Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697705415169.pdf (Zimbabwe)
Government of Zimbabwe I X H P A R G D R - Government of Zimbabwe Equitable Access & Quality National Surgical Obstetric and Anaesthesia Strategy 1 2022-2025 Ministry of Health and Child Care (NSOAS) Equitable Access & QualityMinistry of Health and Child Care Table of Contents Foreword.................................................................................................................................................................... 5 Acknowledgements.................................................................................................................................................. 6 Acronyms.................................................................................................................................................................... 7 Executive Summary.................................................................................................................................................. 9 1 Situational Analysis................................................................................................................ 13 1.1 Background................................................................................................................................................... 13 1.2 Overview of the SOA Services in Zimbabwe......................................................................................... 14 1.2.1 Service Delivery........................................................................................................................................... 15 1.2.2 Infrastructure, Supplies and Equipment............................................................................................... 17 1.2.3 Equipment for SOA services.................................................................................................................... 19 1.2.4 Health Workforce........................................................................................................................................ 21 1.2.5
21 1.2.5 Financing....................................................................................................................................................... 23 1.2.6 Governance and Leadership................................................................................................................... 26 1.2.7 Monitoring, Evaluation and Research.................................................................................................... 26 2 Strategic Direction........................................................................................................... 29 2.1 Vision............................................................................................................................................................. 29 2.2 Mission.......................................................................................................................................................... 29 2.3 Goal............................................................................................................................................................... 29 2.4 Guiding Principles...................................................................................................................................... 29 2.5 SOA Service Priorities/Outcomes.......................................................................................................... 29 Strategic Interventions.................................................................................................... 31 3 3.1 Service Delivery.......................................................................................................................................... 31 3.2 Health Workforce For Surgical, Obstetric, And Anaesthesia........................................................... 32 Infrastructure Equipment And Products............................................................................................. 33 3.3 3.4 Monitoring, Evaluation And
 Research.................................................................................................. 34 3.5 Healthcare Financing................................................................................................................................ 34 3.6 Leadership And Governance.................................................................................................................. 35 4 Implementation Framework for the National Surgical Obstetric and Anaesthesia Strategy....................................................................................................... 37 4.1 Financing the National Surgical Obstetric and Anesthesia.............................................................. 38 5 National Surgical Obstetric and Anaesthesia M & E Plan............................................. 40 6 References.......................................................................................................................... 47 2 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Table of Contents List of Figures Foreword.................................................................................................................................................................... 5 Acknowledgements.................................................................................................................................................. 6 Acronyms.................................................................................................................................................................... 7 Figure 1 Adapting the WHO building Blocks to NSOAPs (Source: Peters et al.,2020)........................... 15 Figure 2 Infrastructure availability for SOA Services (2019 SOA Assessment Report Zimbabwe)...... 17 Figure 3 Infrastructure availability for SOA Services (2022 SOA Assessment Report Zimbabwe)...... 18 Executive
 Summary.................................................................................................................................................. 9 Figure 4 Availability of Surgical Operating Equipment (2019 SOA Assessment Report Zimbabwe)... 19 Figure 5 Availability of Tracer Medicines for SOA (2019 SOA Assessment Report Zimbabwe)............ 21 Figure 6 Work Force Distribution in Zimbabwe (2022 SOA Assessment Report Zimbabwe)............... 22 Figure 7 Overall Funding for Health in Zimbabwe (MoHCC Resource Mapping Report 2021)........... 24 Figure 8 Domestic Funding and External Funding by Cost Category 2021 (MoHCC Resource Mapping Report 2021)......................................................................................................... 24 Figure 9 Cost of SOA Services at Institutions in Zimbabwe (2022 SOA Rapid Assessment Zimbabwe)......................................................................................................................... 25 Figure 10 Consolidated Health Sector Partner Coordination Structure (Health Sector Coordinantion Framework 2019)............................................................................. 38 1 Situational Analysis................................................................................................................ 13 1.1 Background................................................................................................................................................... 13 1.2 Overview of the SOA Services in Zimbabwe......................................................................................... 14 1.2.1 Service Delivery........................................................................................................................................... 15 1.2.2 Infrastructure, Supplies and Equipment............................................................................................... 17 1.2.3 Equipment for SOA
 services.................................................................................................................... 19 1.2.4 Health Workforce........................................................................................................................................ 21 1.2.5 Financing....................................................................................................................................................... 23 1.2.6 Governance and Leadership................................................................................................................... 26 1.2.7 Monitoring, Evaluation and Research.................................................................................................... 26 2 Strategic Direction........................................................................................................... 29 2.1 Vision............................................................................................................................................................. 29 2.2 Mission.......................................................................................................................................................... 29 2.3 Goal............................................................................................................................................................... 29 2.4 Guiding Principles...................................................................................................................................... 29 2.5 SOA Service Priorities/Outcomes.......................................................................................................... 29 3 Strategic Interventions.................................................................................................... 31 3.1 Service Delivery.......................................................................................................................................... 31 3.2 Health Workforce For
 Surgical, Obstetric, And Anaesthesia........................................................... 32 3.3 Infrastructure Equipment And Products............................................................................................. 33 3.4 Monitoring, Evaluation And Research.................................................................................................. 34 3.5 Healthcare Financing................................................................................................................................ 34 3.6 Leadership And Governance.................................................................................................................. 35 4 Implementation Framework for the National Surgical Obstetric and Anaesthesia Strategy....................................................................................................... 37 4.1 Financing the National Surgical Obstetric and Anesthesia.............................................................. 38 5 National Surgical Obstetric and Anaesthesia M & E Plan............................................. 40 6 References.......................................................................................................................... 47 3 Equitable Access & QualityMinistry of Health and Child Care List of Tables Table 1 The SOA Service Priorities and targets.............................................................................................. 30 Table 2 Service Delivery Strategic Interventions............................................................................................ 31 Table 3 Health Workforce for SOA Services Strategic Interventions........................................................ 32 Table 4 Infrastructure, Equipment and Products Strategic Interventions.............................................. 33 Table 5 Monitoring, Evaluation and Research Strategic Interventions.................................................... 34 Table 6 Health Financing Strategic
 Interventions.......................................................................................... 34 Table 7 Leadership and Governance Strategic Interventions.................................................................... 35 4 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Foreword The Health Sector in Zimbabwe is guided by the National Health Strategy (NHS) 2021-2025 which feeds into the Health and Wellbeing Thematic area in the National Development Strategy (NDS) 1.
The vision of the NHS 2021-2025 is to have “The highest possible level of health and quality of life for all citizens and permanent residents of Zimbabwe by 2030”.

In recent years, developing countries, Zimbabwe included have been facing a dual epidermic of both communicable and non-communicable diseases.

The previous NHS 2016-2020 had a strong focus towards public health and in particular communicable disease.

As a result, tremendous progress has been made towards controlling communicable diseases.
Whilst investments towards sustaining the gains made in controlling communicable diseases, more investments are also required to tackle the emerging challenge of NCDs.

To that effect the current NHS 2021-2025 has ensured that both communicable and non- communicable diseases receive the necessary attention.
Implementation of the NHS 2021-2025 will be supported by various program specific strategic documents such as this National Surgical Obstetric and Anaesthesia Strategy (NSOAS) to realize the intended goals and objectives.

This strategic document is also coming in at an opportune time when the Ministry of Health and Child Care has undergone a restructuring exercise to enhance efficiency in the health sector.

Specifically, this NSOAS is coming in to address the burden of disease amenable to surgical care.
The unprecedent COVID-19 pandemic in Zimbabwe and globally, has shown the need for building resilient health systems that are well equipped to respond to emergencies but also sustaining essential health services.

Continuity of essential health services include provision of surgical, obstetric and anaesthesia care at all levels noting the complexity of the services offered as patients navigate through the higher levels of care in the Zimbabwean health system.
Adoption of the resolution WHA 68.15 at the World Health Assembly in 2015 declared emergency and essential surgical and anesthesia care as essential and indispensable components of UHC.

My Ministry responsible for Health and Child Care has no intention of leaving anyone behind including patients affected by health conditions amenable to surgical care, as Zimbabwe progresses towards attaining the SDG3 targets by 2030 and the ultimate vision of achieving Universal Health Coverage.
I would therefore urge our health development partners and relevant stakeholders including the private sector to rally behind and complement the Government of Zimbabwe efforts in addressing morbidity and mortality amenable to surgical care as guided by this NSOAS.

HON.

GEN. (RETD).
HON.

GEN. (RETD).

DR. C. G. D. N. CHIWENGA ‘GCZM’ Vice President and Honourable Minister of Health and Child Care 5 Equitable Access & QualityMinistry of Health and Child Care Acknowledgements For the first time in the history of the Health Sector the Ministry of Health and Child Care has successfully put together this National Surgical Obstetric and Anaesthesia Strategy (NSOAS).
The success of putting together this strategic document was a result of the coordination efforts of the various stakeholders in the health sector.

