Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696590824465.pdf (Zimbabwe)
Coordination Framework for the Health Sector 4 | Foreword The major determinants that shape the health status of Zimbabwe are greatly influenced by factors located in other non-health sectors (agriculture, education, housing, social services, water etc.)

yet their unique contribution to health remain undocumented.

These determinants may broadly be categorized into four areas: health behaviours, clinical care, physical environment, and social and environmental factors.
Some studies suggest that clinical care is responsible for only 20 percent of a person’s health outcomes.

The other 80% is attributable to health behaviours, the physical environment and socioeconomic conditions.

This means that paying attention to clinical care alone is insufficient to address challenges related to health outcomes.
Addressing the broader determinants of health will therefore require inter-sectorial action, and it is partly the responsibility of the Ministry of Health and Child Care (MOHCC) to coordinate the different stakeholders contributing to health, accordingly credit to their unique contributions.

The MOHCC has different roles in promoting an inter-sectorial approach depending on the setting.

The different roles include being a leader, facilitator or supporter of health initiatives.
The MOHCC has excelled in the role of leadership and not done so well as a supporter and promoter of health initiatives in other Ministries, Departments and Agencies (MDAs).

While the MOHCC produces five-year strategy documents, there is no document that explicitly provides a framework for health sector coordination.
There is no framework or guidelines to inform how various health interventions by the MOHCC are coordinated and how the Ministry should interface with other sectors that contribute to improved health outcomes.

It is against this background that a comprehensive Health Sector Coordination Framework is long overdue, to strengthen both intra-ministerial and multi sectorial coordination.
The overall objective of the Health Sector Coordination Framework is to coordinate shared effort by the MOHCC and all key stakeholders with a stake in financing, planning and implementing health related interventions to maximize health outcomes.

This framework articulates the institutional arrangement for efficient and effective coordination of partners in the health sector, defining roles and responsibilities of different stakeholders.
The document also seeks to strengthen the linkages amongst the different coordinating structures within MOHCC and beyond the health sector.

It is hoped that this framework will be a useful reference document for strengthening health sector coordination.
Air Commodore (Dr) Jasper Chimedza PERMANENT SECRETARY FOR HEALTH AND CHILD CARE, ZIMBABWE Ministry of Health & Child Care Republic of Zimbabwe | Acknowledgements 5 The MOHCC would like to extend its gratitude to all who contributed to the development of the first Health Sector Coordination Framework.

Crafting this Framework could not have been possible without the participation of diverse stakeholders in the country (national, provincial and district).
Special gratitude goes to different Government Ministries who provided valuable insights into inter-ministerial coordination issues and the health development partners for their contribution to the Partnership coordination component.

The MOHCC would like to acknowledge the financial assistance provided by the World Health Organization (WHO), Clinton Health Access Initiative (CHAI) and United Nations Children’s Fund (UNICEF) in the development of this Framework.
Ministry of Health & Child Care Republic of Zimbabwe | Table Of Contents 4 6 Foreword Acknowledgements Table Of Contents Table Of Contents List Of Acronyms List Of Acronyms 1 1.1 1.2 1.3 1.4 1.5 2 3.1 Introduction And Background Country Context Multi Sectorial Nature Of Human Health Rationale For Health Sector Coordination In Zimbabwe Purpose Of The Document Designing Process Swot Analysis Of Health Sector Coordination In Zimbabwe 16 Objectives Of Health Sector Coordination Framework 3.1.1 Overall Objective 3.1.2 Specific Objectives 3.2 3.3 3 3.4 Guiding Principles Health Sector Coordination Architecture The Zimbabwe Health Sector Coordination Framework Intra-Ministerial (Intra-Organisational) Governance Coordination Structures 3.4.1 National Level Coordination 3.4.2 Sub-National Level Coordination 3.5 Inter-Ministerial/Inter-Sectorial Coordination Structures 3.5.1 Interministerial Coordination Structures With Government Of Zimbabwe Mandates Include 5 6 7 10 11 13 13 13 14 15 15 19 19 19 19 19 19 21 24 27 32 35 Ministry of Health & Child Care Republic of Zimbabwe | Table Of Contents 3.5.2 Recommended Action Points To Strengthen Multi-Sectorial And Inter-Sectorial Collaboration 3.6 Partners Coordination Structures (Internal And External Partners) 3.6.1 The Health Development Partners Coordination Forum (Hdpcf) 3.6.2 Health Development Partners Coordination Group (Hdpcg) 3.6.3 Mohcc Sector Technical Working Group (Mohcc Swg) 3.6.4 Public-Private Partnership Committees That Coordinate Work With The Private Sector
 7 42 43 43 46 46 47 3.6.5 Recommended Action Points To Strengthen Partner Coordination 48 4.1 Integrated Results-Based Management And Modo Meetings 4 Making It Happen: Strengthening Existing Coordination Mechanisms 4.1.1 Subnational Planning And Review Coordination Mechanisms 4.1.2 Recommended Action Points 4.2 Steering Committees And Technical Working Groups 4.2.1 Crosscutting Guidelines For Governance And Management Of Committees; Meetings And Workshops 4.2.1.1 Guidelines For Governance And Management Of Meetings 4.2.1.2 Guidelines For Governance And Management Of Workshops 4.3 4.4 Integrated Supportive Supervision (Iss) Visits Joint Review Missions (Jrm) 4.4.1 Recommended Action Points To Strengthen Integrated Supportive Supervision And Joint Review Missions: 4.5 Memorandum Of Understanding (Mou), Grant Agreements & Contracts 51 51 54 55 56 58 59 61 61 62 62 62 Ministry of Health & Child Care Republic of Zimbabwe 8 | Table Of Contents 4.5.1 Recommended Action Points To Strengthen Memorandum Of Understanding, Grant Agreements And Contracts 4.6 Events Management Systems 4.6.1 Recommended Action Points To Strengthen Events Management Systems 4.7 4.7.1 Health Information And Monitoring And Evaluation Systems Recommended Action Points To Strengthen Health Information, Monitoring, And Evaluation Systems 4.8 Reporting Health Sector Events 4.8.1 Recommended Action Points To Strengthen Reporting 4.9 4.9.1 4.9.2 4.9.3 4.9.4 4.9.5 Health Sector Events: Strengthening Service
 Delivery Coordination Household/Family Delivery Platform.
Community Level Delivery Platform Primary Health Level (Health Centre) Service Delivery Platform Hospital Level Service Delivery Platform Recommended Action Points To Strengthen Service Delivery Coordination 4.10 Strengthening Communication 4.10.3 Recommended Action Points To Strengthen Communication 4.11 Legal Requirements 4.11.3 Recommended Action Points To Strengthen Implementation 63 64 64 64 65 65 66 66 67 67 68 68 69 69 72 72 Of International And Regional Commitments And Country’s Statutory Requirements: 73 4.12 Resource Mapping 4.12.3 Recommended Action Points To Strengthen Resource Mapping 4.13 Budget Support 4.13.3 Recommended Action Points To Strengthen Budget Support 73 73 74 75 Ministry of Health & Child Care Republic of Zimbabwe | Table Of Contents 9 5 Implementation Modalities 6 Annexes Annex 1 List of Specialized Technical Working Groups (Committees) 8 76 76 3 84 Annex 2.Technical Working Group Terms Of Reference Template 85 7.
References 88 Ministry of Health & Child Care Republic of Zimbabwe 10 AIDS CCM CD CHC CHT CSO | List Of Acronyms Acquired Immuno-Deficiency Syndrome Country Coordinating Mechanism Chief Director (changed from Principal Director) Central Hospital Committee Central Hospital Team Civil Society Organization DEVPROMIS Development Projects Management Information System DHE DHT DHO DIPA DMO DP EDC EHR GAVI District Health Executive District Health Team District Health Officer Departmental Integrated Performance Agreement District Medical Officer Development Partner Epidemiology and Disease Control Electronic Health Records Global Alliance for Vaccines and Immunization GFTAM The Global Fund to Fight AIDS, TB and Malaria GOZ HCC HDF HDPCF HDPCG HIPA HIV HTF Government of Zimbabwe Health Centre Committee Health Development Fund Health Development Partners Coordination Forum Health Development Partners Coordination Group Hospital Integrated Performance Agreement (HIPA) Human Immunodeficiency Virus Health Transition Fund Ministry of Health & Child Care Republic of Zimbabwe | List Of Acronyms 11 Framework on integrated people-centred health services Integrated Based Results Management Integrated Supportive Supervision Information Technology Joint Review Mission Key Informant Interview Monitoring and Evaluation Maternal and Child Health Ministries, Departments and Agencies Millennium Development Goals Maternal Neonatal and Child Health Ministry of Health and Donors planning and review meeting Ministry of Finance and Economic
 Development Ministry of Health and Child Care IPCHS IRBM ISS IT JRM KII M&E MCH MDAs MDGs MNCH MODO MOFED MOHCC MOHCC SWG Ministry of Health and Child Care Sector Technical Working Group MOU NGO NHS NIHR OPC PCU PDC PHC PHE PHT Memorandum of Understanding Non-Governmental Organization National Health Strategy National Institute of Health Research Office of the President and Cabinet Programme Coordinating Unit Provincial Development Committee Primary Health Care Provincial Health Executive Provincial Health Team Ministry of Health & Child Care Republic of Zimbabwe 12 PMD PHO PPP PS PVT RDC | List Of Acronyms Provincial Medical Director Provincial Health Officer Public-Private Partnership Secretary for Health and Child Care Private Rural Development Council RMNCH Reproductive Maternal New-born, Child and Adolescent Health SDG SH SOP TORs TSP TWG UHC Sustainable Development Goal Stakeholders Standard Operating Procedure Terms of Reference Transitional Stabilisation Programme Technical Working Group Universal Health Coverage UNICEF United Nations Children’s Fund WHO ZNHS UZ World Health Organization Zimbabwe National Health Strategy University of Zimbabwe Ministry of Health & Child Care Republic of Zimbabwe 01| 1.
Introduction And Background 13 1.1.

Country context The Republic of Zimbabwe is a country in Southern Africa, with a population of 13.6 million, two thirds of which reside in rural communities.

The population is relatively young with 40% of the population being below age 15 years and only 6% aged 65 years and above (1).
The youth are a vulnerable sub-population that has shown deteriorating health indicators over the years in terms of behaviour change towards HIV, other sexually transmitted diseases, unplanned pregnancies, increased incidence of substance abuse and worsening perceptions about gender violence and unhealthy lifestyles (2).

A systematic review of existing reports and surveillance data shows that Zimbabweans still face a double burden of communicable and non-communicable diseases.
The country is prone to epidemics such as diarrhoeal illnesses, rabies and anthrax, highlighting the importance of public health surveillance and disaster preparedness (2).

HIV prevalence remain relatively high at 14.1% amongst adults and deaths due to TB remain high, predominantly driven by HIV co-infection (2, 3).

Non-communicable diseases are emerging as major cause of morbidity and mortality amongst both the rich and the poor.
(2) These challenges are compounded by health systems constraints related to shortage of critical health workforce, aging infrastructure, deficiencies in supply chain of medicines and other commodities and restricted health funding.

Addressing these challenges requires strengthened service delivery platforms, creating an enabling environment with attention to issues of policy and administration, multi-sectorial partnerships and research and development (2).

1.2.
1.2.

Multi sectorial nature of human health While it has long been recognised that influences on human health are multiple, complex and often rooted in contexts over which Ministries of Health have very limited control, tackling the multi sectorial nature of human health challenges appears increasingly central to the development agenda.

The Sustainable Development Goals (SDGs) underscore this point, identifying how non-health goals may lead to health gains.
From promoting early childhood health and development, to addressing the challenge of non-communicable diseases, reducing injuries, addressing malnutrition - all of these pressing public health problems require establishing and sustaining collaborations across functional sectors, such as health, agriculture, education, social welfare, trade and industry and environment (4).
By leveraging the strengths and approaches of different partners, effective multi sectoral coordination can eliminate policy implementation barriers, facilitate scale-up, and increase the impact that one sector or partner might have had alone.

Coordination across government ministries, for example, Ministry of Health & Child Care Republic of Zimbabwe 14 is essential for identifying intersections among the sectors and identifying opportunities for collaborative planning.
Successful multi sectoral collaboration is dependent on political, economic, and social factors and requires buy-in and commitment from all parties working together (5).

