collection and drafting of the article: A.T.M.

Reflexivity statement

This manuscript deals with health systems strengthening in Zimbabwe by majorly relying on the input of individuals who have intimate knowledge about Zimbabwe’s health system. The study was jointly undertaken by two researchers who are based in Zimbabwe and Malawi. The manuscript is co-authored by scholars at different levels of seniority: A.T.M. is an early career health policy and system researcher who holds an MSc, C.C.M. is a senior academic who holds a PharmD.

Ethical approval.

Formal ethical approval for the study was received from the Medical Research Council of Zimbabwe reference number MRCZ/11/2023.

Conflict of interest:

None declared.

References