The journey of developing this document started in the pre-pandemic period of the COVID-19 spearheaded by specialist anaesthetists who persisted to see this cause becoming successful.
Let me therefore first and foremost acknowledge the selfless commitment by these NSOAS champions in an effort to ensure that surgical, obstetric and anaesthesia care is given the priority it deserves in our health system.

Appreciation is rendered to the MoHCC directorates and the subnational levels who came together throughout the development process to ensure this document became a reality.
Specifically, let me mention the Directorate of Policy Planning for leading the whole process working with a technical core team from the beginning to the end.

The Ministry would also like to acknowledge the technical expertise from World Health Organization (WHO), together with the SDG3 GAP signatory partners (Global Financing Facility (GFF), UNFPA, UNICEF and World Bank).
Appreciation is also extended to the SADC TEWG, Private sector and professional associations for their dedication throughout the whole process.
Air Commodore (Dr) Jasper Chimedza SECRETARY FOR HEALTH AND CHILD CARE 6 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Acronyms ASOS African Surgical Outcomes Study CCU CDs CEOs DALYs DIPAs DHIS2 DHTs DP EDC EHR EMT FBOs GAP GFF Coronary Care Unit Chief Directors Chief Executive Officers Disability Adjusted Life Years Departmental Integrated Performance Agreement District Health Information Software 2 District Health Teams Development Partners Epidemiology and Disease Control Electronic Health Record Emergency Medical Technician Faith Based Organizations Global Action Plan Global Financing Facility GMO.
Government Medical Officer HCW HDU Health Care Workers High Dependency Unit HDPG Health Development Partners Group HSB HIV HMIS HR Health Services Board Human Immune Virus Health Management Information System Human Resources HS3/5 Hospital Services 3/5 form ICU JRM LMA’s LMICs Intensive Care Unit Joint Review Mission Laryngeal Mask Airways Low- and Middle-Income Countries MMED Master’s in Medicine MODO Ministry of Health and Donors Meeting MoHCC Ministry of Health and Child Care NCDs NDS 1 NGOs NHA NHS Non-Communicable Diseases National Development Strategy Non-Governmental Organization National Health Accounts National Health Strategy NSOAP National Surgical Obstetrics and Anaesthesia Plan NSOAS National Surgical Obstetrics and Anaesthesia Strategy OPC OOP Office of President Cabinet Out of Pocket 7 Equitable Access & QualityMinistry of Health and Child Care PACU Post Anaesthesia Care Unit PC PICES PHT Palliative Care Poverty Income Consumption and Expenditure Survey Provincial Health Team POMR Post Operative Mortality Rate PS Permanent Secretary RMNCAH Reproductive Maternal, Newborn, Child and Adolescent Health SADC Southern African Development Community SDG SOA TB TBD Sustainable Development Goals Surgical Obstetric and Anaesthesia Tuberculosis To be determined TEWG Technical Expert Working Group TWG UHC Technical Working Group Universal Health Coverage UNFPA United Nations Population Fund UNICEF United Nations International Children’s Emergency Fund UNITAR United Nations Institute for Training and Research VMAHS Vital Medicines Availability and Health Services WHA WHO ZWL World Health Assembly World Health Organization Zimbabwean Dollar 8 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Executive Summary The provision of health services in Zimbabwe is guided by the National Health Strategy (NHS) 2021-2025 which feeds into the National Development Strategy (NDS)1 2021-2025.
The aim is to contribute to the country’s attainment of SDG3 targets on Health and Wellbeing by 2030.

Eleven key priority outcomes have been outlined in the NDS 1 2021-2025 and NHS 2021- 2025.

These key national strategic documents have noted that Zimbabwe faces a double burden of both communicable and non-communicable diseases with NCDs being fifth of the top 10 leading causes of death in the country in 2019, according to WHO.
Several of these have surgery as a component of their care, such as road injuries and diabetes mellitus, which this document the National Surgical Obstetric and Anaesthesia Strategy seeks to address.

The Lancet Commission Report on Global Surgery together with the World Bank’s Disease Control Priorities 3 (DCP-3) publication presented surgical care as a cost-effective intervention activating the discourse for health systems to focus on SOA services.
This was followed by adoption of the resolution WHA 68.15 at the World Health Assembly in 2015, declaring emergency essential surgical and anesthesia care as essential and indispensable components of UHC.

Since then, a number of countries including some in the Sub-Saharan Region have developed National Surgical Obstetrics and Anaesthesia Plans.

Zimbabwe has therefore followed suit in developing this document, the first National Surgical Obstetric and Anaesthesia Strategy.
The process of developing this strategic document commenced in 2019 with a Rapid Assessment for SOA services using a WHO facility assessment tool.

This allowed for comprehensive analysis of the availability and quality of critical components of safe surgical, obstetric, and anaesthesia care using the WHO six building blocks.

Given that the assessment was conducted in 2019, another rapid assessment was conducted in 2022 considering investments made to the health sector during the COVID-19 response.
The following is a summary of the situation analysis for SOA services in Zimbabwe.

On Service Delivery generally, there is limited access to surgical, obstetric and anaesthesia services in Zimbabwe at lower levels of care with an estimated 10% of district hospitals performing “Bellwether” procedures based on a 2019 SOA assessment.
To indicate capacity for performing basic surgery, three procedures namely laparotomy, caesarean section and stabilization of an open fracture, have been chosen as “Bellwether” procedures to act as a proxy measure for the ability of a hospital to carry out basic surgery, anaesthesia and obstetric care.

Zimbabwe national operative volumes remain below the WHO recommended target of 5000 procedures per 100 000 population by 2030.
On infrastructure, equipment and medical supplies, notable improvements have been noted in some respects such as provision of Oxygen as part of the COVID-19 response infrastructural investments.

However, SOA services in Zimbabwe remain affected by inadequate infrastructure, equipment and erratic supply of medicines and sundries for SOA related services.

This is due to the high costs as most of the medical products are imported.
Most hospitals have poorly equipped and poorly functioning support services, like laboratory and radiology services.

There is erratic provision of adequate surgical sundries and other commodities like, anesthetic drugs, sedatives, and other relevant medicines.

Efforts made by the Government of Zimbabwe to procure 9 Equitable Access & QualityMinistry of Health and Child Care fully kitted ambulances have been noted but more needs to be done to address the inadequate ambulance services.
On the SOA health workforce, the surgical, anesthetic, and obstetric provider density for Zimbabwe in 2021 was 10/100,000 against a target of 20/100,000, which may have worsened due to the HRH crisis during the COVID-19 Pandemic characterized by high staff attrition.

In Zimbabwe, of SOA specialists, the anaesthesia workforce remains the most deficient.

With regards to health financing, the landscape in Zimbabwe is comprised of domestic and external resources.
Given the focus on communicable diseases which received ZWL $12,549,308,000 as compared to non-communicable diseases which only received ZWL $839,829,000 under the Public Health programme in the 2022 for recurrent expenditure, funding for SOA services also presents a unique challenge in Zimbabwe requiring resource mobilization through both local and global actors.
Inadequate funding towards SOA from both external and domestic sources results in households funding their health care through out of pocket (OOP) expenses which may result financial impoverishment.

Under leadership and governance, SOA services in MoHCC do not have well organized governance structures in comparison to communicable disease programs.

On monitoring, evaluation and research, there has not been a defined M&E system for SOA services in Zimbabwe.
Absence of this system has contributed to limited data for SOA services in the Health Management Information System to allow for evidence-based decision making.

The private for-profit facilities in Zimbabwe particularly in urban areas provide a significant proportion of SOA services, however private sector SOA services data is not being captured into the Health Management Information System despite many SOA services being offered in that sector.
Considering the above identified challenges this National Surgical Obstetrics and Anaesthesia Strategy seeks to achieve the following outcomes: 1.

Ensure access to timely essential surgery by such that 80% of patients requiring essential SOA services within 2 hours at a district hospital by 2025 access the services 2.

Improve Specialist surgical workforce density to at least 5 SOA providers per 100,000 population by 2025 3.

Increase the Surgical Volume to meet 80% of the surgical need by 2025 4.
Begin tracking perioperative mortality rate (POMR) and link to HMIS by end of 2022 5.

Percentage incurring catastrophic expenditure for surgery, obstetrics, and anaesthesia should be reduced to zero by 2025 The above will be achieved through key identified and prioritized strategic interventions and activities which have been detailed in an implementation plan in the annexes of this document.
To monitor progress a monitoring an evaluation plan supported by an M and E Framework has also been developed as part of this strategic document.

The overall goal of this strategy is to attain the highest possible quality of surgical, obstetric, and anaesthesia services for all.

10 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Some of the key strategic interventions are: (see section 3 for details) i.
Built capacity for Central, Provincial and District hospitals to carry out the SOA services in compliance with the provisions within the District Core Health Services i.

Establish SOA specific centres of excellence ii.

Prioritize procurement of fully kitted ambulances fit for the terrain iii.

Develop and implement equipment and infrastructure maintenance plans iv.
Ensure availability and equitable distribution of trained and qualified SOA providers at all levels v. Establish new, renovate and upgrade existing health infrastructure (theatres, ICU/HDUs, PACUs and designated surgical wards) to serve the population and ensure equitable and timely access to SOA services vi.