1.3.

Rationale for health sector coordination in Zimbabwe Zimbabwe’s health sector is financed by a mix of both domestic and external sources with a variety of implementation arrangements.
Following the dollarization of the economy in 2009, financing for health significantly increased albeit with most of it flowing off budget outside the visibility and control of the MOHCC, specifically to vertical disease programs.

Although Zimbabwe greatly benefited from these multiple streams of funding, there is still need for efficient management and coordination of the available resources.
This is to ensure that current gains achieved are sustained, and funding is prioritized to the core needs of the population and the overall health sector (6).

The major determinants that shape the health status of the nation are located in other sectors (agriculture, education, housing, social services, water etc.)

yet their unique contribution and linkage to the health of the nation remain undocumented.
Addressing the broader determinants of health will require inter-sectoral action and it is partly the responsibility of the MOHCC to enhance collaboration among the myriad of stakeholders contributing to the health of the nation, and give credit to their unique contributions (7).
While the MOHCC produces five-year strategy documents for the health sector, and in 2018 produced the Zimbabwe Health Sector Performance Monitoring and Evaluation Policy Guidelines and Strategy (8), there is no document that explicitly provides a framework for health sector coordination.
Currently, there are no formal mechanisms or guidelines to inform how various health interventions by the MOHCC are coordinated and how the Ministry should interface with other sectors that contribute to improved health outcomes.

Incidentally, vertical health programs, largely driven by donor funding have established disease specific coordination structures, at the expense of an overall health sector coordination framework.
Vertical disease programs often lead to fragmented chains of command and funding mechanisms, duplication in supervision and training efforts and consequently increased transaction costs of delivering services.

Funding partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria have repeatedly made recommendations to strengthen integration of vertical disease programs to address this challenge.
On-going efforts to strengthen coordination include calls to mainstream HIV programming into Maternal New-born and Child Health services, promote one-stop-shop provision of TB and HIV services, integrate electronic health systems and establish private-public partnerships among other clarion calls.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 15 The Integrated Results Based Management (IRBM -2005) (9) system as one of the strategies for strengthening both intra-ministerial and multi-sectoral coordination has not achieved the desired results of coordinated planning, implementation, monitoring, and evaluation.

However, there are ongoing efforts to train and retrain MOHCC officials in the IRBM approach.
To coordinate the contributions of various development partners, the MOHCC set up a Health Development Partners Coordination Forum in 2008 with well-defined terms of reference (TORs), chief of which was to align development assistance with national development priorities and harmonize partner and donor assistance modalities, advocating for increased commitment to the Paris Declaration on Aid effectiveness (10, 11).
At a meeting of the Minister of Health and Child Welfare with Development Partners in December 2018, it was resolved to review and update the terms of reference as a starting point for strengthening coordination with development partners.

One of the recommendations of the review exercise was to not only strengthen coordination between the ministry and development partners but also within the MOHCC (12).
It is against this background that a comprehensive Health Sector Coordination Framework has been developed to strengthen both intra-ministerial and multi sectorial coordination.

1.4.

Purpose of the document The overall objective of the Health Sector Coordination Framework is to consolidate and coordinate shared efforts by MOHCC and all key stakeholders with a stake in financing, planning and implementing health related interventions to maximize health outcomes.
This framework articulates the institutional arrangement for efficient and effective coordination of partners in the health sector, defining roles and responsibilities of different stakeholders that contribute to the health of the nation.

This document also seeks to strengthen the linkages amongst the different coordinating structures within MOHCC and beyond the health sector.

1.5.
1.5.

Designing process Development of this framework has drawn lessons from an exercise undertaken to review and update the TORs for the Health Development Partners Coordination Forum (HDPCF); key informant interviews; self-administered questionnaires on the subject matter; an inter-ministerial consultative workshop and extensive review of literature, including reference documents from MOHCC and Ministry of Finance and Economic Development (MOFED).
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 16 02| 2.

Swot Analysis Of Health Sector Coordination In Zimbabwe Simply put, coordination means multiple actors working together in a logical way towards accomplishing a shared goal, in this case, improved health and quality of life for all Zimbabweans.

Coordination within the MOHCC (intra-ministerial coordination) is an important first step in strengthening overall health sector coordination.
Intra-ministerial coordination is, in this framework, a necessary antecedent for successful inter-sectoral/ multi-sectoral or health sector-wide coordination.

A clear understanding of the status quo of health sector coordination in relation to strengths/opportunities and threats/ weaknesses as summarized in Table 1 below will help define practical interventions to strengthen health sector coordination for optimized use of available resources.
Table 1: SWOT Analysis of Health Sector Coordination in Zimbabwe Strengths/Opportunities • Political will to strengthen coordination from the highest level of the MOHCC as well as development partners.

• Existence of functional governance and management structures at all levels of the health system (Ministry of Health and Donors planning and review meeting (MODO), Provincial Health Teams, and District Health Teams).
• Availability of an updated National Development Cooperation policy by the Ministry of Finance and Economic Development • Availability of legal framework that promote inter-sectoral collaboration/coordination (National constitution; Public Health Act -2018) • International commitments to Sustainable Development Goals and International Health Regulations that demand inter-sectoral collaboration.
• Government commitment to Integrated Results-Based Management (IRBM) • Availability of a shared National Health Strategy as the rallying point for alignment and harmonization of health sector interventions • Government commitment to Paris declaration on principles of Aid Effectiveness • Availability of coordinating-facilitating tools and initiatives such as Memorandum of Understanding, annual Resource Mapping, National Health Accounts, Joint Review Missions and Integrated Supportive supervision.
• Existence of inter-ministerial and multi-sectoral coordination structures and mechanisms targeting health determinants such as Civil Protection Committees; National Epidemics and Zoonotic Crisis Subcommittee etc.)
• Existence of technical expertise in Ministries Departments and Agencies (MDAs) for support and cross pollination and capacity building Ministry of Health & Child Care Republic of Zimbabwe 17 Weaknesses/Threats Cross-Cutting • Lack of a comprehensive health sector coordination framework • Integrated Results-Based Management approach not fully embraced as evidenced by a few departments and units that have developed Department Integrated Perfomance Agreements (DIPA) and work plans • Weak enforcement of existing coordination mechanisms such as Event Management System not implemented, fragmented Integrated Supportive Supervision; information systems and monitoring and evaluation activities.
• Partial operationalization of existing coordination enabling legislation such as the Public Health Act.
• Inadequate governance and management of committees and technical working groups • Ineffective communication channels within the MOHCC, key stakeholders and between ministry and development partners as well as the public Specific to Intra-ministerial Coordination • Lack of clarity over the division of responsibilities within the MOHCC, with national policy actors at times playing the role of implementers.
• Dependence on donor support for key health sector activities including planning and review processes • Donor driven agenda and priorities • Uncoordinated competing priorities at national level diverting staff time away from their core business/workstations.

• Silo departmental planning/implementation, with ring fencing of activities for personal gain i.e.

activities that cannot be done if head of department is not there.
• Nonresponsive national level to input from subnational level (Top-down planning) • Weak enforcement of mandate of donor coordination unit within the MOHCC with multiple grants management units and processes • Inadequate linkages between technical and strategic levels of the MOHCC e.g.
many high level TWGs that make decisions without adequate technical input and with no mechanisms to cascade decisions made to implementation level • Ineffective change management resulting in resistance/reluctance to embracing progressive financial and procurement reforms likely to enhance coordination Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 18 Specific to Inter-sectorial/Multi-sectorial Coordination • Non-involvement of non-health sectors in MOHCC planning and budgeting • Missed opportunities by MOHCC to participate in relevant non-health sector planning, implementation and review processes • Little or non-involvement of stakeholders at planning and concept development stages for programmes • Inadequate management of MOUs, agreements and contracts, with partial compliance to requirements of existing agreements including failing to apply penalties for poor performance • Some MDAs not aware of their role or what is expected of them on health determinants of health • No boundaries set on the extent to which an MDA can address a “cross cutting determinant of health” without leading to duplication of activities • Insufficient resources allocated to support building collaborative relationships • Inappropriate level of representation at key committee meetings and relegation of responsibility to junior staff.
• Nonexistence of policy document and guidelines on cross cutting issues e.g.

Health in all Policy.

• Inadequate senior level supervision and follow-up at the central level.

• Weak implementation of the national M & E Framework (resulting in resource wasting duplication of effort, for example • Ministry’s negotiating directly with donors for support without participation of treasury • Limited or weak accountability and consequences thereof.
Specific to Health Partners (Donor) Coordination • Irregular Health Development Partners Coordination Forum (HDPCF) meetings • Partial compliance to principles of AID Effectiveness by both the MOHCC and development partners with most partners not using Government Financial and Procurement systems; • Duplication of effort amongst partners • Partial compliance with MOUs requirements Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 03| 3.
The Zimbabwe Health Sector Coordination Framework 19 3.1 Objectives of Health Sector Coordination framework 3.1.1 Overall objective • 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.
3.1.2 Specific objectives • To strengthen intra-ministerial coordination within MOHCC structures/departments for more efficient delivery of health interventions.

• To facilitate inter-ministerial/inter-sectorial coordination with other ministries and non-health sector to streamline support linked to maximizing health outcomes.

• To coordinate and harmonize partner/donor assistance in pursuit of increased commitment to the Paris Declaration on Aid Effectiveness.
3.2 Guiding principles The framework is guided by the following principles: • Equity in health - Everyone, no matter where he or she lives, has the right to enjoy good health and deserves to have access to health care services.

• Partnership for shared ownership - A collaborative relationship between two or more parties based on trust, equality and mutual understanding is crucial for the achievement of a shared goal.
• Transparency and accountability Transparency - openness, a willingness to provide clear information to all stakeholders.

Accountability - obligation and responsibility to give an explanation or reason for the organization’s actions or inaction and conduct.

• Value for money - Using public resources in a way that maximises public value is a non-negotiable in the context of diminishing resources for health.
3.3 Health sector coordination architecture This framework will leverage on existing coordination structures, enforcing mechanisms and tools in place to facilitate intra-ministerial, inter-sectorial and partner coordination, for joint planning/implementation and resource pooling to support the shared goal of better health outcomes.

These structures are summarized in Figure 1 below.
Ministry of Health & Child Care Republic of Zimbabwe 20 Figure 1: Health sector coordination architecture Intra-ministerial Coordination Inter-sectorial coordination •Weekly MOHCC coordination •Government ministries meetings (Minister of Health and Child Care, Permanent Secretary; Chief Directors, Directors, PMDs & CEOs) •Academia (University Joint Planning Meetings) •Interagency committees •Divisional (Thematic) Working •Health Professional bodies Groups meetings •Central, Provincial, District & Primary level coordination Meetings (Central Hospital Team, Provincial Health Team, District Health Team, Health Centre Committee) •Others Health Partners Coordination • Health Development Partners Coordination Forum • Health Sector Technical Working Group • Private sector engagement forum • Civil Society/NGO engagement forum • Project/Donor specific project coordinating mechanisms (GAVI, Global Fund CCM) Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 21 Coordination platforms or mechanisms that enable stakeholders to work together towards a common goal are summarized in Figure 2 below.
Figure 2: Coordination platforms or mechanisms to enable stakeholder coordination Planning embedded in the Integrated Results Management System (IRBM) - a management approach integrating strategy, people, resources, processes, & measurements to improve decision-making, transparency & accountability Thematic committees, Technical working group meetings & workshops Contracts, Memoranda of Understanding & Grant agreements Resource mapping, Stakeholder mapping & National Health Accounts Events management systems Joint review missions & Integrated supportive supervision visits Joint studies, research & surveys Intra-ministerial (Intra-organisational) governance coordination 3.4 structures Intra-organisational collaboration is a necessary antecedent for successful health sector coordination.
Intra-organisational collaboration is here defined, as individuals from different departments/units and functions working collaboratively towards a common goal.

There are two types of intra-ministerial coordination structures: vertical and horizontal intra-ministerial coordination.

Vertical intra-ministerial coordination ensures that national strategic decisions are linked with activities implemented at the provincial, district and community levels.
Vertical coordination defines the lines of decision-making responsibilities and the lines of accountability.

Horizontal intra-ministerial coordination is the linking of activities and sharing of information across departments/units.