Systematically collect quality SOA data in a timely manner to provide information for decision making vii.
Improve funding levels and establish budget lines and systems for resource tracking for SOA services to achieve Universal Health Coverage.

viii.

Strengthen and implement policies and strategies to improve accountability in SOA services at all levels An implementation framework for SOA services has also been clearly outlined in this document for effective integrated implementation as Zimbabwe progresses towards Universal Health Coverage.
11 Equitable Access & QualityMinistry of Health and Child Care 12 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 1 Situational Analysis 1.1 Background The provision of health services in Zimbabwe is guided by the National Health Strategy 2021- 2025 which feeds into the National Development Strategy 1.

The aim is to contribute to the country’s attainment of SDG3 targets on Health and Wellbeing by 2030.
Globally, whilst notable progress has been noted for low and middle income countries (LMICs) including Zimbabwe as far as communicable diseases are concerned, progress in addressing Non-Communicable Diseases (NCDs) such as cardiovascular disease, cancer and injury has been lagging behind (Truché et al., 2020).

The slow progress is due in part to the perceived low burden on NCDs as well as the perceived high costs and complexity of surgical care.
This is despite the fact that in LMICs there is now a dual burden of non- communicable and communicable diseases(Meara et al., 2015).

Zimbabwe faces a double burden of both communicable and non-communicable diseaseswith NCDs being fifth of the top 10 leading causes of death in the country in 2019, according to WHO.

Several of these have surgery as a component of their care, such as road injuries and diabetes mellitus.
According to global annual reports, between 28% and 32% of the burden of disease in LMICs is attributable to diseases that are amenable to surgical care.

This translates to 401 million disability- adjusted life years (DALYs) lost each year and almost double to the total combined DALYs (214 million DALYs) for Malaria, Tuberculosis and HIV(UNITAR, 2020).
In a report published by the Lancet Commission on Global Surgery in 2015, approximately 70% of the world still lacked access to safe, affordable emergency and essential Surgical Obstetric and Anaesthesia care when needed (Peters et al., 2020)(Johnson et al., 2017).

The situation is worse in LMICs where nine of ten people cannot access basic surgical care(Meara et al., 2015).
The Lancet Commission Report on Global Surgery together with the World Bank’s Disease Control Priorities 3 (DCP-3) publication which presented surgical care as a cost-effective intervention activated the discourse for health systems to focus on SOA services.
The much needed political will was then provided with the passing of the resolution WHA 68.15 at the World Health Assembly in 2015 declaring emergency and essential surgical and anesthesia care as essential and indispensable components of UHC (Peters et al., 2020) (Johnson et al., 2017).
This has resulted in countries including those in the Sub-Saharan region developing National Surgical, Obstetric and Anesthesia Strategies (NSOAS) to address the burden of disease amenable to surgical care guided by overarching national health strategic documents (Truché et al., 2020).
Whilst surgical care services provision may be viewed as disease specific, it also provides an opportunity to strengthen long term health systems investments ultimately increasing overall access to and capacity for health systems (Chao et al., 2014).

If UHC is to be attained, important synergistic health services beyond primary health care along the continuum of care should be considered(Peters et al., 2020).
If investments are not made to scale up surgical care, LMICs will incur losses in economic productivity estimated cumulatively at US $12·3 trillion (2010 US$, purchasing power parity) between 2015 and 2030 (Meara et al., 2015).

13 Equitable Access & QualityMinistry of Health and Child Care 1.2 Overview of the SOA Services in Zimbabwe Zimbabwe subscribes to the Universal Declaration of Human Rights, which provides for health care as a basic human right, (Chao et al., 2014).
Furthermore, The Constitution of Zimbabwe recognizes that “Health is a Human Right”.

The Constitution explicitly provides for the right to health care in Section 76, sub-section 1 to 4 that: 1.

Every citizen and permanent resident of Zimbabwe has the right to have access to basic health-care services 2.

Every person living with a chronic illness has the right to have access to basic healthcare services for the illness 3.
No person may be refused emergency medical treatment in any health-care institution, and 4.

The State must take reasonable legislative and other measures, within the limits of the resources available to it, to achieve the progressive realization of the rights set out in this section” Considering the above, provision of SOA services has been through the five-tiered health care system starting with basic surgical services at the primary health facilities (clinics).
Patients navigate the health system from the lower level (clinics) to the secondary level (district hospitals), tertiary level (provincial hospitals) and quaternary level (central hospitals).

The quinary level is the most recently added tier to the health system for super specialist health services and research according to the MoHCC new structure.

There are currently six national (central) referral hospitals.
Each of the eight administrative provinces has a tertiary (provincial) hospital that acts as a referral center for secondary level hospitals in that province which include the district and mission hospitals.

In-order to ascertain the status of SOA services at country level, WHO recommends system wide facility assessments which are essential to understanding the availability and quality of critical components of safe surgical, obstetric, and anaesthesia care.

(Johnson et al., 2017).


In Zimbabwe an assessment was conducted in 2019 targeting 106 facilities.

Given that this was conducted pre-COVID-19 a rapid assessment was also conducted in June 2022 to determine the most recent status.

The findings from the 2019 assessment validated at a stakeholder consultation engagement workshop in April 2022 and the rapid assessment informed the greater part of the situation analysis of SOA services in Zimbabwe.
The discussion in the next sections is a concise summary of the findings on the SOA services around the 6 core domains adapted from the WHO health systems building blocks (see Figure 1).
14 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Figure 1: Adapting the WHO building Blocks to NSOAPs (Source: Peters et al.,2020) NSOAS Foundation WHO Building Blocks Access to essential medicines Health workforce Service delivery Financing Health information systems Leadership/governance Lancet Commission NSOAS Pillars Infrastructure Surgical facilities Facility readiness Blood supply Access and referral systems Workforce Surgical, anesthetic, obstetric providers Allied health providers Service Delivery Surgical volume System coordination Quality and safety Financing Health financing and accounting Budget allocation Information Management Information systems Research agenda Governance Leadership and management Adapting the WHO six building blocks in the analysis allows for a comprehensive picture as SOA care requires many elements of the health system to function well.
“In addition to the ecosystem within the operating theatre and capacity for postoperative rehabilitation, additional elements include community education, prehospital care, emergency department care, robust supply chains of consumables, and laboratory services” (UNITAR, 2020) 1.2.1 Service Delivery 1.2.1.1 Access to timely essential surgery Generally, there is limited access to surgical, obstetric and anaesthesia services in Zimbabwe with an estimated 10% of district hospitals performing “Bellwether” procedures based on a 2019 SOA assessment.
The same assessment noted that, 83% of provincial and central hospitals and the 10% of district hospitals were mainly mission hospitals performing the bellwether procedures.

To indicate capacity for performing basic surgery, three procedures namely laparotomy, caesarean section and stabilization of an open fracture, have been chosen as “Bellwether” procedures to act as a proxy measure for the ability of a hospital to carry out basic surgery, anaesthesia and obstetric care(Peters et al., 2020).
Ideally, a Bellwether hospital should be accessible within two (2) hours to ensure access to timely surgical care and the target by 2030 is for a minimum of 80% coverage of essential surgical and anaesthesia services per country by 2030.

Most district hospitals (95%) in Zimbabwe provide Caesarian Sections (VMAHS, 2022).

However, the national Caesarian Section rate remains low 9% with some districts not offering cesarean section at all against the ideal target of 10-15%.
The main reasons for hospitals failing to offer caesarean section include lack of functional operating theatres, anaesthetic machines and anesthesia providers.

Global studies have shown that for first-level hospitals (the equivalent of district hospitals in Zimbabwe), only 64% could provide a caesarean delivery, 58% could provide a laparotomy and only 40% could 15 Equitable Access & QualityMinistry of Health and Child Care provide surgical treatment for an open fracture.
District-level hospitals should be able to deal with 80–90% of essential surgical conditions, therefore SOA care at this level needs serious attention if SDG3 targets are to be realized (UNITAR, 2020).

1.2.1.2 The SOA Services Referral System Traditionally, there has been a referral hierarchy in the accreditation of facilities.
However, it has been noted that some district hospitals are offering specialist care services with support from expatriate specialist doctors resulting in patients seeking services, which ideally are sought at Central Hospital level.

The major challenge is that this has resulted in the staff establishment of the district hospitals not being commensurate with the volume and type of services on offer, therefore compromising on quality of the service delivery.
The referral system is faced with a number of challenges such as having the same level, cadre referrals, self-referrals, critical shortage of resources such as ambulances, on site specialist, and equipment shortages.

The limited capacity at district hospital level results in unnecessary referrals to provincial and central hospitals resulting in work overload including simple cases and a compromise on quality of care.
This scenario has also been documented by the Lancet Commission on Global Surgery, which noted that lack of provision at the first and district-level hospitals leads to excessive referrals to tertiary care.

In addition to delaying treatment and exacerbating catastrophic expenditure, these referrals also place an undue burden on tertiary level hospitals, which often operate at 200–300% capacity(Peters et al., 2020).
For Zimbabwe, this has also resulted in long waiting lists for surgical procedures at central hospitals and frequent cancellations of theatre lists for the clients, (MoHCC, reports).

1.2.1.3 Surgical volume Zimbabwe national operative volumes remain below the WHO recommended target of 5000 procedures per 100 000 population by 2030.

Most of the surgical procedures occurred at central and provincial hospitals () in 2021 compared to only at district hospital level.
While provincial hospitals should be offering more specialist services than district hospitals, they are having difficulties attracting and retaining specialists.

To fill in the current gap MoHCC has been riding on the integrated outreach program with the few specialist doctors from Provincial Hospitals conducting outreach activities at district hospitals while at the same time mentoring the government medical officers at this level.
Private hospitals with better availability of specialist services are not widely accessible by the majority of the population, especially those in rural areas.

1.2.1.4 Quality of Care Globally, tracking of peri-operative mortality, and post operative complications allows for assessment of the quality of SOA services on offer.

For Zimbabwe there is limited consolidated data to assess peri-operative mortality through the DHIS2, which constrain the ability to monitor quality of SOA services.
However, this data is available in the institutional patient records and theatre registers at the various hospitals.

Multiple studies have shown that postoperative mortality in LMICs exceeds that of high-income countries.
ASOS 1 and 2 study conducted in 25 African countries found that mortality rates are twice the global average when compared with high-income cohorts, despite the African patients being younger and having fewer co-morbidities 16 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care (UNITAR, 2020).

The SOA Facility Rapid assessment conducted in 2019, most institutions were found not to be utilizing the surgical safety checklist.
1.2.2 Infrastructure, Supplies and Equipment SOA services in Zimbabwe are affected by inadequate infrastructure, equipment and erratic supply of medicines and sundries for SOA related services.

This is due to the high costs as most of the medical products are imported.
It is well documented that Surgery in LMICs faces implementation challenges given that surgery needs more infrastructure such as clean operating rooms, anaesthesia, electrical power for monitoring equipment, and ancillary laboratory services (Chao et al., 2014).

In an assessment conducted by WHO for 800 facilities in LMICs, challenges to providing surgical care included lack of electricity (31%), running water (22%), oxygen (24%) and postoperative care space (47%) (UNITAR, 2020).
For Zimbabwe according to the assessment conducted in 2019 the findings showed erratic provision of basic resources, like running water and electricity.
Figure 2: Infrastructure availability for SOA Services (2019 SOA Assessment Report Zimbabwe) Availability of Select General Infrastructure n o i t n e M f o y c n e u q e r F - y t i l i c a F 20 10 0 Availability 100% (Always) 76-99% (Almost Always) 51-75% (Often) 26-50% (Sometimes) 1-25% (Rarely) 0% (Never) Internet Oxygen Running water The Government of Zimbabwe is commendable for mounting a successful COVID-19 response which has also been characterized by infrastructural investments.
In light of this the 2022 Rapid SOA assessment showed that for the visited facilities, particularly on Oxygen availability improvements have been made (See the following figure).
17 Equitable Access & QualityMinistry of Health and Child Care Figure 3: Infrastructure availability for SOA Services (2022 SOA Assessment Report Zimbabwe) Rating 0: Never 1: 1-25% 2: 26-50% 3: 51-75% 4: 76-99% 5: 100% Xray Water Vasopressers Urinalysis Ultrasound Spinal_anaesthesia Sedatives Sedation_anaesthesia Relaxants_paralytics Regional_anaesthesia Oxygen Operative_antibiotics Op_narcotics Mri_scanner Iv_fluids Internet Infrastructure electricity Infectious_panel General_anaesthesia Ct_scanner Complete_blood_count Coagulation_studies Chemistry_panel Blood_transfusion 0.00 0.25 0.50 Share 0.75 1.00 With regards to infrastructure, three out of eight (Bindura, St Luke’s and Marondera) provincial hospitals do not have Intensive Care Units and High Dependency Units (ICU/HDU).
This has resulted in limited theatre time for the specialists at the provincial level and patients are now being referred to central hospitals for ICU facilities which affects the morale of the specialists at this level who are now working as the government medical officers.
In all the districts and provinces that were surveyed in June 2022; it was noted that most facilities do not have adequate theatre suites to accommodate all the operating teams performing Bellwether procedures, no purpose-built recovery rooms and designated surgical wards for SOA services.

The lack of designated surgical wards can compromise infection control protocols.
District Hospitals also do not have ICU/HDU to cater for patients operated by specialists from the provincial hospitals during the integrated outreach and mentorship program discussed earlier.

For central hospitals it was noted that approximately 57% of the theatres were functional mainly due to obsolete or lack of equipment and staff, (Table 1) Most of the district hospitals surveyed in the 2022 Rapid Assessment had obsolete anaesthesia equipment, a number of which are no longer serviceable.
This has the potential of compromising patient care considering that the nurse Anesthetists and the GMO’s rotated in Central Hospitals which have more modern equipment.

Some theatres at district hospital level were not fit for purpose as they do not have recovery rooms e.g., one district hospital repurposed an OPD examination room to be a theatre.
MoHCC has plans to expand infrastructure using new emerging technology with plans to construct 30 fully equipped facilities (22 bedded) and 5 district hospitals (60 bedded).

18 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 1.2.3 Equipment for SOA services Though there are efforts by GOZ to re-equip hospitals most hospitals remain inadequately equipped.
The main challenges in equipment are mostly due to inadequate allocation of foreign currency to procure equipment, as most of the equipment is imported.

Furthermore, there is no dedicated budget to support service and maintenance of equipment.

There is a critical shortage of biomedical engineers and technicians.

Training of end users remains a priority.

There is erratic provision of surgical and other support services equipment.
As shown in the figure below whilst some facilities mentioned 100% availability of certain equipment, some institutions did not have the relevant equipment for SOA services.

Of note some of the items e.g., Oral Airways, LMA’s, breathing circuits which were reported as 100% available in the 2022 Rapid Assessment, were recycled disposable equipment.

infrastructural investments, a similar picture was noted on equipment for SOA from the 2022 SOA Rapid Assessment as shown in the figure below.
Figure 4: Availability of Surgical Operating Equipment(2022 SOA Assessment Report Zimbabwe) Urinary_catheters Tourniquet Thermometer Syringes Sutures Sunction Stethoscope Sterilizing Sterilizer Sterile_gloves Sterile Sharps_disposal Scissors Scalpel Retractor Pulse_oximetry Pulse_oximeter Paediatric_oropharyngeal Paediatric_magil Paediatric_laryngoscope Paediatric_facemask Paediatric_ondotracheal O_pulse_oximetry Needle_holder Nasogastric_tube Lma Light_source Gowns Forceps Face_masks Eye_protection Electrocautory Disinfectant Chest_tube Checklist_utilisation Bp Adult_oropharyngeal Adult_magil Adult_laryngoscope Adult_facemask Adult_endotrachea 0.00 0.25 0.50 Share 0.75 1.00 Rating 0: Never 1: 1-25% 2: 26-50% 3: 51-75% 4: 76-99% 5: 100% 19 Equitable Access & QualityMinistry of Health and Child Care Most hospitals have poorly equipped and poorly functioning support services, like laboratory and radiology services.
The 2019 SOA service Rapid Assessment noted that 28out of the 67 secondary health facilities could not run a full chemistry panel.
The 5 central hospitals could run full spectrum of laboratory tests 50% of the time Seventy two percent of district hospitals (n=57) did not have capacity for coagulation studies however 81% (N=64) had the ability to run an infectious disease panel (HIV) clearly showing the focus of investments which have been towards communicable diseases at the expense of non-communicable diseases as discussed in earlier sections.
In the 2022 SOA Facility Rapid Assessment, none of the district hospitals could run a full chemistry panel and coagulation studies.

This is mainly due to lack of reagents and obsolete equipment.

HIV, TB and Malaria were still the microbiological tests available at all levels.

However, microscopy, culture and sensitivity of the other infective agents is not routinely available in the hospitals.
There is erratic provision of adequate surgical sundries and other commodities like, anaesthetic drugs, sedatives and other relevant medicines.

Generally, blood and blood products availability still remain a challenge despite the MoHCC initiative of the coupon system.

As a result, some district hospitals are left with no option but to refer patients to the next level.
20 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Figure 5: Availability of Tracer Medicines for SOA (2019 SOA Assessment Report Zimbabwe) Tracer Pharmacy Items Available for Surgery Vasopressors Spinal anaesthesia Sedatives Regional anaesthesia available Post.op.narcotics Peri.operative.antibiotics Muscle.relaxants.paralytics IV.sedation.anaesthesia.Ketamine.Midazolam.Propofol IV.fluids Inhalational.general.anaesthesia 0 10 20 Facilities - Frequency of Mention Availability 100% (Always) 51-75% (Often) 1-25% (Rarely) 76-99% (Almost always) 26-50% (Sometimes) NA The major contributing factor to the erratic supply of SOA medicines at hospitals is that the required medicines are not always available at Natpharm as they are imported, There is inadequate ambulance service.
In most districts that were assessed in the 2022 facility Rapid assessment it was noted that the ambulances were either old and broken down or ill-equipped.