Horizontal coordination is essential as most departments depend on each other.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 22 The success of this Health Sector Coordination Framework lies in making the existing governance structures fully functional and the ministry top management enforcing existing coordination mechanisms and tools.

The starting point is strengthening the executive management structures at each level in managing coordination.
This will involve capacitating national level Top management, Provincial, Hospital and District Health Executives as well as primary level managers through team-building initiatives.

It is assumed that strong leadership at each level will facilitate seamless coordination both intra-ministerial and inter-sectorial.

Illustrated in Figure 3 is the intra-ministerial coordination framework.
The principal mechanism for health sector coordination is planning that is embedded in the Integrated Results Management System (IRBM).

IRBM integrates planning, budgeting and human resources development with a transparent performance measurement framework.

Results-based management engages an array of stakeholders to work on achieving a collective outcome.
Fully implementing the provisions of the Integrated Results-Based Management System will address most of the current health sector coordination gaps across all levels of the MOHCC.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 23 Figure 3: Intra-ministerial coordination framework Level Executive authority Coordination structure Minister of Health & Child Care Minister’s meeting - Policy direction Health Service Board Hospital Management Boards Secretary for Health & Child Care Secretary for Health & Child Care meetings a. CDs & all Head Office Directors b. CD, CEOs, PMDs & City Directors (Operational & technical policy direction) Divisional meetings (Technical policy direction) MODO (Technical direction) Quaternary Hospital CEOs & Hospital Executive Central hospital committees (Operational) Provincial PMD & PHE PHT (Operational oversight) District DMO & DHE Primary Nurse in Charge DHT (Operational oversight & implementation) Health Centre Committee (Operational oversight & Implementation) Community Community structures and community health workers Accountability relationship (Vertical coordination) Planning together, information sharing and working towards one goal Key: CEO- Chief Executive Officer; PMD-Provincial Medical Director; PHE-Provincial Health Executive; DHE-District Health Executive; MODO - Ministry of Health and Child Care & Donor Planning and Review Meetings Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 24 3.4.1 National level coordination At the helm of intra-ministerial coordination are meetings of the Minister of Health and Child Care that provide policy direction for the health sector.
Meetings of the Secretary for Health and Child Care with Chief Directors and Directors at national level and the PMDs and CEOs from provincial and central hospital levels respectively, provide technical policy direction.

The Directors of Human Resources for Health and Finance Administration provide policy advice on human and financial resources for the health sector respectively.

Table 2 summarizes the different national level coordination structures within the MOHCC.
Table 2: National level Intra-ministerial ministerial coordination structures Minister of Health and Child Care weekly meetings Meeting composition Purpose • Minister of Health & • Set the health sector strategic direction and objectives Child Care (Chair) • Deputy Minister • Make health sector policies, rules, regulations and standards • Mobilise and allocate adequate resources to accomplish • Secretary for Health & strategic goals and objectives and institute controls Child Care • Oversee and make sure the strategic goals and objectives are • All Chief Directors in accomplished (monitoring and evaluation) the MOHCC & Directors (Human Resources, Finance) • Enhance collaboration among state and non-state actors (inter-sectorial collaboration) • Administer the provisions of Public Health Act • Prepare and publish public health reports and statistics • Account to stakeholders on health issues Secretary for Health and Child Care bi-monthly meetings • Chief Directors & • Review and consolidate recommendations on policies, all Directors in the regulations and national priorities from thematic working groups MOHCC for Minister’s consideration • Follow-up issues raised by the Minister of Health and Childcare • Ensure proper accountability for resources in the ministry.
• Ensure adequate and effective communication within the ministry and outside community.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 25 Top management team meeting •Secretary for Health and Child Care (Chair).
• Platform for Secretary Health and Child Care to meet PMDs and Central Hospital CEOs for information sharing •All Chief Directors, • Direct contact point for PMDS and CEOs on service provision/ •CEOs of Central Hospitals •PMDs referrals • Platform for PMDs, CEOs and City Health Directors to input into formulation and development of national policies • Coordinating and improving communication between primary, secondary care and tertiary health facilities.
• Identify and address service gaps at the interface between primary and speciality outpatient care, Divisional monthly operational meetings Curative service • Provide overall strategic direction, support and coordination of • Chief Director (Chair) • Nursing, Pharmacy, • Laboratory, Dental, provision of quality clinical services.

• Coordinate clinical, specialist and nursing services, the essential drugs supply programme as well as laboratory services.
• Provide technical guidance in management of public health • Pathology, Traditional hospitals Medicine Services • Ensure efficient and effective provision of quality health care Chief Director Public • Provide overall strategic direction, management and coordination Health • Epidemiology & Disease Control, • Environmental Health, • Health Promotion, • Family Health, • HIV, AIDS, STI and TB • Radiation Protection, • Government Analyst • National Institute of Health Research.
of programs for health protection, prevention and control of epidemics, communicable, non-communicable diseases and injuries.

• Formulate and review national policy frameworks for program implementation of Family Health Services, Primary Health Care activities, Health Promotion, Environmental Health and Disease surveillance program monitoring and evaluation.
• Provide advice on any matter relating to public health Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 26 Planning, Monitoring • Coordinate integrated planning, monitoring and evaluation of and Evaluation Health Sector • Chief Director (Chair).
• Quality Assurance, • Performance Monitoring & Evaluation, • Policy and Planning • Coordinate development of policies and strategies and their review • Coordinate health sector stakeholders • Monitor implementation of the National Health Strategy • Produce quarterly and annual health sector reports.

Specialized technical committees • The MOHCC and Donor Planning and Review Meeting (MODO).
• Budget committee • Human Resources Taskforce • Health Financing for Universal Health Coverage Technical Working Group • Health Systems Research committee • National Health Information System Committee • National Monitoring and Evaluation Committee • Procurement and supply management committee (Medicines and medical supplied committee) • Public Private Partnership Committee and • Others as defined by the MOHCC Committee meetings and workshops are common coordination mechanism used in the MOHCC.
National level meetings are generally looking into policy issues whilst subnational level meetings address technical and operational issues.

At the operational level (hospitals and primary care facilities), the emphasis is coordinated client care or patient centre care.

The number and type of committees is linked to the number of divisions and departments in the MOHCC and therefore to the structure of the MOHCC.
Over the years, some of the work, which used to be done in the MOHCC is now the responsibility of other MDAs such as the Environmental Management Agency, Radiation Protection Authority, the Food and Nutrition Council, Child Welfare Council etc.

Each of these MDAs have established committees that in some cases have led to duplication.
The MOHCC of Health and Child Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 27 Care structure (13) (Annex 1) has not been reviewed since 2007.

There might be need to revisit the MOHCC structure and this will result in rationalizing the number and type of committees.

There is, however, still need for the Chief Directors to critically review the various committees that fall under their departments.
The major committees are mentioned under each department in annex 1 and the functions and composition of some of them are provided as Annex 2.

3.4.2 Sub-national level coordination Sub-national management structures are summarized in Table 3 below.

These include structures to facilitate coordination of health interventions in hospitals, provinces, districts and more peripheral primary health care facilities.
Table 3: Subnational intra-ministerial coordination structures Hospital Management Board Composition Purpose • Each hospital • Provide for the care and treatment of the patients at the hospital management board for which the board is the responsible authority consist of not more than seven officials with the Hospital Superintendent or CEO of the hospital being the chairperson • Other appointments by the MOHCC as defined in the Health Services Act • Hire and fire staff; • In the case of a teaching hospital, to provide facilities for the teaching and training of medical practitioners, medical student nurses and other personnel; • Conduct negotiations with the Ministry responsible for health with respect to the provision and terms of any grants appropriated or to be appropriated by Act of Parliament or otherwise obtained for the benefit of the hospital or Government and State-aided hospitals generally; • Ensure the best use of the resources available to the hospital in the interests of the patients; • Implement Government health policy as communicated to the hospital management board from time to time by the Board; • Devise means of financing the operations of the hospital on a continuing and sustainable basis; • Maintain and improve the hospital.
• Have regard to the social obligation of the hospital as a Government hospital to provide for the health needs of the public; • Assist in the implementation of national health policies and the formulation of institutional health management arrangements.
• Develop an annual plan Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 28 Hospital Executive • Chief Executive Officer • Ensuring that the hospital provides appropriate quality diagnostic (CEO); clinical services (including referral services), technical support • Clinical Director; • Matron; • Pharmacist; • Finance Director and • Operations Director (including training in clinical care to peripheral health institutions), monitoring, evaluation and corrective action as required; • Development, implementation and evaluation of patient safety measures.
• Taking care of day-to-day management of the hospital • Oversee all expenditures for the hospital according to existing regulations; • Prepare and submit quarterly and annual plans, budgets and reports; • Developing and regularly reviewing hospital policies and procedures, • Ensuring compliance with regulations, laws, procedures and policies.

• Holding regular hospital departmental staff to discuss plans, budgets and allocation of recurrent budget for use in service areas.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 29 Provincial Health Executive • Provincial Medical • Contributing to the review, formulation and development of Director; • Provincial Epidemiology & Disease Control Officer; • Provincial MOHCC policies and strategies.
• Preparing strategic plans (inclusive operational targets) in conformity with the national health policy for the province annually; ‘Facilitating the development of and approving operational plans, that are in line with national health policies • Negotiating service contracts with the DHE Executive and Environmental Health Hospital Health Executives officer; • Working in collaboration with the Provincial Council and • Provincial Nursing participating in interprovincial and inter-sectoral co-ordination Officer; and collaboration; • Provincial Health • Planning and managing the provincial health information system; Services Administrator; • Co-ordinating and monitoring the quality of health services and • Provincial Accountant; facilities in the province; • Provincial Family • Promoting community participation in the planning, provision and and Child Health evaluation of health Officer; (g) Provincial Pharmacist; • Providing managerial, technical and logistical support and supervision • Provincial Nutritionist; • Producing monthly, quarterly and annual reports.
• Provincial Health Promotion Officer; • Provincial Laboratory Scientist; (Functions and Membership as provided for in the Public Health Act) Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 30 District Health Executive • District Health (Medical) Officer • Government Medical Officer; • Organizing and running of the district hospital services.
• Managing all government health facilities within the district • Ensuring the availability of a full range of primary health care and other related service in the community and all health facilities • District Environmental serving the community.
Health Officer; • Coordinating the preparation and production of costed quarterly • District Nursing and annual health plans and monthly generic, quarterly and annual Officer; reports • District Health • Co-ordinating, supporting and supervising local health providers Services Administrator; including community health workers • District Accountant; • Monitoring and evaluating the performance of providers in meeting • District Pharmacist; • District Nutritionist; • District Health Promotion Officer; • District Lab Scientist; • District Hospital Matron;.
(Functions and Membership as provided for in the Public Health Act) agreed targets and ensure that quality health services are being delivered.

• Promoting and facilitate community participation and involvement in local health services planning, implementation and monitoring.

• Identifying district training needs and arranging for training of staff • Allocating and monitoring the use and management of health resources in the district to ensure value for money.
• Coordinating and supervising all government, non-government and private health services within the district • Initiating and promoting partnership with other health providers and other sectors • Administering Public Health Regulations and participate in the formulation of health by-laws.
• Organizing and managing health management information system and ensure effective use of data • Monitoring and evaluating health care performance in the district in terms of quality and continuity of care and to take corrective action where required.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 31 Health Centre Team • Ensuring the provision of quality-integrated (all staff at the Health o Promotive Services Primary Care Centre) • Nurse-in-Charge • All nurses at the clinic • Environmental Health Technician • Nurse Aids • Groundsman/ Caretaker o Preventive Services o Curative Services o Medical Rehabilitation Services o Surveillance and Health Information System services • Taking care of day-to-day management of the health centre • Oversee and coordinate community health services • Prepare and submit monthly, quarterly and annual plans, budgets and reports; •Ensuring compliance with public health regulations, laws, procedures and policies The following are recommended action points for further strengthening existing intra-ministerial coordination structures: • Reviewing the MOHCC structure in light of changes that have taken place in the Ministry with some of the functions transferred to other MDAs.
• Reviewing and rationalizing committees based on the MOHCC structure • Consistency in holding meetings with follow-up of action points Section 4 of this document covers other action points on strengthening existing intra-ministerial coordination structures such as supervision, joint planning, effective communication etc.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 32 3.5 Inter-ministerial/inter-sectorial coordination structures The factors that influence health outcomes are complex and extend well beyond the provision of health care services.