The same ambulances are sometimes used as service vehicles since the hospitals do not have alternative vehicles.

This therefore results in delays in transfer of patients, compromised infection control protocols and also reducing the lifespan of the vehicle as it is always on the road.

(Include the issue of the terrain).


1.2.4 Health Workforce The Surgical, anesthetic, and obstetric provider density for Zimbabwe in 2021 was 10/100,000 against a target of 20/100,000, which may have worsened due to the current HRH crisis characterized by high staff attrition (see table 1 below).

This challenge is not just peculiar to Zimbabwe as many LMICs have the shortage of health-care providers as a crucial constraint on the scale-up of surgical care.

(Chao et al., 2014).


This is also compounded by poor distribution of the available staff with a bias towards urban areas, particularly Harare.

“According to WHO’s 21 Equitable Access & QualityMinistry of Health and Child Care global surgical workforce database, in low-income countries the average the number of specialist SOA providers is just 0.7 per 100 000 population.
In LMICs, the average of 5.5 per 100 000 is still well below the target of 20–40 per 100 000 recommended for an adequate health system’ (UNITAR, 2020).

From the 2019 assessment conducted for Zimbabwe, 76 % of Provincial and central Hospitals and 4% of District Hospitals had all SOA personnel.
Figure 6: Work Force Distribution in Zimbabwe (2022 SOA Assessment Report Zimbabwe) Rating 0: Never 3: 51-75% 4: 76-99% 5: 100% Surgical_Provider_Availability_24hours Obstetric_Gynaecology_Provider_Availability_24hours Anaesthesia_Provider_Availability_24hours 0.00 0.25 0.50 Share 0.75 1.00 For 2022, 72% of surveyed facilities reported having a Surgical Provider and Obstetrics and Gynaecology Provider available 24 hours a day; and 79% indicated an Anaesthesia Provider being always available.
22 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care In Zimbabwe, of SOA specialists, the anaesthesia workforce remains the most deficient.

In Zimbabwe the Physician Anesthetist Density is currently 0.56/100 000 population (15million population).

At district and provincial hospital levels most anaesthesia services are being provided by Nurse Anesthetists.
Lack of access to anaesthesia has often been cited as the major limiting factor in the quantity and complexity of surgical care delivered (UNITAR, 2020).

The number and distribution of posts for SOA staff on the HR establishment has not updated to keep with population growth and movement over the years, which compounds the deficit in actual availability.
For Zimbabwe, in previous years there used to be a moratorium where senior resident medical officers after completing their houseman-ship were allowed to train for the Master in Medicine (MMed) Anaesthesia without the requirement to work in the districts.

However, since the removal of this moratorium, fewer doctors are coming back for the MMed in Anaesthesia program after the 2 years requirement to work in the districts before specialisation.
Whilst the notable challenges highlighted above have been affecting SOA service provision, the Health Services Board (HSB) is seized with the matter of high staff attrition.

Frequent engagement of treasury for better remuneration of HCW has been a constant feature for the HSB.

Unfortunately, with limited fiscal space, the challenge is that government is responsible for catering for the public service wide improved remuneration and not just focus for health workers.
Midwifery training has now been reduced to one year from two years as this was now a disincentive for nurses to go for this post basic training.

Nurse tutors will be upgraded to lecturers moving forward, and this will result in improved remuneration given that there has also been a reported high nurse tutor turnover with the current HRH crisis.

1.2.5 Financing The health financing landscape in Zimbabwe is comprised of domestic and external resources (see figure 5).
Since 2014, MoHCC has been conducting Resource Mapping and Expenditure Tracking exercises on an annual basis.

Over the years there has been increasing allocation of domestic resources towards health such that in 2021 when the COVID-19 related allocations are considered, Zimbabwe met the Abuja Target of allocating at least 15% of the national budget towards the health sector.
“ For Zimbabwe, in previous years there used to be a moratorium where senior resident medical officers after completing their houseman-ship were allowed to train for the Master in Medicine (MMed) Anaesthesia without the requirement to work in the districts.
“ 23 Equitable Access & QualityMinistry of Health and Child Care Figure 7: Overall Funding for Health in Zimbabwe (MoHCC Resource Mapping Report 2021) Whilst the increased domestic funding towards has been noted, a further analysis has shown that a bigger percentage has been towards health care workers’ salaries (54% for 2021) as shown in Figure 6 below, with only 10% towards infrastructure and equipment and 7% towards medicines.
Figure 8: Domestic Funding and External Funding by Cost Category 2021 (MoHCC Resource Mapping Report 2021) 2021 Domestic Funding by Cost Category 2021External Funding by Cost Category 2% 7% 10% 10% 14% $669M Total Funding 54% 4% 5% 3% 1% 4% 10% 2% 13% 17% 3% 3% $481M Total Funding 35% Health Worker Salaries Capital Costs - Infrastructure & Equipment Drugs and Medical Supplies Planning & Policy Meetings Community Outreach Technical Assistance Administration Expenses Facility Operating Costs Health Worker Training Communication Costs Research + M&E Other 24 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Given the focus on communicable diseases which received $12,549,308,000 as compared to non-communicable diseases which only received $839,829,000 under the Public Health programme in 2022 for recurrent expenditure, funding for SOA services also presents a unique challenge in Zimbabwe requiring resource mobilization through both local and global actors.
LMICs are estimated to potentially lose up to 2% of their economic growth by 2030 if no investments are made towards SOA care systems, (Truché et al., 2020).

Resource mobilization can only be effective with adequate advocacy for increased funding towards SOA services.

Having SOA services in national strategic documents, which are key advocacy tools, shows the importance and allows for political commitment to improved funding allocation.
Unfortunately in a 2015 study of national health plans in sub-Saharan Africa, 63% of plans had less than five mentions of surgery and 33% had no targets relevant to surgery in contrast to 95% of the national health plans adequately reporting the prevalence of HIV, tuberculosis, infant mortality and maternal mortality, with associated targets for each (UNITAR, 2020).

This therefore results in limited allocation of resources for SOA both from domestic and external sources.
Compounding this is that fact that budget allocation for SOA cannot be tracked as there are not defined categories and indicators for this.

However, a desk review of 2022 budget for curative services using proxy SOA tracer services (medical gas, blood services, x-ray, surgical supplies) shows that 6.22% of the budget was allocated to core SOA services.
Inadequate funding towards SOA from both external and domestic sources results in households funding their health care through out of pocket (OOP) expenses which may result financial impoverishment.

According to Meara et al., 2015, a quarter of people who have a surgical procedure experience financial catastrophe more so if they are from LMICs and the burden is worse on the poor.

In the case of Zimbabwe according to the 2019 NHA report, the catastrophic health expenditure was found to be at 9%.
However, triangulation with the PICES survey showed the possibility of most people were foregoing care.

Financial barriers to seeking surgical care are in two ways, patients may be prevented from seeking care or for those who choose to receive care they are left catastrophically impoverished.
Figure 9: Cost of SOA Services at Institutions in Zimbabwe (2022 SOA Rapid Assessment Zimbabwe) 400 300 200 100 0 ) $ S U ( t s o 600C 400 200 0 C_Sections Chest_Xray FBC 25 20 15 10 5 0 25 20 15 10 5 0 Laparotomy Op_Fracture 600 400 200 0 25 Equitable Access & QualityMinistry of Health and Child Care Those covered by the private medical insurance schemes face the challenge of inefficient re- imbursement mechanisms as they are usually asked to make co-payments for them to access SOA care.
1.2.6 Governance and Leadership SOA services in MoHCC do not have well organized governance structures in comparison to communicable disease programs.

For instance, communicable diseases such as HIV and TB have specific units, unlike SOA.

Another challenge has been weaknesses in management of the programme resulting in unnecessary referrals to provincial hospitals due to reasons requiring leadership at district hospital level such as lack of specific SOA consumables.
The HSB has however strengthened this area as recruitment of management positions have a master’s qualification in leadership and management qualification as a requirement.

Generally, quality of documentation and clinical audits is poor.

In 2022, the MoHCC started implementation of the Health Sector Coordination Framework which provides new opportunities for strengthening governance of SOA services through the Hospital Service Technical Working Group.
1.2.7 Monitoring, Evaluation and Research There has not been a defined M&E system for SOA services in Zimbabwe.

Absence of this system has contributed to limited data for SOA services in the Health Management Information System to allow for evidence-based decision making.
The Lancet Commission on Global Surgery and WHO have recommended 6 indicators to be tracked globally for cross comparison among countries by 2030(Peck and Hanna, 2018).Zimbabwe is currently not tracking the Lancet Commission on Global Surgery Indicators, however the country is tracking 2 Indicators for SOA services in the Weekly Routine Monitoring Report namely; Cesarean Sections done and Major Surgeries done.
In Zimbabwe there is heavy reliance on a paper-based system by most of the hospitals offering SOA services.

Only 7 hospitals were utilizing the Electronic Health Record (EHR) in the 2019 assessment.

MoHCC is currently rolling out EHR, but this process has started with the primary health care centers due to the simplicity of service package at this level.

Given the complexity of services offered at Provincial and Central Hospitals, the EHR module on SOA is yet to be developed.
The heavy reliance on the paper-based system limits research as accessing patient records is cumbersome.

This contributes to limiting efforts to ensure that surgical care policies are evidence-based and that interventions are cost-effective and clinically beneficial (Truché et al., 2020).

Whilst clinical audits are being performed, these are only limited to maternal and newborn health issues.

Another challenge is the poor quality and documentation of such clinical audits.
There are limited evaluations that have been done on SOA services, which limits availability of evidence- based decisions.

Another observation is that the HS3/5 form which is used to capture hospital services, has a small section on SOA, which is inadequate to inform decision.
This is coupled with limited knowledge by the clinicians, who have not been capacitated on the HMIS 26 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Private sector reporting in Zimbabwe to the HMIS has been a challenge in general.

Private sector SOA services data is not being captured into the Health Management Information System despite many SOA services being offered in that sector.
One of the major hindrances is the nature of the current tools which are too voluminous to enable private sector reporting given their limited staffing.

Whilst a regulatory framework is in place, the issue of reporting is not included as part of the licensing requirement for private sector which is done annually.

“ The heavy reliance on the paper-based system limits research as accessing patient records is cumbersome.
This contributes to limiting efforts to ensure that surgical care policies are evidence-based and that interventions are cost-effective and clinically beneficial “ 27 Equitable Access & QualityMinistry of Health and Child Care 28 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 2 Strategic Direction 2.1 Vision Highest quality of life for all Zimbabweans by 2030 2.2 Mission To provide accessible, timely and quality surgical, obstetric, and anaesthesia services to all in need of care in Zimbabwe.
2.3 Goal To attain the highest possible quality of surgical, obstetric, and anaesthesia services for all.

2.4 Guiding Principles a.

Equity Provision of surgical, obstetric, and anaesthesia services and care to everyone according to need regardless of social background.

b.

Quality Provision of appropriate services ensuring safety, good surgical, obstetric, and anaesthesia outcomes and meeting the expectations of clients (including reducing waiting times and care delays for those receiving care.
c. Essential Provision of all Bellwether procedures at relevant hospitals ensuring clients d. Partnerships Strengthening partnerships and collaborating across sectors on health receive services within 2 hours matters including team work e. Efficiency Provision of surgical, obstetric, and anaesthesia services and care in a timely f. Professionalism To abide to the dictates of the profession which include Empathy, Integrity and cost effective manner without waste of resources.
and, Patient centeredness 2.5 SOA Service Priorities/Outcomes In 2015 the Lancet Commission on Global Surgery developed six indicators to evaluate progress towards timely access to safe surgical, obstetric and anaesthesia.

Whilst the aim of these indicators was to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery, limitations were noted.
Data points from which to derive the indicators were not defined, limiting comparability across time or settings.

As a result global experts convened to evaluate and explicitly define for the first time the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.

The revised set of indicators (Utstein indicators) have been adopted for this SOA strategic document for Zimbabwe as shown in the table below.
29 Equitable Access & QualityMinistry of Health and Child Care Table 1 The SOA Service Priorities and targets Minimum Standard Baseline Estimates Target 2025/2030 Proportion of a country’s population with geographic access (within 2 hours) to a facility capable of providing surgical and anaesthesia care for the Bellwether procedures (caesarian section, laparotomy, and surgical management of open long bone fracture) Number of each of surgery, obstetric, or anaesthesia providers who are actively practicing per 100 000 population.
Number of surgical procedures done in an operating theatre using any form of anesthesia per 100,000 population per year Deaths from all causes, before discharge (up to 30 days), in all patients who have received any anaesthesia for a procedure done in an operating theatre, divided by the total number of procedures, per year, expressed as a percentage.
Percentage of the population at risk of catastrophic expenditure if they were to require surgical procedure Min 80% of patients requiring essential SOA services within 2 hours at a district hospital by 2025 At least 5 SOA providers per 100,000 population by 2025 Meet 80% of the surgical need by 2025 Begin tracking perioperative mortality rate (POMR) and link to HMIS by end of 2022 Percentage incurring catastrophic expenditure for surgery, obstetrics, and anaesthesia should be reduced to zero by 2025 Priority Intervention a Access to timely essential surgery b Specialist surgical workforce density c Surgical Volume d Perioperative mortality e Financial-risk protection 30 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 3 Strategic Interventions 3.1 Service Delivery Strategic Objective 3.1 Strategic Outcome: Improved SOA Service Delivery Strategic Objective: To ensure that all people in need of SOA services receive quality and timely care at all levels of the healthcare system.
Table 2 Service Delivery Strategic Interventions Strategic Direction Illustrative Interventions No 3.1.1 Address gaps in access, quality and improve SOA service availability and service readiness ix.

x. xi.

xii.

xiii.

xiv.

xv.

xvi.

i. ii.

iii.

iv.

v. i. ii.

iii.

ii.

iii.

iv.
Built capacity for district hospitals to carry out the SOA services in compliance with the provisions within the District Core Health Services Build capacity for provincial hospitals to carry out SOA services Build capacity for central hospitals to carry out SOA services Scaling up outreach services and mentorship programs Decentralise paediatric SOA services Palliative Care Integration Prioritize procurement of fully kitted ambulances fit for the terrain Develop and implement equipment and infrastructure maintenance plans integration of statutory instruments governing the conduct in SOA service delivery into pre-existing instruments.
Review and enforce the referral policy to ensure patients receive timely care at the nearest equipped health facility Enforce responsibility, professionalism and accountability and disciplinary action Promote transparency and accountability in procurement of SOA equipment and products Enforcement of use and compliance to SOA quality guidelines Engage the community in health education promotion programs to appraise them of the referral policy, patient’s rights and responsibilities in prevention, access and utilization of SOA services.
Appraise the community and build confidence on available SOA services at all levels.

Engage community development committees.
Review the regulatory frameworks regarding recognition and registration of sub specialities Identifying and equipping facilities to carry out sub-speciality SOA services Establish SOA specific centres of excellence 31 3.1.2 Enforcement of standards-based SOA Quality Services 3.1.3 Engage and work with communities in improving SOA service outcomes 3.1.4 Recognition and support of SOA subspecialties Equitable Access & QualityMinistry of Health and Child Care 3.2 Health Workforce for Surgical, Obstetric, and Anaesthesia Strategic Objective 3.2 Increase the number of and retain trained SOA providers ensuring numerical adequacy at all levels of health care in Zimbabwe.
Table 3 Health Workforce for SOA Services Strategic Interventions Strategic Direction Illustrative Interventions No 3.2.1 Address numerical adequacy gaps of SOA service providers i. ii.

iii.

i.
iii.

i.

Ensure availability and equitable distribution of trained and qualified SOA providers at all levels Train SOA providers and ensure maintenance of the quality standards of education and practice Ensure all SOA providers are updated in terms of their medical knowledge and skills required to provide safe care Implement mechanisms to ensure SOA providers with specialized skills are placed in appropriate salary scales ii.

Competitive Locum rates iii.


Develop and implement policies that require i. i. ii.

iii.

iv.
iii.

iv.

mandatory minimum service provision to public hospitals by private practitioners Revise establishment for hospitals to enable attainment of ideal SOA provider densities Review remuneration of SOA providers Incentive relocations for specialists Ensure availability and equitable distribution of trained and qualified SOA providers at all levels Provide and support leadership and career advancement training to improve interpersonal relationships and personal growth amongst health care workers.
3.2.2 Improve conditions of service, bonding and retention mechanisms 3.2.3 3.2.4 Expand the establishment to provide positions that will meet the demand for SOA services Improve SOA service providers welfare and development 32 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 3.3 Infrastructure Equipment And Products Strategic Objective 3.3 Expand equitable access to improved SOA service and care infrastructure that is appropriately equipped Table 4 Infrastructure, Equipment and Products Strategic Interventions No 3.3.1 Strategic Direction Provide sustainable and appropriate infrastructure and equipment needed for the delivery of safe surgery, obstetrics, and anaesthesia at all levels of the health care system Illustrative Interventions i. ii.
iii.

iv.

Establish new, renovate and upgrade existing health infrastructure (theatres, ICU/HDUs, PACUs and designated surgical wards) to serve the population and ensure equitable and timely access to SOA services a.

Establish new facilities fit for purpose at primary and secondary levels of care b.
Involve end users in the planning/designing of new structures and structures to be renovated c. Develop standards and guidelines for theatre infrastructure and equipment at different levels of care Improve SOA infrastructure for tertiary and quaternary care facilities a. Renovate and upgrade existing health facilities b.
Develop new health infrastructure for quinary SOA care services Procure, and equip ambulances and strengthen referral management for SOA services Procure equipment for endoscopy and minimal access surgery a.

Engage tertiary and quaternary facilities to prioritise equipment used in endoscopy and minimal access surgery b.
Engage end-users in procurement of essential equipment c. Evaluate donated equipment for usability before acceptance and distribution v. Procure, rehabilitate and maintain SOA equipment and infrastructure a.