Many also fall outside the authority of the health ministry.

As a result, accountability for the progressive realization of the right to health must be shared across government as a whole (14).
Coordinated, inter-sectoral action to improve health, including between ministries, between different levels of government, and with stakeholders outside government, is necessary to address complex and persistent health challenges (14).

Inter-sectoral structures may provide a solution when governments have multiple pieces of legislation that overlap and share common goals but administered across several ministries.
While the overlapping tasks mandated under the different pieces of legislation could be merged within a single ministry, another alternative is to create an inter-sectorial framework to facilitate collaboration among the different government entities.
Multi-sectoral coordination/inter-sectoral coordination refers to deliberate collaboration among various stakeholder groups (e.g., Government, civil society, and private sector) and sectors (e.g., health, environment, economy) to jointly achieve a policy outcome.

By engaging multiple sectors, partners can leverage knowledge, expertise, reach, and resources, benefiting from their combined and varied strengths as they work toward the shared goal of producing better health outcomes.
In the Alma Ata Declaration (1978), (15) inter-sectoral action was recognized as a key to improving primary health care, through coordinated action across a range of sectors.

In 1986, the Ottawa Charter for Health Promotion recognized that inter-sectoral action is fundamental to reducing inequalities in health status within the population (16).
It is for that reason the Government of Zimbabwe adopted the Primary Health Care Approach in service delivery in 1980 and reaffirmed its commitment to the Primary Health Care Approach by signing the Declaration of Astana (17) to strengthen primary health care coverage and accelerate progress towards Universal Health Coverage.
The MOHCC recognizes that attaining the aspiration of the highest possible health and quality of life for Zimbabweans does not solely depend on the health sector, but broad-based social determinants of health, such as living conditions, nutrition, safe drinking water, sanitation, education, and early child development, which are beyond the purview of the health sector.
As defined by the World Health Organization (WHO), social determinants of health (SDOH) are “the conditions in which people are born, grow, live, work and age.

These circumstances are shaped by the distribution of money, power and resources at global, national and local levels” (18).

The major determinants of health may broadly be categorized into four areas: health behaviours, clinical care, physical environment, and social and environmental factors.
Some studies suggest that clinical care is responsible for only 20 percent of a person’s Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 33 health outcomes.

The other 80% is attributable to health behaviours, the physical environment and socioeconomic conditions (19, 20, 21).

This means clinical care alone will not solve the challenges in the health sector.

This therefore calls for inter-sectorial collaboration.
The national vision of health for all is only possible through partnership with key sectors with a stake in impacting health outcomes.

In this partnership, the MOHCC plays different roles in promoting the inter-sectorial approach depending on the situation.

The different roles the MOHCC can play include being a leader, a facilitator and a supporter for health initiatives.

The MOHCC has excelled in the role of leadership and not done so well as a supporter for health initiatives in other MDAs.
At the local level, the MOHCC has promoted the inter-sectoral approach by involving all sectors of society – Government, business, civil society organisations and communities in health activities.

In this process, the MOHCC assumes a leadership position in those health initiatives that relate most directly to its mandate and fall within its realm of expertise.
These include, but are not limited to health promotion, disease and injury prevention, population health assessment and health surveillance initiatives.

Some of the committees that fall into this category include Epidemic Response and Control, Weekly Disease Surveillance, program-specific technical committees such as HIV TB, MNCH etc.

The MOHCC has often usurped the role of facilitator or advisor in situations where health initiatives extend beyond obvious health interests or capacities.
Such platforms include Sustainable Development Goals committees; Health Officers Forum for Urban Authorities; National Health Consultative Forum; Civil Protection Unit; Water and Sanitation National Coordinating Unit to mention but a few.

Figure 4 below illustrates scenarios where MOHCC assume different roles of lead initiator or facilitator.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 34 Figure 4: Government structures facilitating inter-sectorial coordination through community participation Local Government levels and structure Mechanism for Community Participation & Coordination MOHCC coordination structures Central Government Heads of Ministries Meetings Minister’s meetings National Committee e.g.
SDG Advisory Board on Public Health PS Meetings; MODO; Various Committees Provincial Council Provincial Development Committee Provincial Council Sub-health committee Provincial Health Team Rural District council District Development Committee District Council Sub-health committee District Health Team Ward Assembly Village Assembly Ward Development Committee Village Development Committee Ward Health Committee Health Centre Committee Village Health Committee Health Post meetings The community and community health workers Key: Green arrows (Advisory role); Blue arrows (Facilitator role); Red arrows Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 35 There are inter-sectorial collaborations that are provided for through statutes such as Health Centre committees, Hospital management and Advisory boards.
One of the functions of Provincial and Metropolitan Councils, as provided for in the constitution of Zimbabwe (22), is coordination and implementation of governmental programmes.

Each province/district has a multi-sectorial technical team, the Provincial and District Development Committees or Councils, each headed by a Provincial Administrator.

Each committee has sub-health committees, inclusive of membership from the health sector.
This committee discusses pertinent health issues, tabling recommendations to the Provincial/District Development Committees.

Inter-sectorial coordination can also be viewed from the perspective of who provides the mandate for action.
There are inter-sectorial coordination structures composed of organizations that draw their mandate from the Government of Zimbabwe (such as inter-ministerial committees) and those that draw their mandate from outside the Government of Zimbabwe here falling under Partnership Coordination Structure.

Some structures fall under both categories.


3.5.1 Interministerial Coordination structures with Government of Zimbabwe mandates include • The Health Development Partners Coordination Forum (HDPCF) serves as both a health sector apex joint forum for (Development) Partners to interact at the policy level with the Minister of Health and Child Care and as well as the highest inter-sectorial coordination mechanism in the health sector.
• The MOHCC Sector Technical Working Group (MOHCC SWG) is the highest technical inter-sectorial coordination structure with the MOHCC in leadership position.

The main source of information for the MOHCC SWG is the MOHCC Planning and Review Meeting (MODO).

• MOHCC Planning and Review Meeting MODO) is an integrated planning and review meeting, usually held biannually and chaired by the Secretary for Health and Child Care.
The MODO is a platform for reviewing and planning all activities in the health sector supported by both the Government of Zimbabwe and development partners’ resources.

• The Provincial Health Team and District Health Team meetings (7, 23, 24) at subnational level are the highest inter-sectorial coordination mechanism within the MOHCC assuming the leadership position.

They play similar roles as the MODO at the provincial and district levels.

They feed into the MODO.


The inter-sectorial coordination structure at the community level is the Health Centre Committee (7).

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 36 • Academia - The MOHCC has a longstanding relationship with the University of Zimbabwe (UZ).

The Joint MOHCC and UZ meetings act as a platform for linking the academia and public health practice.
The MOHCC will resuscitate the “Joint MOHCC and University meetings” that used to be held on a quarterly basis.

Table 4 summarizes the inter-sectorial and partnership coordination structures.

Table 4: Inter-sectorial and partnership coordination structures.
Health Partners Development Coordination Forum Composition Functions The membership of the HDPCF consists of the MOHCC and health sector Development Partners; Key Government ministries such as the Ministry of Finance and Economic Development (MOFED), Ministry of Local Government, Public Works and National Housing, Ministry of Industry and Commerce, Ministry of Primary and Tertiary Education, Ministry of Agriculture; Trade Unions, Medical Insurance Companies, health sector Professional Associations and representatives of users of services.
Information sharing • To share information and experiences, to improve dialogue among partners, donors and the MOHCC.

Alignment and harmonization • To promote harmonization and alignment between and amongst Development Partners in development assistance and the MOHCC priorities.

• To promote harmonization and alignment of Aid with the health sector’s priorities, systems and procedures and helping to strengthen their capacities.
Policy dialogue • To ensure inclusive policy dialogue based on local, regional and international best practice.

Resource mobilization • To ensure resource mobilization, including identification of resources gaps (human, funding, material).

Partnerships • To maintain and strengthen the partnership between the MOHCC and Development Partners in general, to achieve complementarity of effort, in line with the MOHCC’s existing and future strategy and policy frameworks.
• To provide recommendations on the formulation, implementation, monitoring and evaluation of aid effectiveness initiatives.

Mutual accountability /Monitoring and Evaluation • To monitor and evaluate the National Health Strategy and the impact of Development Partners’ support, towards the achievement of National Health Objectives.
• To increase transparency and accountability between the MOHCC and Developing Partners and to Zimbabwean citizens in the management of development cooperation Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 37 •The Permanent Secretary as chair.
•Representatives of the MOFED; OPC; Relevant MDA that have substantial linkages in terms of production of health outputs and outcomes; •Development Partners active in the sector; •Members of NGO community; •Relevant state-owned and private companies; •Academia and educational institutions with an active interest in health MOHCC Sector Working Group • To mitigate against duplication and identify ways of continuously improving complementarity both within the MOHCC’s departments/programs and amongst those providing the support and assistance • To share information related to MOHCC policies, strategies, new initiatives, successes and challenges • To share, build upon and promote wide utilization of good practices in health systems, leveraging the expertise and experience of a wide range of development partners • To receive feedback on and consider, discuss major interventions, events, relevant proposals and studies related to the health sector development referred by TWG • To review and identify issues that need further follow up and report to the high-level Ministers Forum.
• To follow up and report on issues referred by the minister’s high-level forum • To provide and recommend advice on policy, regulatory/ legislative initiatives in the health sector.
• To review and approve new donor/partner projects, studies, surveys and researches (mitigating against duplication) • To facilitate capacity building of TWGs that feed into MOHCC SWG • To monitor agreed on performance indicators for the work of TWG; the commitments to the principles of Paris declaration and the performance of the work the group (MOHCC SWG) is doing.

• To coordinate the lobbying for resources based on consolidated health sector support and assistance requirements.
• To harmonize and align stakeholder resources to the National Health Strategy priorities • To monitor, evaluate and report to the high-level forum on: o o o Sector results framework Effectiveness and impact of all resources.
Commitments to the principles of Paris declaration Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 38 Ministry of Health and Child Care and Donor Planning and Review Meeting (MODO) • All Ministry departments, • MDAs that work with the MOHCC especially the Ministry of Finance, • NGOs, Faith-Based Organizations and • Representatives of • Review implementation progress & constraints over the past twelve months, results achieved and remedial actions to improve performance • Sharing information on available resources both from government and from development partners that can be used in the following year.
• Review and agree on the priorities, work-plan and budget for the following year development partners and private sector • Share best practices • Examine lessons learnt and apply these lessons in the next implementation cycle.
Provincial Health Team Advise entity to the Provincial Medical Directorate on; a) Policy concerning any matter that will protect, promote, improve and maintain good health in the population served; b) Propose legislation relating to health matters for tabling to Parliament; c) Set norms and standards for the establishment of health institutions; d) Follow-up implementation of health-related activities by all health care providers in the districts; e) Ensure inter-sectorial coordination of health-related issues.
Provide a forum for exchange and dissemination of information • Provincial Health Officer (Provincial Medical Director); • All members of the PHE; • Chairperson and in charge of the provincial hospital; • All DHE of the province; • A nominee from teaching hospitals or college of medicine operating in the province; • A nominee from religious body sponsoring a mission hospital; • Nominees from civil society-organisa- tions operating in the province, as the PHO may determine; • Representative from each local authority in the province Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 39 District Health Team (DHT) • District Health Officer (District Medical Officer); • All members of the The DHT functions as per Public Health Act are:- • Translate the national health policies into comprehensive annual district health plans with very clear targets in accordance with local situations.
• Monitor and evaluate district health services and programmes on regular basis, and reporting (generic monthly reports) to the provincial level.
• Advise the District medical officer in coming up with mechanisms for the involvement of communities in health at all levels of the health system; • Raise awareness and identify needs and priorities for health; • Act as a communication and information channel between communities and health systems; • Mobilize, plan and monitor resource allocations for health: • Mobilize community and social actions for health; • Hold providers accountable for services; • Support enforcement of public health laws and standards.
• Initiate and promote partnerships with other health providers and other sectors to enhance collaboration and communication.