Regular training of technicians on equipment maintenance to 3.3.2 Ensure availability of quality and affordable supplies for safe SOA i. ii.

strengthen equipment maintenance service b.


Establish service level and maintenance agreement with the suppliers to conduct preventive maintenance of equipment for SOA services c. Ensure end-users are regularly trained on use and cleaning of essential equipment Ensure adequate stocks of essential medical and surgical supplies so as to provide safe and quality SOA services a. Vet suppliers and ensure they meet minimum standards b.
Strengthen systems for procurement and management of essential SOA supplies to ensure consistent access to affordable essential medical and surgical supplies and medicines Promote blood donation programs and ensure adequate supply and storage of blood and blood products.

a.
a.

Resuscitate the capacity of blood banks at provincial and district levels 33 Equitable Access & QualityMinistry of Health and Child Care 3.4 Monitoring, Evaluation and Research Strategic Objective 3.4 Systematically collect, process, and utilize quality SOA data in a timely manner to inform decision making.
Table 5 Monitoring, Evaluation and Research Strategic Interventions No 3.4.1 Strategic Direction Illustrative Interventions i. Systematically collect quality SOA data in a timely manner to provide information for decision making.

Standardize the HMIS data collection tools to include SOA a.

Include the SOA surgical procedures in the EHR b.

Implement the EHR to all levels of the health care system.
c. Use of existing staff in HIS for entering data to speed up the update of the HER d. Include SOA reports in DHIS2 ii.

iii.

iv.

i. i. Digitize the SOA service provision Expand internet connectivity at all levels Include submission of SOA data as part of licensing and renewal for SOA providers and private health facilities Ensure SOA programme data Evaluations Ensure SOA programme data Conduct Oversight Activities Ensure ease of access to SOA scientific data for timely decision making i. ii.
SOA operational research (rapid assessments and surveys) 3.5 Healthcare Financing Strategic Objective 3.5 Ensure sustainable funding for Surgical, Obstetric, and Anaesthesia Care Table 6 Health Financing Strategic Interventions No Strategic Direction Illustrative Interventions Improve funding levels and establish budget lines and systems for resource tracking for SOA services so as to achieve Universal Health Coverage.

i. ii.

iii.

iv.
Establish cost of SOA services to determine the funding levels required for SOA care services Improve funding for SOA services and strengthen resource mobilization from insurance providers Implement measure to reduce wastage of resources Efficient use of available resources 3.5.1 34 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 3.6 Leadership And Governance Strategic Objective 3.6 Improve leadership and governance of surgical, obstetric and anaesthesia service delivery at all levels.
Table 7 Leadership and Governance Strategic Interventions Strategic Direction Illustrative Interventions No 3.6.1 Strengthen and implement policies and strategies to improve accountability in SOA services at all levels 3.6.2 Promote research and evidence generation for effective SOA program development and policy i. ii.

iii.

iv.

i.
Strengthen the policy, strategies and guidelines for SOA services and enforce their implementation Implement a leadership and management capacity development plan for all levels Establish and Support SOA Coordination framework at all levels (organogram) Ensure integration of palliative care in all SOA services and other health policies Establish the true burden of Non-communicable Diseases (NCDs) 35 Equitable Access & QualityMinistry of Health and Child Care 36 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 4 Implementation Framework for the National Surgical Obstetric and Anaesthesia Strategy Implementation of this strategy will be guided by the Integrated Results Based Management Framework.
The results based framework is an enhanced Performance Accountability System which has been put in place following a whole of government approach, through the Permanent Secretary’s Performance Contract, with the Permanent Secretary at its apex.

This include simple formats for quarterly Operational plans linked to Departmental Integrated Program Agreements (DIPAs), Ministry Annual Strategic plans and National Health Strategy, which this strategic plan will feed into.
An implementation plan (see annex) has also been developed as part of this strategy to ensure effective implementation.

Therefore, the governance structure to oversee implementation of this strategic document will rely on existing platforms that have been set up by MoHCC in the Health Sector Coordination Framework as shown in the figure below.
The MoHCC has developed the Health Sector Coordination Framework whose overall objective is “To coordinate efforts by the MOHCC and all stakeholders in financing, planning, implementation including monitoring and evaluation of all health-related interventions, to maximize health outcomes among the people of Zimbabwe”.
As highlighted in the situation analysis and later elaborated in the strategic direction and illustrative intervention section, clear governance structures for SOA services are a key factor to successful implementation of this strategy.

The identified structure for SOA services will feed into the existing MoHCC structures for sustainability and effective coordination.
To operationalize the implementation of the Health Sector Coordination Framework, the MoHCC has set up Technical Working groups which will include the SOA Technical Working group.

The SOA TWG will comprise of MoHCC, SOA Professional Associations, Private Sector, Health Development Partners, and UN Technical Agencies.
As highlighted in the situation analysis and later elaborated in the strategic direction and illustrative intervention section, clear governance structures for SOA services are a key factor to successful implementation of this strategy.
37 Equitable Access & QualityMinistry of Health and Child Care Figure 10: Consolidated Health Sector Partner Coordination Structure (Health Sector Coordinantion Framework 2019) 4.1 Financing the National Surgical Obstetric and Anesthesia The Strategy will be costed and costed scenarios will guide financing options.

An NSOAS investment case will be developed to direct investments based on the identified gaps and national priorities for SOA services.
38 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 39 Equitable Access & QualityMinistry of Health and Child Care 5 National Surgical Obstetric and Anesthesia M&E Plan a.

Introduction of the Monitoring and evaluation Plan The Health Sector Monitoring and Evaluation Plan 2021-2025 outlines the principles that guide Monitoring and Evaluation (M&E) in the Health Sector .

The SOA M&E Plan is informed by the Health sector monitoring and evaluation plan.
This Plan seeks to establish a monitoring and evaluation system for Surgical, Obstetric and Anesthesia Services in Zimbabwe.

Goal The overall goal of the M&E Plan is to provide a framework for regular and systematic tracking and documenting of progress in the implementation of the National SOA Strategic Plan.

The plan also seeks to define mechanisms and processes for systematic and structured tracking of progress towards SOA strategy objectives and performance targets.

b.
b.

Theory of Change GOAL: Improve the surgical, obstetric and anaesthesia services in Zimbabwe to promote the highest level of health and quality of life for all.
Inputs Processes Outputs Outcomes Impact Human Resources, Equipment and tools, Health facilities, Labs, Funding Coordination of activities, Trainings and Mentoring and Evaluation Availability of services needed for SOA, such as laboratory, clinical services etc, availability of trained staff Improved SOA services coverage, improved quality of services, SOA services rates, SOA outcome rates Reduced morbidity and mortality rates, shorter waiting times, shorter waiting lists Assumptions: Improved conditions of service, Availability of foreign currency, Performing economy, improved referral system 40 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care c. Data Management: 1.
Data collection Standard data collection tools (registers, templates) will be developed in consultation with stakeholders.

The developed data collection tools will allow for disaggregated data to be collected and disseminated at all levels of care.

The current improvised tools will be incorporated in the tools that are going to be developed.

Develop a checklist or AIDs to guide the clinicians to be able to fill in the SOA data collection tools.
Develop a curriculum for training all staff involved in SOA data collection.

SOA indicators will be added to DHIS2.

The ultimate aim is to have a SOA module in EHR.

2.

Reporting Review the current reporting templates to include SOA data elements.

In consultation with all stakeholders, a list of all priority SOA indicators will be agreed upon for reporting.

This list of priority indicators will be reported through the DHIS2 and other Health Information Management systems.
The reporting of SOA data will be in line with reporting timeliness in the Ministry.

The flow of data is illustrated in the diagram below.

Data source for Program Monitoring and sharing with partners Provincial and National Level analysis Data by the 28th From 7th to the 21st of the month, DHIO capture Data into DHIS2 Consolidate Monthly Reports e.g.

T5, T12 to send to HIOs before the 7th of the month National level DHIS2 Provincial District Primary Primary Level Site e.g.
Council and Government Clinics Secondary Level e.g.

District and Mission Hospitals Tertiary Level e.g.

Provincial Hospitals Quaternary Level e.g.

Central or Referral Hospitals 41 Equitable Access & QualityMinistry of Health and Child Care The primary includes the community contribution Data Quality - Data quality principles will be adhered to at all levels of data collection.

All the data will be validated at the institution of collection before being reported to the next level.
Onsite data verification, spot checks and data quality audits will be undertaken routinely and periodically to ensure data meets the minimum standards.

SOPs and guidelines will be developed and distributed to all levels to ensure data quality assurance.

Key players in SOA will be capacitated in processes that ensure data quality.

3.

Data Analysis, Dissemination and Use A standard data analysis plan will be developed for all levels of the M&E system.
The M&E sub- committee will develop a data analysis plan for use at all levels that will serve as a guide on how to analyze and interpret data.

Different software will also be used in the analysis of data depending on availability and the purpose of the report.

Monthly, quarterly and annual data analysis meetings will be conducted at all levels to produce reports for dissemination.

A detailed data dissemination plan will be developed.
Feedback sessions will be conducted both physically through meetings, workshops and electronically through web-portals, situation rooms, websites, dashboards and online meeting platforms to stakeholders at all levels.

The reports produced will be simplified and will have an action matrix (std.

template) annexed to ensure evidence based decisions by the stakeholders.

4.
4.

Data Storage All the SOA data collected manually will be stored in files using an established standard record archiving system at all levels.

SOA data collected electronically will be stored electronically in the HMIS servers.

Specific databases will also be created in the existing HMIS databases to manage both composite and disaggregated SOA data.

d. NSOAS routine oversight Oversight activities will be conducted by key players in NSOAS routinely during programme implementation.
The oversight activities will include but not limited to support and supervisions, routine monitoring, mentorship, hand holding activities, spot-checks and onsite data verification missions.

The frequency of these activities is based on issues, type of mission or other relevant factors.

Frequency ranges from weekly, monthly and quarterly or annually.

A detailed activity matrix will provide the details with regards to the scope and frequency of these activities.
e. Evaluation, Survey and Research SOA research agenda will be developed to guide operational research which will generate key information to guide evidence based decision making in programming.
The following NSOAS evaluations will be conducted: l Baseline assessments l Process evaluations l Mid-term evaluation l End of term evaluations l 42 Impact evaluation National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care These will be conducted to measure the effectiveness of strategies and interventions.

Key rapid assessment and surveys will also be conducted to augment and triangulate data for evidence based decision making.
A database for all the research, surveys and evaluations conducted will be created for future reference.

Key players in the SOA processes will be capacitated with research and evaluation skills for them to conduct the processes internally.

f. Operationalization of the M&E Plan l The key players in SOA must be capacitated with knowledge and skills development to conduct M&E activities.
l Provision of tools of trade to be able to conduct M&E functions (laptop, data, stationary e.t.c) l Management at all levels should ensure that focal persons are adequately capacitated to conduct M&E for programmes.
l A dedicated budget of 10% must be allocated for NSOAS M&E Performance Framework: National Surgical, Obstetric and Anaesthesia Services 2022-2025 Pillar KPI KPI Definition Service Delivery Surgical volume Surgical cancellation rate Perioperative mortality rate OPD Waiting time Theatre waiting time Procedures done in an operating theatre per 100,000 population per year (adults 18 years and above) Procedures done in an operating theatre per 100,000 population per year (paediatric 0-17 years) Number of cases cancelled divided by number of total scheduled cases (adults 18 years and above) Number of cases cancelled divided by number of total scheduled cases (paediatric 0-17 years) All-cause death rate at 30 days or at time of discharge (whichever comes first) in patients who have undergone a procedure in an operating theatre, divided by the total number of procedures, presented as a percentage Time taken by SOA patients from first presentation to diagnosis and treatment plan (adults 18 years and above) Time taken by SOA patients from first presentation to diagnosis and treatment plan (paediatric 0-17 years) Time taken from diagnosis to SOA intervention for elective surgeries (adults 18 years and above Baseline Value (Year) Data Source Frequency Target 2023 2024 2025 TBD DHIS 2 Monthly TBD TBD DHIS2 Monthly TBD TBD TBD Matron’s report Matron’s report Monthly TBD Monthly TBD TBD Patient records Quarterly TBD TBD TBD Quarterly TBD Quarterly TBD Client Satisfaction Survey (CSS); patient notes Client Satisfaction Survey (CSS); patient notes TBD Patient notes Monthly TBD 43 Equitable Access & QualityMinistry of Health and Child Care Baseline Value (year) Data Source Frequency Target 2023 2024 2025 TBD Patient notes Monthly TBD TBD 87% VMAHS (2015) 85% VMAHS (2022) 80% VMAHS (2015) 80% VMAHS (2014) 71% VMAHS (2014) Monthly 30 mins for dire emergencies Form in use at Sally Mugabe Hospital to be standardized across all institutions VMAHS Quarterly 100% 100% 100% VMAHS Quarterly 100% 100% 100% VMAHS Quarterly 96% 97% 98% VMAHS
 Quarterly 95% 96% 97% VMAHS Quarterly 100% 100% 100% Pillar KPI KPI Definition Time taken from diagnosis to SOA intervention for elective surgeries (paediatric 0-17 years) Time taken from decision to perform C-section to the delivery of the baby Decision Delivery Interval Proportion of districts hospitals performing Caesarean Section on pregnant women who require it Proportion of districts with at least 3 doctors Proportion of District Hospitals having at least two health professionals who can do Caesarean Sections Proportion of district hospitals with at least two health professionals who can provide anaesthesia for emergency obstetric surgery Proportion of district hospitals with the capacity to provide blood transfusion for emergency obstetric care Number of patients on theatre waiting list Surgical site infection rate 44 Monthly TBD Monthly TBD Monthly TBD Theatre waiting list Theatre waiting list Standardized tool (to be developed) Monthly TBD Standardized tool (to be developed) TBD TBD TBD TBD Number of surgical patients on theatre waiting list (adults 18 years and above) Number of surgical patients on theatre waiting list (paediatric 0-17 years) Number of infections associated with surgical operation within thirty days of an operation or 1 year if an implant has been introduced over the total number of surgical operations done multiplied by 100,000 population (adults 18 years and above) Number of infections associated with surgical operation within thirty days of an operation or 1 year if an implant has been introduced over the total number of surgical operations done multiplied by 100,000 population (paediatric 0-17 years) National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care Pillar KPI KPI Definition Number of patients receiving PC in hospitals Proportion of district hospitals performing Bellwether procedures Finance Incidence of catastrophic expenditure from out of pocket payments for SOA Infrastructure and
 supplies Proportion of hospitals with adequate SOA supplies Proportion of health facilities with fully functional communication equipment for emergency referral Proportion of district hospitals with efficient oxygen supplies Number of central hospitals with functional paediatric theatres Proportion of private sector health facilities reporting SOA indicators in HMIS Monitoring, Evaluation and Research Number of SOA-related operational research articles published in peer-reviewed journals Number of patients receiving at least 2 palliative care components Number of district hospitals performing Bellwether procedures divided by total number of district hospitals Number of households that received SOA services that used more than 25% of their monthly income over total number of households that received SOA services per 100,000 population.
Number of district hospitals with adequate SOA supplies (based on tracer list) divided by total number of hospitals.

Tracking essential medicines Number of provincial hospitals with adequate SOA supplies (based on tracer list) divided by total number of hospitals.

Tracking sundries Number of central hospitals with adequate SOA supplies (based on tracer list) divided by total number of hospitals.
Tracking sundries Number of private hospitals with theatres reporting on SOA divided by total number of private hospitals with theatres One article per year Number of SSV conducted Proportion of private sector health facilities reporting SOA indicators in HMIS Number of private hospitals with theatres reporting on SOA divided by total number of private hospitals with theatres Baseline Value (Year) Data Source Frequency Target 2023 2024 2025 TBD PC register Monthly TBD 10% (2019) Theatre registers Quarterly TBD 15% 20% 25% TBD TBD TBD TBD National Health Accounts Every 2 years TBD Pharmacy records Monthly TBD Pharmacy records Monthly TBD Pharmacy records Monthly TBD 90% VMHAS (2014) VMAHS Quarterly 97% 98% 100% TBD Number of hospitals with availability of uninterrupted oxygen supply in theatre and CCU divided by total number of hospitals Excluding Ingutsheni 2 (2022) Pharmacy, CCU and theatre records Hospital records Monthly 100% 100% 100% 100% Quarterly TBD 3 4 5 TBD HMIS Monthly 100% 0 0 SOA TWG, MRCZ Annual SSV Reports Quarterly 1 4 1 4 1 4 30% HMIS Monthly 80% 80% 80% 45 Equitable Access & QualityMinistry of Health and Child Care Pillar KPI KPI Definition Baseline Value (year) Data Source Frequency Target 2023 2024 2025 Quarterly 4 4 4 Monthly TBD Meeting minutes PC register, meeting minutes HRH records Quarterly TBD HRH records Quarterly TBD HRH records Quarterly TBD HRH records Quarterly TBD TBD TBD TBD TBD TBD TBD HRH records Quarterly TBD TBD HRH records Quarterly TBD Governance Number of SOA TWGs meetings conducted National TWG with participation of stakeholders at all levels including sentinel 0 Number of hospitals with functional PC teams Workforce Surgical workforce density (public sector) Teams holding meetings, using the PC register and providing services Obstetric specialist who are working per 100 000 population Anaesthetic specialist who are working per 100 000 population Nurse anaesthetist who are working per 100 000 population Surgical specialist who are working per 100 000 population Theatre nurses who are working per 100 000 population Critical care nurses who are working per 100 000 population 46 National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care 6 References 1.
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47 Equitable Access & QualityMinistry of Health and Child Care Government of Zimbabwe National Surgical Obstetric and Anaesthesia Strategy 2022-2025 Ministry of Health and Child Care (NSOAS) 48 Government of Zimbabwe Equitable Access & Quality I X H P A R G D R - National Surgical Obstetric and Anaesthesia Strategy (NSOAS)Ministry of Health and Child Care