DHE; • Chairperson of Community Health Council • In charge of district hospital; • All Environmental Health Technicians; • In-charge nurses of rural health centres; • Nominee of religious body sponsoring a mission hospital; • Nominees of civil society organizations operating in district; • As the DMO may determine, one representative from the relevant local authority.
(Functions and Membership as provided for in the Public Health Act) Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 40 Health Centre Committee • Clinic Health Workers, • Representative from other government departments • Community • Inform, educate and empower members of the community on health matters; • Use information gathered from the communities to plan, monitor and evaluate health programmes; • Coordinate health programmes in the area serviced by the health representatives centre; • Represent communities and their interests before relevant authorities; • Support local health care planning activities, including resource mobilisation; • Support local community based workers in health; • Perform such other functions and duties as the Minister may assign Some of the existing inter-sectorial structures are not functioning optimally.
Provincial and Metropolitan Councils remain silo in function, where resources are restricted for use only within a specific ministry, stifling joint programming.

It remains to be seen how the current discourse will pan out with Provincial and Metropolitan Councils now likely to receive budget allocations from the national fiscus under the new constitution.

All the Ministry of Health Strategy documents recognize the importance of other Ministries in promoting health.
However, the development of such key documents is done without the active participation of sectors whose mandate significantly contribute to modifying key determinants of health.

Documents that define the unique contributions of other sectors and how they link with the health sector are not available.

All eleven Ministries that responded to a self-administered questionnaire indicate that they contribute to the health of the nation in various ways and most have a focal person dealing with health issues.
There is however no structure for the focal persons to meet, share and where possible harmonize activities.

The MOHCC needs to fully exploit provisions of the Public Health Act, to actively involve other sectors in health for promoting multi- and inter-sectorial coordination.

In collaborating with other Ministries, the MOHCC needs to harness the comparative contribution of such ministries in shaping health outcomes.

Table 5 shows how different Government Ministries contribute to health.
The posture when engaging other Ministries must be less instructional, from a position of “we know it all” to a more participatory approach akin to a “more listening Ministry”.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 41 Table 5: Contribution of Government ministries to the health of the nation Ministry How the Ministry contributes to health outcomes Ministry of Defence, Security and War Veterans Emergency response Ministry of Energy and Power Development Ministry of Environment, Tourism and Hospitality Industry Ministry of Finance and Economic Planning Ministry of Foreign Affairs and International Trade Powering health facilities; powering all economic activities’ that improve health and quality of life Environmental protection; Clean and safe environment through the Environmental Management Agency Resource mobilization; Donor coordination; legislating levies/taxes on tobacco/alcohol, redirecting such taxes to funding initiatives to reduce risk factors to ill health Following up on International agreements MOHCC Health stewardship Ministry of Higher Education, Science and Technology Development Training health workers; health promotion; health literacy Ministry of Home Affairs and Culture Enforcing public health regulations Ministry of Industry and Commerce Safe food standards Ministry of Information Communication Technology and Courier Services Communication networking; e-messaging; telemedicine Ministry of Information, Publicity and Broadcasting Services Information dissemination Ministry of Justice, Legal and Parliamentary Affairs Ministry of Public Service, Labour and Social Welfare Legal advice, legislative direction; safeguarding the right to health; child-friendly courts; Conditions of service for public sector employees; Health assistance (AMTO), Children’s Rights Ministry of Lands, Agriculture and Rural Resettlement Ensuring food security Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 42 Ministry How the Ministry contributes to health outcomes Ministry of Mines and Mining Development Reducing pollution Ministry of Primary and Secondary Education Increasing health literacy; School health program Ministry of Youth, Sports, Arts and Recreation Health promotion; promoting physical exercise Ministry of Transport and Infrastructure Development Physical accessibility, Ministry of Women Affairs, Community, Small and Medium Enterprises – Developments Mainstreaming gender in all activities; Empowerment of women The MOHCC needs to be more proactive and pragmatic in motivating other Ministries to fully exert their potential in promoting health.
The SDGs are an important entry point to engage other sector Ministries in health and development.

Sharing with and explain the provisions of the Astana Declaration to other Ministries can also be used as a strategy for promoting inter-sectorial collaboration on health development.

3.5.2 Recommended action points to strengthen multi-sectorial and inter-sectorial collaboration • Integrated Based Results Management (IRBM) requires the involvement of other sectors during planning and budgeting.
(9) • Recognition of other sectors in health development - MOHCC must acknowledge the contribution of other sectors to health development.

• Operationalizing the Public Health Act - through revitalizing the National Advisory Board on Public Health and convening annual National Consultative Forum.

This forum brings together public and private stakeholders to promote and facilitate interaction, communication and the sharing of information on national health issues.
• Full participation in Government-led health-related committees - The MOHCC should fully participate at the appropriate level in all health-related committees.

The MOHCC will actively participate in all SDG committees.

• Sharing the Astana Declaration with other Ministries.
• Identifying opportunities to share and advocate for health - riding on Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 43 existing platforms with opinion leaders such as the Annual Chiefs Council Conference, the Parliamentary Portfolio on Health and Provincial Councils among others to promote health as a developmental issue.
• Guidelines – Developing guidelines to train MOHCC officials in identifying opportunities and encouraging other sectors to promote health.

• Inter-sectorial coordination must be one of the outputs of Policy Planning Monitoring and Evaluation Division.

• Redefining the role of the Donor coordination unit in the MOHCC and providing support.
3.6 Partners coordination structures (Internal and External partners) 3.6.1 The Health Development Partners Coordination Forum (HDPCF) The MOHCC receives funding and technical assistance for several programmes, medical supplies, health infrastructure, and workforce development and training from both internal and external partners.
Over the years, this support has included (among others) support for Malaria control, TB control, combating HIV/AIDS, reproductive health, the EPI programme, and hospital and health clinic development.

Strong coordination and prioritising among development partners and the MOHCC is required to promote the effectiveness and efficiency of all the support being provided.
To coordinate the contributions of various development partners, the MOHCC set up a Health Development Partners Coordination Forum in 2008 (10)with well-defined terms of reference, chief of which was to align development assistance with national development priorities and harmonize partner and donor assistance modalities, advocating for increased commitment to the Paris Declaration on Aid effectiveness.
(MOHCC, 2014) (11) At a meeting of the Minister of Health and Child Welfare with Development Partners in December 2018, it was resolved to review and update the terms of reference as a starting point for strengthening coordination with development partners.

The Health Development Partners Coordination Forum (HDPCF) is the health sector apex joint forum for (Development) Partners to interact at the policy level with the Minister of Health and Child Care.
The main purpose of the Health Development Partners Coordination Forum is to ensure that all support from partners is aligned towards the achievement of National Health goals and objectives.

The Minister of Health and Child Care convenes and chairs the HDPCF meetings.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 44 The objectives and membership of the Health Development Partners Coordination Forum are summarized in Table 4.
The Terms of reference of the Health Development Partners Coordination Forum updated at the beginning of 2019 (12), await approval by both the Minister of Health and Child Care and the Development partners.

The High-Level MOHCC- Health Sector Technical Working Group is the major source of information for the minister as shown in Figure 5.

The minister gets information through the Secretary for Health and Child Care.
The Advisory Board of Public Health, Audit General, Parliamentary Portfolio on Health and the Health Service Board are the other sources of information for the minister.

The Minister of Health and Child Care takes issues raised in the HDPCF meeting needing further Government interrogation to the Cabinet Committee on Development Cooperation (or other forum as the minister sees fit/appropriate).
It is, therefore, proposed that one of the HDPCF meetings be scheduled just before the Minister attends the Cabinet Committee on Development Cooperation, which will be held in October each year according to the new Zimbabwe Development Cooperation Policy of 2019.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 45 Figure 5: Health Sector Partner Coordination Structure Internal Minister of Health and Child Care meeting with PS & CD Health Development Partners Coordination Forum – Partners meet Minister – biannual meetings Health Development Partners Group - High-level platform for Partners to deliberate before HDPCF High Level Sector Working Group (PS as Chair; CD; Senior level DP; ICD, MDAs; Representative CSO, Pvt, NGOs, Academia etc.)
Review all reports and submissions that will need Minister and HDPCF consideration and approval (Quarterly Meeting) Specialized Technical Committees – advise SWG on specific thematic technical area Technical committees might have ad-hoc committee for in-depth discussion and analysis & l e v e l l a n o i t a r e p O A key success factor for the HDPCF is commitment to holding meetings by both parties at agreed times.
This commitment will start with both parties signing the updated terms of reference.

The TOR include a section on self-evaluation, which can be used as one of the factors of ensuring that the meetings do not fail.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 46 3.6.2 Health Development Partners Coordination Group (HDPCG) Development partners working in the health sector have their donor coordination forum: the Health Development Partners Coordination Group (HDPCG).

The Health Development Partners Coordination Group is an internal arrangement for development partners where they meet on their own.
The Health Development Partners Coordination was established in recognition of the need for better information sharing and coordination of efforts among donors and development partners in the health sector to avoid duplication.

The HDPCG has had regular meetings.


3.6.3 MOHCC Sector Technical Working Group (MOHCC SWG) The Ministry of Health and Child Care shall operationalize the new Government of Zimbabwe Development Policy of 2019 by establishing the Ministry of Health and Child Care Sector Technical Working Group (MOHCC SWG) (25).

The MOHCC SWG will serve as a national MOHCC focal point for coordination and information exchange between the MOHCC and partners on health sector priorities, gaps and support required.
It is a forum for ensuring transparent discussions on all support (domestic and external) required for the health sector so that overlaps can be minimised and the financing of priority activities can be negotiated in a comprehensive and coordinated manner.

The forum also helps in reducing the number of individual meetings with partners.
The main objective of the MOHCC SWG is to ensure convergence of the support and assistance to the health sector; and aligning and harmonizing the different approaches of providing that support and assistance.

The responsibilities and membership of the MOHCC SWG are summarized in Table 4.

The Permanent Secretary will chair the quarterly MOHCC SWG meeting.
The Sector Technical Working Group will get input from the several committees set up by the MOHCC, Joint Review Missions, ministries and agencies, NGOs and the private sectors with health-related activities.

The Sector Technical Working Group will, therefore, provide overall coordination of all committees and TWGs in the health sector.
After careful analysis of inputs from committees, the MOHCC SWG will prepare a short report with recommendations for the Health Development Partners Coordination Forum for consideration and finalization The Sector Technical Working Group will schedule one of its meetings just before the high-level Health Development Partners Coordination Forum meeting chaired by the Minister.
To ensure that there is regular high-level contact between the MOHCC and development partners, the Secretary for Health and Child Care will share the proceedings of the MOHCC SWG with the HDPCF members quarterly.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 47 At provincial and district levels, partners are coordinated through the PHT and DHT meetings.

3.6.4 Public-Private Partnership committees that coordinate work with the private sector.
Public-Private Partnership is the collaboration between the public and private sector organizations where there is pooling of resources (financial, human, technical and information) from public and private sources to achieve a commonly agreed social goal.

Public-Private Partnership (PPP) in the health sector has been in existence, but in a more uncoordinated environment due to lack of properly defined policy, regulation and guidelines.
Examples of private-public collaboration include the “adoption” of wards in hospitals to improve service provision.

The provision of services, such as laboratory, radiography, security and laundry, are being provided with the involvement of and cooperation with the private sector operators.

There is, therefore, need for a more formalized Health Sector PPP structure and this will start by having a Public-Private Partnership Coordinating Committee.
The functions of Public-Private Partnership Committee (adapted from the Zimbabwe Joint Ventures Act Chapter 22:223) (26) shall be: • Adapt Joint Venture Act to make it applicable to public-private partnerships in the health sector • Assist MOHCC formulate health policy, strategy and implementation guidelines on public partnerships in the health sector.
• Ensure that all public-private partnerships ventures in the health sector are consistent with national priorities • Make recommendations to Ministry to approve or reject project proposals submitted • Develop a database on the private sector partners in the health sector • Monitor the public-private partnership and its contribution to the Health sector • Propose financing mechanisms for the partnership • Submit monthly, quarterly and annual reports The policy and strategy guidelines will define the governance and management structures for the health sector public private partnership.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 48 3.6.5 Recommended action points to strengthen Partner Coordination • MOHCC and Health Development partners shall commit to convene HDPCF meetings at least biannual.

• Minister of Health and Child Care and Health Development partners shall sign the updated HDPCF terms of reference.
• The HDPCF and Sector Working group shall conduct annual self-evaluation • The Sector Working group shall hold quarterly meetings and submit reports to the HDCPF.

• There shall be an annual calendar of HDPCF and Sector working group meeting • Establish a health sector Public-Private Partnership structure and regulations The proposed Health Sector Coordination Framework is summarized in Figure 6.

The terms of reference of key committees that feed into this framework are annexed.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 49 Figure 6: Consolidated Health Sector Partner Coordination Structure Minister of Health monthly meeting with PS & CDs Secretary for Health Bi-monthly meetings Biannual HDPCF partners’ meeting with Minister Internal HDPCG meeting of DP on their own DP individual organization HIGH-LEVEL TECHNICAL SECTOR WORKING GROUP (PS as Chair, CD, Senior Level DP, ICD, OPC, MDAs Representative from CSO, Pvt, NGOs, FBO, Academia etc.)
(Quarterly) DP SWG Working group PS, CEO & CD Forum National Planning and Review (MODO) Forum Cabinet Committee on Development Cooperation Oversight 1.

Audit General 2.

Parliament Portfolio Committee 3.

HSB 4.

Advisory Board of Public Health 5.

HPA 6.

JRM Reports 7.

Others Subnational committee Central Hospital PHT, DHTs, Health Centre Specialized committees a.

Human Resources Taskforce b.


Health Financing for UHC Committee c. Medicines and Medical supplies committee d .Health Systems Research committee e. Public Private Partnerships f. Budget committees Others National committees a.
Family Health committee b. M&E and HIS committee c. EDC committee Other committees MOHCC internal reporting: Linkages: Partner reporting line starting from TWG: Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 50 In summary, health sector co-ordination will consist of the following interactions: 1.

Most of the coordination work will be done in committees represented by the RED outlined boxes.

2.
2.

Technical policy analysis and review recommendations will be done in the Secretary for Health and Child Care internal meetings and the High –level Health Sector Working Group represented by BLACK outlined boxes 3.

Ministry of Health policy decisions and health sector strategic direction will be done by the Minister’s meeting represented by the GREEN outlined boxes 4.
MOHCC stakeholders/partners discuss and agree among themselves on policy advice they will give to the MOHCC including health sector priorities for programmes and projects they will support.

Health stakeholders/partners are represented by the BROWN outlined boxes 5.

Sources of information, advice and partly health sector oversight functions are represented by the YELLOW box.

6.

The BLUE box represent linkage with central Government that result in overall national policy decisions.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 04| 4.

Making It Happen: Strengthening Existing Coordination Mechanisms 51 Coordination of effort, plans, activities and finances from the several stakeholders contributing to improving the health of the nation helps to improve the efficiency of operations by avoiding overlapping efforts and duplication of work.
The MOHCC has several uncoordinated mechanisms that directly and indirectly facilitate health sector coordination.

However, the MOHCC does not have one specific document capturing existing coordination mechanisms.

This section of the document describes the existing coordination mechanisms that are in use to facilitate coordination and suggestions for improving or strengthening the mechanisms.

Most of the issues raised and proposals made, in this section are not new.
The challenge is translating the good practices in the Ministry into action and ensuring compliance.

Part of the answer lies in having strong leadership at the highest level that will ensure implementation and compliance to existing and new good practices.

Integrated Results-Based Management and MODO meetings 4.1 Coordination brings different stakeholders to plan, implement, monitor and work together towards an agreed result or outcome.
The major tool for coordinated planning and budgeting, monitoring and evaluation of health sector activities is the Government of Zimbabwe Integrated Results-Based Management (IRBM) (9) system.

The IRBM process integrates budgeting, human resource development and planning with a transparent measurement framework.
The components of the IRBM system are: • Integrated Development Planning; • Results based Budgeting, • Personal Performance, • Monitoring and Evaluation, • Management Information and Decision Support System.

The review and development of the MOHCC National Health Strategy and the annual MOHCC and Donor Planning and Review meetings (MODO) are part of the IRBM process.
The National MOHCC and Donor Review and Planning Forum (MODO) is an integrated planning and review meeting, usually held biannually and chaired by the Secretary for Health and Child Care.

The MODO is a platform for reviewing and planning all activities in the health sector supported by both the Government of Zimbabwe and development partners’ resources.

The forum brings together all discussions and recommendations that would have taken place in the different programmes in the MOHCC.
The MODO provides a forum through which the programming of all resources – domestic and Ministry of Health & Child Care Republic of Zimbabwe 52 external – are discussed transparently so that overlaps can be minimised and the financing of priority activities can be discussed and agreed in a comprehensive and coordinated manner.
All Ministry departments, relevant Ministries that work with the MOHCC especially the Ministry of Finance, NGOs, Faith-Based Organizations and representatives of development partners, attend the forum.

It, therefore, serves also as an intra-ministerial, Inter-sectorial and health partners’ coordination mechanism.
The products of the MODO are: • A national picture on the implementation progress report of the past twelve months; • A list of expected national outputs for the next twelve months (or Annual Strategic Plan); • Indication of available funding for activities to be undertaken (GOZ and partner funding) Based on the MODO outputs the MOHCC develops the Ministerial Integrated Performance Agreement (MIPA) (9) out of which departments and central hospitals develop Departmental Integrated Performance Agreement (DIPA) and Hospital Integrated Performance Agreement (HIPA) respectively and eventually work plans.
It is therefore imperative that every ministry official be communicated and made aware of the why and how IRBM is conducted.

Going forward, IRBM responsibilities shall be included in the individual performance agreements of all managers of the MOHCC at all levels (national, provincial, district and clinic levels).
Vertical disease control programs have in the past held their review and planning meetings as dictated by funding principles, even after doing the same at the MODO thereby creating competing priorities for implementers.

This, in some cases, has led to incoherence between national and operational plans.

The sequencing of all planning and review events should be as outlined in the MOHCC Planning Circle (Figure 7).
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 53 Figure 7: MOHCC Planning Cycle May: programs and partners review previous year’s performance.

Who attends: Program staff & partners Submission of HIPAs, DIPAs & plans by departments & provinces November Production of MIPA, DIPAs, HIPAs & plans 4th week May Review previous year performance & 1st quarter of current year.
Who attends:CD, Directors, CEO, PMDs August: programs meet with partners to prepare for mid year performance report: Who attends: Program staff & partners August: Review mid year’s performance, prepare for the coming year’s budget bid plan Who attends: CDs, Directors, CEOs, PMDs October MODO Review the current year’s performance for the coming year’s plan guided by the GoZ budget indicative figures.
Who attends: MOHCC all levels and partners Going forward, program review meetings, provincial, and district and primary level review meetings shall take place before the MODO so that their results feed into the national planning and review meeting as depicted in Figure 8.

Such a process ensures the coherence of national and operational plans i.e.

what is agreed upon at the national planning and review meeting is not only what programmes but also provinces, districts and primary level facilities implement.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 54 Figure 8: Sequencing of coordinated planning and review meetings (Source: Authors) The MODO, PHT, CHT and DHT meetings are supposed to be held regularly but due to financial constraints, these planning and review meetings have been irregular.

For sustainability and regularity, there should be an MOHCC annual budget allocation for the MODO, PHT, CHT and DHT meetings.
Combining and fully implementing the IRBM approach and the three-ones principle (one national plan, one coordinating mechanism and one monitoring and evaluation mechanism) is a first and critical step in strengthening coordination in the health sector.

This, therefore, calls for training and retraining in the IRBM approach.
4.1.1 Subnational Planning and Review coordination mechanisms Provinces and districts have similar committees and meetings with features similar to those obtained at the central level, to facilitate and promote coordinated health Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 55 interventions and delivery of comprehensive integrated health care.
Intra-ministerial planning and review coordination at the subnational level is done through: • PMD/DMO daily briefing meetings • PMD/DMO Bimonthly Meetings • Departmental Meetings At the sub-national levels, inter-ministerial/inter-sectorial coordination is done through the PHT/DHT meetings, Health Centre Committee Meetings, Provincial and District subcommittees on health under the Ministry of Local Government, Public Works and National Housing (Figure 4).
At the provincial level, Provincial Health Team meetings are supposed to be held quarterly.

The purpose of these meetings is to review the performance of the province by the district and to make plans for the next implementation phase whilst addressing causes of failure in the previous period or using best practices from the meeting to improve other districts.
The meetings are supposed to be attended by the Provincial Health Team led by the PMD, District Health Executive (DHE) members led by the DMO, and representatives from the Rural District Councils, missions, private sector and funding and implementing development partners in the province.
At the district level, District Health Team (DHT) meetings should be held quarterly with the DHE and teams from RHCs (both MOHCC and RDC), Executive Officer for Health from the local authority, mission representatives, private sector and funding and implementing partners in the district.

The DHT reviews the performance of the district by health facility and the findings inform the next planning and implementation cycle.
Central Hospitals are supposed to have regular Hospital Executive and Central Hospital Planning & Review meetings (CHT) led by the Chief Executive officer.

4.1.2 Recommended action points to strengthen the Integrated Results-Based Management (IRBM) approach: • Ministry stakeholders shall adhere to the MOHCC Planning Cycle.
• There shall be an annual calendar of DHT, PHT, (CHT) and MODO meetings that shall be shared with MDAs and partners • DHT, PHT, CHT and MODO meetings shall include relevant MDAs and both internal and external partners • IRBM responsibilities shall be included in the individual performance agreements Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 56 of all managers of the MOHCC at all levels (national, provincial, district and clinic levels).
• All managers and subordinates in the MOHCC shall be trained/retrained in the IRBM processes and team building approaches.

• IRBM shall be strengthened at all levels • The MOHCC shall set aside funds for the MODO, PHT, CHT and DHT meetings.

• The secretariat for the MODO, PHT, CHT and DHT meetings shall be capacitated to strengthen their skills in managing such meetings.

• MOHCC shall seek opportunities to participate in relevant non-health sector planning, implementation and review processes.
• MOHCC shall involve stakeholders at the planning and concept development stages and not at final stages of policy or strategy development.

4.2 Steering Committees and Technical Working Groups The MOHCC conducts most of its coordination business through committees, programme/department-specific meetings, technical working groups and task forces (all together covered as Committee).

The composition of such committees varies and can include other ministries, NGOs, development partners etc.
depending on the subject matter assigned to the committee.

Committees are established to conduct in-depth research, discussion, and analyses of policy, strategic and programmatic issues that are relevant to each group’s mandate.

Committees will when necessary, set up taskforces to investigate specific issues and propose recommendations for consideration by its committees.

It is expected that a task force will be disbanded once it completes the work it was set up to do.
Departmental/Technical Committees are answerable and report (through the director responsible for the subject area) to their respective divisional heads (Chief Directors) who in turn report to the Secretary for Health and Child Care.

The Secretary for Health and Child Care after analysis and input, in turn, advises the Minister.

Figure 9 shows the committee reporting lines.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 57 Figure 9: Schematic presentation of Technical committee reporting lines and linkages Technical Committees & TWG reporting lines and linkages Cabinet Minister for Health & Child Care Policy announcements y r a t e r c e S f e i h C Secretary for Health & Child Care HDPCF where Stakeholders are informed of MOHCC policy Stakeholder own Organization HDPCG own meeting Stakeholder’s representative report back to own Organization Chief Director Technical committee inclusive stakeholder representation Each committee might have a TWG/Taskforce for in-depth discussion & analysis of specific issues Internal MOHCC Reporting or Internal communication channel Stakeholder representative in TWG reports to own organization or Stakeholder communication channel Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 58 The representatives of other Ministries or organizations that are members of the Technical Committees report to their respective organizations on the deliberations and decisions made during meetings.
Through this process, the Minister of Health and Child Care and the head of the organization providing support to the MOHCC have the same information provided through their respective channels (see communication channels in Figure 9).

The Minister of Health and Child Care and the head of the organization that is supporting the MOHCC meet in the apex Health Development Partners Coordination forum to jointly share opinions on the progress of the support given to the MOHCC.
Ideally, it is after this joint meeting that the Minister can make a pronouncement on the status of the support given to the MOHCC.

A rapid review of the Technical Working Group’s Terms of Reference (TORs) conducted between the first and second week of March 2019 revealed that there is neither a standardised TORs template for TWGs nor are there clear reporting lines and linkages between the TWG and the MOHCC policymaking body.
Most TORS do not have a monitoring and evaluation system, a code of conduct, an explicit decision-making process and neither do they mention how long meetings are supposed to last and when TORs are supposed to be reviewed.

Whilst a good number of Technical committees and TWG exist, they are not aware that they are an important mechanism of strengthening coordination within the MOHCC itself and between the MOHCC and Development Partners.
Going forward, all committees should have their terms of reference revised and updated in terms of their specific roles, mandates and decision-making powers to ensure a common understanding.

The proposed MOHCC Template for TWG TORs (Annex 3) will be used to revise and update committees’ TORs.
4.2.1 Crosscutting guidelines for governance and management of committees; meetings and workshops To get maximum benefit from committee activities (27), the following shall apply: • Terms of Reference shall guide committee activities (see proposed generic TWG template).

• Committees shall facilitate open dialogue and informed by an agreed code of conduct.
• The appointed chairperson needs to be fully committed, with authority and be able to deal with matters arising on the spot as well as to guide discussions smoothly Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 59 • Committee members shall be:- o Well-informed, technically or substantively competent, and o Appropriate high-level department/stakeholder organization representatives mandated to represent the views of their department/organization and who can provide required information and facilitate follow-up action within their own department/organization.
• Committee members shall bring information and knowledge from their respective offices and communicate back for dissemination and decision on any recommendations or suggestions made during meetings, as well report back on actions taken.

Likewise, stakeholder representatives at committee meetings need to bring all information about ongoing and proposed programmes they support; they should also disseminate deliberations and decisions of the committees to other members of the organizations they represent.
• The focus of committees shall be to achieve (directly or indirectly) the goals and targets of the National Health Strategy (NHS).
Therefore, the committee Terms of Reference shall be linked to the NHS through the identification of NHS strategies, priorities and indicators that fall within the remit of the committee and must have identifiable substantive targets that the committee will help achieve through its work; • Discussions in committees shall always have in mind ways of strengthening coordination in the health sector.
• Committees shall provide regular reports on their activities • Committees shall self-evaluate and allow themselves to be independently evaluated.

• The roles and responsibilities of existing committees shall be reviewed to combine those that have duplicating roles and if not efficient, be improved upon or otherwise be disbanded.
• Committees shall be oriented on how to organize and manage their business • Revised terms of reference of committees shall be shared with all levels of care 4.2.1.1 Guidelines for governance and management of meetings Meetings are the most commonly used mechanism for coordinating activities.

They are a good example of horizontal coordination as they facilitate information sharing across departments.
During meetings heads of departments or programmes report Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 60 on the work underway, difficulties being encountered, support needed and plans.
The purpose of the meetings is sharing information on one’s departmental or programmes activities intending to reduce duplication and align activities with other departments where possible; getting ideas to improve one’s activities; solving problems; coordinating plans etc.

The way meetings are being managed is a big “untold” challenge in the MOHCC.
To be politically correct and be seen attending all meetings, some officers have come up with what one can call “meeting survival tactics” a situation where the “Body” is physically in the meeting but “Mind” is somewhere else.

The main challenge of meetings includes spending an inordinate amount of time in the meeting; limited participation of relevant members; meetings spending more time on administrative issues; action points not being followed up etc.
The following is proposed for effective meetings (28, 29): • Having a clearly understood and agreed-upon purpose of the meeting.

Meetings should always be contributing to the goal of the MOHCC.

• Being clear about who should attend the meeting and how they can benefit from as well as contribute to the meeting’s goals.

• Having the agenda distributed to the attendees at least 24 hours before the start of the meeting so that everyone is given time to prepare.
If it is, a regular meeting, such as a weekly meeting, create an agenda template that will be used each week.

Mail or e-mail it with the minutes of the previous meeting.

(Minutes shall be produced and distributed within 48 hours after the meeting) • Reviewing the agenda at the beginning of the meeting, and making any changes (allocate time for each agenda item).

• Starting on Time, Finishing on Time (Sticking to the agreed-upon timeframe.

Meetings should be not more than two hours).


• Review the minutes and action items from the previous meeting.

Get a progress report on each action item from the person responsible for it • Ban or control use of personal networking technology during meetings • Establishing Ground Rules for Meetings including a decision-making process.

(Voting?

Consensus?

Majority rules?

When to “sleep on it”?).


• Clarifying action items - At the end of the meeting, the person recording the minutes should read off the action items including who is responsible for each item and any Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 61 deadline associated with that item.
• Regularly evaluating meeting processes 4.2.1.2 Guidelines for governance and management of workshops The MOHCC has a document on “Guidelines for Conducting Workshops/Training Programmes” (30) which provides processes to be followed when organizing and managing training workshops.

Key issues in the guidelines include: • All training/workshops which are to be conducted during a particular year should be in the approved annual training/workshop plan.
• The annual training plan/workshop plan should be in the approved MIPA.

HIPA and DIPA.

• All departments should be aware of training activities that shall take place during the year.

• The approved annual training plan should be split into quarterly plans for that year.

• The quarterly plan should be shared after approval by the departmental or unit head of the programme organizing a training.
The sharing of training plans is meant to facilitate the integration of training activities across departments The amount of time officers spend in workshops per month/year has been a cause of great concern.

There might be need to consider developing guidelines on how much time officers should spend out of office or away from work station attending meetings and workshops.
4.3 Integrated Supportive Supervision (ISS) visits Integrated Supportive and Supervision (ISS) visits are an excellent mechanism for coordinating MOHCC activities.

The MOHCC Care has an Integrated Supportive and Supervision guideline (31) but operationalizing it has been a challenge.

Some programs have continued implementing vertical program based supportive supervision on the pretext that a more detailed program-specific supervision is required.
Of concern is the fact that the supervision of activities at the primary care level is carried out by national program officers instead of letting the provinces conduct the exercise.

The same scenario applies to monitoring activities.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 62 The action points for Integrated Supportive and Supervision are linked to Joint Review Missions.
4.4 Joint Review Missions (JRM) The purpose of JRM is for the MOHCC and partners to go into the field and experience the situation on the ground and see the work that is being done with the resources that are being injected into the system by MOHCC development partners.

Of note is that JRMs have been fragmented along project lines e.g.

HDF, RBF, CCM, Parliament, etc.

although it is invariably the same people from MOHCC who are part of these visits.
The good practice that has been started by the CCM and HDF to have combined meetings and JRMs should be continued.

It is important and progressive for other development partners to join the JRM even if they may continue with their programmatic JRMs.

It is also important that the JRM be conceptualized as a mechanism for review of the whole system, and not as a way of validating or invalidating success or failure of programs or projects.
4.4.1 Recommended action points to strengthen Integrated Supportive Supervision and Joint Review Missions: • There shall be a calendar for Integrated Supportive Supervision (ISS) visits, Integrated M&E visits and Joint Review Missions (JRM) at the beginning of each year.

• Chief Directors shall facilitate joint supportive supervision visits, joint monitoring and evaluation activities and Joint Review Mission visits.
• MOHCC shall set aside funds for Integrated Supportive Supervision (ISS) visits, Integrated M&E visits and Joint Review Missions (JRM).. • The good practice started by the CCM and HDF to have combined meetings and JRMs should be continued • JRM should be conceptualized as a mechanism for reviewing the whole system, and not as a way of validating or invalidating success or failure of programs or projects.
• Budgets for Integrated Supportive Supervision (ISS) visits, Integrated M&E visits and Joint Review Missions (JRM) should cover the costs of officers at the operational levels.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 63 4.5 Memorandum of Understanding (MOU), Grant Agreements & Contracts The MOHCC signs agreements with partners that clearly show priorities partners will support and, in some cases, even the geographic area of support.
All the MOUs require partners to provide regular reports to the MOHCC.

The Secretary for Health and Child Care is expected to sign performance agreements with Chief Directors, Provincial Medical Directors and Central Hospital Chief Directors.

Chief Directors, Provincial Medical Directors and Central Hospital Chief Directors are expected to sign work plan agreements with their subordinates.
The challenges with MOUs and Contracts include: • Absence of effective institutionalized monitoring and evaluation of signed MOUs; • The absence of an SOP document for MOUs that would include indications as to how long it takes to have an MOU prepared and finalized • Inadequate subnational level consultation in planning and decision making for areas that will be supported by development partners in their respective areas (Partners come with already signed MOUs to subnational levels) • Within the MOHCC, performance contracts are not being implemented as planned.
4.5.1 Recommended action points to strengthen Memorandum of Understanding, Grant Agreements and Contracts • Contracts, Memoranda of Understanding & Grant agreements shall be aligned to National and Ministry strategic documents • CEOs, PMDs and DMOs should be involved in finalizing MOUs that will be applicable to their area of jurisdiction • Deliverables in the MOUs will be monitored on an annual basis • MOUs will be renewed based on meeting agreed performance indicators.
To that end, CEOs, PMDs and DMOs shall submit reports on the performance of partners operating in their areas.

• Memoranda of understanding will be reviewed or updated when the players and/ or the context changes.
• Simplified MOU SOPs will be developed • Secretary for Health and Child Care shall sign performance contracts with Chief Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 64 Directors, Provincial Medical Directors and Central Hospital Chief Directors latest beginning of each year.

• Chief Directors shall ensure that all staff have signed work plans and submit regular reports.
This will strengthen the accountability process within the MOHCC 4.6 Events Management Systems To improve both internal and external MOHCC coordination, an events management system was developed as a coordinating mechanism aimed at reducing competing priorities that require the same people to attend.

If fully implemented, the Events Management System will have a significant impact on creating internal efficiencies, enabling re-direction of resources to actual operational issues.
The Ministry of Finance and Economic Development will be installing a web-based Development Projects Management Information System (DEVPROMIS) to improve information sharing between the State, Development Partners and CSOs.

This will address concerns over accountability, duplication and overlaps in the implementation of programmes and projects.
Both the MOHCC and Health Development partners as per requirement will designate at least one focal person to work closely with the International Cooperation Department in the Ministry of Finance and Economic Development to feed information onto DEVPROMIS.

Linked to both Events Management System and the DEVPROMIS is the MOHCC website that needs strengthening.

The MOHCC website can be used to share information on policies, guidelines, ongoing studies etc.
4.6.1 Recommended action points to strengthen Events Management Systems • The Division of Policy, Planning, Monitoring and Evaluation shall mobilize resources to operationalize the Events Management System • The MOHCC shall appoint/designate an officer to feed into the DEVPROMIS • Guidelines for Event Management System, DEVPROMIS and the MOHCC website shall be developed and shared with stakeholders.
• MOHCC shall re-introduce a simple weekly/monthly calendaring system as a mechanism for coordinating national level activities whilst waiting for the opera- tionalization of the Event Management system.

4.7 Health Information and Monitoring and Evaluation Systems Health information requirements by the different programmes in the MOHCC are another example of the need for coordination within the health sector.
A primary care facility Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 65 has to contend with over 40 registers for different programs, and today some clinics have to also deal with different mobile applications to satisfy the needs of different stakeholders.
Even more depressing is that not all of the information being collected by the primary level whether paper-based or digital flows into a single data platform that can provide holistic information to health managers in the system.

Currently, there are different versions of the DHIS2 being used by different partners.

MOHCC has a Performance Monitoring and Evaluation department with only two positions that of Director and Deputy Director.
Some MOHCC programs each have donor-funded M&E officers who conduct their business independently from the official MOHCC department responsible for monitoring and evaluation.

There is a need to have all M&E officers operating under the Performance Monitoring and Evaluation department, which can then assign responsibilities to officers to deal with specific program requirements.
4.7.1 Recommended action points to strengthen Health Information, Monitoring, and Evaluation Systems • All stakeholders supporting the MOHCC are expected to use the MOHCC Health Information System • All stakeholder supporting the MOHCC are expected to use the MOHCC Performance Monitoring and Evaluation System.

• All officers dealing with health information or monitoring, and evaluation shall fall under the respective official MOHCC department.
• MOHCC should rationalize the various electronic information systems being used by different programmes 4.8 Reporting health sector events According to the Zimbabwe National Monitoring and Evaluation Policy (2015) (32), all Government departments are required to submit regular reports.

While well-written reports of high quality are submitted on time to donors, this is not the same with official MOHCC reports.
It is a struggle to get departments to submit reports and if they do come the quality of the reports is substandard.

Linked to reports, are the different studies and strategic documents produced by the different departments in the MOHCC.

All reports, studies and strategic documents are supposed to be submitted for archiving to the MOHCC library through the Policy and Planning, Monitoring and Evaluation division.

The MOHCC library does not have most of the documents produced in the ministry.
Most hospitals have committees to approve studies and researches to be conducted in their institutions.

Such a committee does not exist at the national level resulting in Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 66 studies or researches that could be combined being conducted in a fragmented manner.

4.8.1 Recommended action points to strengthen reporting health sector events: • Ensure timely submission of reports.
(“Timely report submission” shall be included in the individual performance agreements of all managers of the MOHCC at all levels (national, provincial, district and clinic levels).

• Ensure that studies and researches conducted within the MOHCC are archived in the ministry library and website.

• A committee to review all studies and researches in the MOHCC should be set up.
This role can be given to the National Institute of Health Research (NIHR) as chair of a proposed Health Systems Research and Innovations Committee.

After approval, researches and studies should be referred to the MRCZ if necessary.

4.9 Strengthening service delivery coordination All the efforts of strengthening health sector coordination are aimed at ensuring effective and efficient service delivery by ensuring that all resources are directed to patients/clients.
The delivery of health services is the immediate output of all inputs into a health system.

The most important component of the health delivery system is the interaction between the service provider and the patient/client.

Health services can be delivered to patients/clients via specific delivery modes, channels or platforms (33) depending on the severity or complexity of the presenting condition/disease.
A platform is the level of a health system at which interventions can be appropriately, effectively, and efficiently delivered (33).

The Zimbabwe Health service delivery system is organized to function based on increasing levels of sophistication.

Each level of service delivery platform (community, clinic, district hospital and high tertiary facility) has a well-defined package of core health services.

Patients with more complex health problems are expected to be referred up the referral chain.
This referral chain needs to be well coordinated.

With this in mind, the MOHCC might want to review and align its service delivery system to strategies in the WHO Framework on integrated, people centred health services (34, 35).

4.9.1 Household/Family delivery platform.


The household/Family delivery platform encompasses all efforts by individuals, families and the community to keep themselves healthy after being empowered through health Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 67 promotion strategies or other means.
Some of the activities individuals, families and the community provide to themselves include personal hygiene; production of appropriate foodstuffs; correct feeding practices for young children and mothers; construction, protection and hygienic use of wells and toilets; and the control of insect vectors of disease (e.g.

making rubbish pits, draining stagnant water, clearing undergrowth, spraying insecticide).
The sources of information for households/family are the different MDA extension officers operating at the community level.

Ensuring a common approach and standardized messages by the several players providing health promotion information to households/families shall be the focus of coordination efforts at this level.

4.9.2 Community level delivery platform The community platform encompasses efforts to bring health care services to clients, meeting people where they live.
It includes a wide variety of delivery mechanisms.

Specific sub-platforms include the following (33): • Health outreach and campaigns (such as vaccination campaigns, mass deworming, and face-to-face health information, education, and communication) • Schools (including school health days) • Community Health Workers (Village Health Workers), who are based primarily in the community.

Community Health Workers are the key link between the organized village community and the local health services.
Their role is fundamentally promotive, educative, and preventive, mobilizing the community and the individuals for preventive health activities.

They also help in early detection of epidemics through reporting any unusual occurrences in their areas of operation.

On-going technical supervision of Community Health Workers is provided by the local staff of the rural health centres, which keep the Community Health Workers supplied with medicines and equipment at government expense.
Community Health Workers refer and encourage communities to seek treatment early from a rural health centre or clinic.

The new Zimbabwe National Community Based Health Strategy recommends the development of a standard national Community Essential Community Package of services to be provided at the community level.

This package serves as a reference point for all those that want to provide community health services.

There are other government extension workers providing services at the community level.
The various government extension workers converge at local government led local structures which if effectively and efficiently organized and managed would be excellent horizontal inter-sectorial coordination community structure.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 68 4.9.3.
Primary Health Level (Health Centre) service delivery platform This level provides the first point of contact between the community, community health workers and the formal health delivery system.

The Rural Health Centre or clinic is the most peripheral unit of the health delivery system i.e.

the Primary Care facility.

The Rural Health Centres (RHC) provide basic but comprehensive promotive, preventive, curative and rehabilitative care using the “Supermarket approach”.
Uncoordinated activities at this level are a result of lack of coordination at the national level.

The different programmes are supporting the operational levels with different processes and procedures.

Meetings that will discuss and reach consensus on joint funding arrangements, joint planning, training and standardized financial management and procurement procedures at the national level, will reduce uncoordinated activities at the primary level of care.
To that end, Chief Directors will play a crucial role in enforcing collaboration amongst the different departments/programmes under their jurisdiction through convening quarterly divisional harmonization meetings.

4.9.4.

Hospital Level Service Delivery platform The Hospital Level Service delivery platform comes in two forms: First-level hospitals and Referral and specialized (second- and third-level) hospitals.
• First-level hospitals District Hospital: A first-level hospital is a facility with the capacity to perform surgery and provide inpatient care.

Rural health centres refer patients to District hospitals (Secondary care facilities).

The district Hospital provides referral and supervisory support to the network of clinics and Rural Health Centres in the district.

They also provide comprehensive preventive and curative services.
Patients have their first contact with a medical doctor at this level, within the health delivery system.

• Referral and specialized (second- and third-level) hospitals: This platform includes general and specialist hospitals that provide secondary and tertiary services.

District hospitals refer to Provincial Hospitals (Tertiary care facilities) where patients meet a specialist.
Each provincial hospital is supposed to have specialists in Obstetrics, Surgery, Medicine, Paediatrics, Psychiatry, Ophthalmology, Pathology etc.

Each provincial hospital is supposed to have 12 general practitioners, who are supposed to manage most emergencies including caesarian sections.

The provincial hospital level provides referral support to district hospitals.

Provincial hospitals refer to Central (Quaternary) Hospitals, the more sophisticated type of services within the country.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 69 In theory, patients are required to present at the primary level first and then be progressively referred to the Secondary, Tertiary or Quaternary levels depending on the complexity of illness.

In practice, the experiences of the past decade have shown that the referral chain has broken down, with all referral hospitals replicating the work of the Primary level.
The World Health Assembly in May 2016, approved a resolution on “Strengthening integrated, people-centred health services” (34) that supports the Framework on integrated people-centred health services (IPCHS) (35).

It is recommended that the MOHCC consider adopting and adapting the Framework, since Zimbabwe was one of the countries that contributed to and supported the resolution.

4.9.5.
4.9.5.

Recommended action points to strengthen service delivery coordination • Consider adopting and adapting the WHO Framework on integrated people-centred health services • Strengthening the referral chain • Ensuring all hospitals have quality management teams.

• Regular holding of mortality meetings with special emphasis on the perinatal and maternal death audits and • Regular hospital staff meetings.

4.10.
4.10.

Strengthening communication The communication system plays a vital role in the coordination of efforts and activities within the MOHCC and outside the ministry.
There is inadequate and ineffective communication of information within the MOHCC and between MOHCC and development partners as well as the public • Programs/departments introduce new initiatives at the operational level without fully briefing other departments to avoid duplication • Internal and external trip reports are not regularly submitted and not circulated for sharing of information; • Communication channels are not being followed (Example include bypassing one’s supervisor or supervisors entertaining junior officers without knowledge of immediate supervisor; some departments negotiating directly with partners Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 70 thereby undermining the responsibility of Chief Directors) • Inadequate formal upward feedback • Inadequate sharing of information with stakeholders • Ministry does not have an overall communication strategy • Late submission of reports For communication to work well, roles and responsibilities about who has to communicate what, when and how, has to be clear.
One existing MOHCC policy announcement approach is that only the Minister of Health and Child Care and the Secretary for Health and Child Care can make health-related policy announcements.

This policy is not widely known within the MOHCC.

The policymaking process in the MOHCC has traditionally been through the bottom-up approach where issues arising at community level end up in the Secretary for Health meetings.
The Secretary for Health and Child Care Planning meeting (PS Meeting) is held weekly and is attended by all divisional and departmental heads (Directors and Chiefs).

Chief Directors present all new policy initiatives for final analysis and review in the PS Planning meeting.

The PS-Planning meeting makes recommendations to the Minister of Health and Child Care who will determine whether the policy recommendation should be amended, adopted or referred to the cabinet for further consideration.
Figure 10 depicts the ideal reporting/communication lines for Technical Committees and TWGs in the MOHCC, which however are not always complied to.
Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 71 Figure 10: Ministry of Health and Child Care Ideal Reporting Lines y r a t e r c e S f e i h C Cabinet National Policy announcement Minister of Health & Child Care Policy announcement Minister – Stakeholder Forum Secretary of Health & Child Care Chief Directors Technical Committees & TWG inclusive Stakeholder representation Provincial level and Central Hospital committees District Level committees inclusive Stakeholder representation Primary Care Facilities & Community Structures Technical Working Group – policy recommendations go through Chief Directors to the Secretary for Health and Child Care who presents to the Minister of Health and Child Care; who in turn informs stakeholders of Ministry policies Reporting line Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 72 4.10.3.Recommended action points to strengthen communication • Develop an overall MOHCC Communication strategy.
• Re-introduce the MOHCC quarterly magazine.

• Each department/unit shall have and share a weekly diary of events that includes trips to be undertaken during the month • Short updates of key divisional/department activities during weekly/monthly divisional/department meetings • All new program/department initiatives should be shared in PS meetings before implementation.
• Put in place a mechanism of ensuring all levels receive the same correct (un-doctored) information • Have a policy on the use of social media and internal email etiquette as one of the mechanisms for internal coordination • All MOHCC employees that go for both in-country and external trips, shall provide trip reports through respective Chief Directors • Ministry officials that go on foreign trips shall inform Embassies on the purpose and outcome of foreign institutions visited.
(this will facilitate follow up of issues) • Institutions that are visited shall submit reports on the value of visits 4.11.

Legal requirements There are situations where multi-sectorial action is a legal requirement or a commitment by Government to international and regional obligations.

Examples include the Public Health Act of Zimbabwe which states that “Enhancing collaboration among state and non-state actors and communities”, is one of the functions of the MOHCC.
Some international commitments require a multi-sector-al approach as one Governments sector cannot implement them.

The International Health Regulations and SDGs are a good example of such commitments requiring multi-sectorial approaches.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 73 4.11.3.
Recommended action points to strengthen implementation of international and regional commitments and country’s statutory requirements: • Health-related International and regional multi-sectorial commitments should be an output that is tracked by the Division of Policy Planning Monitoring and Evaluation.

To that end, the division shall keep a register of all Health-related International and regional multi-sector-al commitments and receive updates from respective departments.
• Each department shall identify, track and submit progress reports of health-related International and regional multi-sectorial commitments that fall within their jurisdiction.

• Departments should identify and track implementation of health-related provisions in the country’s statutes.

4.12.

Resource mapping The MOHCC, with support from partners, conducts annual Resource Mapping exercises (6, 36) as one of the strategies for tracking and coordinating resource inflows to the health sector.
In the past, the MOHCC (MOHCC) had a challenge of coordinating the activities of all partners due to a lack of visibility over planned off-budget funding flows.

To partly address this challenge, and in the spirit of promoting transparency and aid effectiveness, the MOHCC introduced an annual Resource Mapping (RM) exercise in 2015.

This exercise tracks budgets of all health sector organisations, thereby providing valuable information for the national annual budgeting process and donor allocation decisions.
It enables organizations to make evidence-based decisions to inform their budgeting process and yearly operational plans, as well as improve resource allocation by coordinating with other stakeholders and harmonizing funding and activities with MOHCC priorities.

4.12.3.

Recommended action points to strengthen Resource Mapping • Stakeholders supporting or contributing to the health of the nation are expected to comply with the requirements of Resource Mapping by providing the required information.
• Participation in the national Resource mapping exercise shall be one of the conditions to be included in MOU’s and other agreements • MOHCC shall share its experiences and if necessary help build capacity in other MDAs on Resource mapping.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 74 4.13.

Budget support Multiple funding sources to support specific disease programmes are one of the major challenges in coordinating health activities.
High fragmentation of funding pools is associated with waste of resources due to duplication of efforts and administrative costs of managing relatively small but numerous funding pools.

The Government of Zimbabwe preferred development assistance modality is the General Budget Support (GBS) and Sector Budget Support (SBS) being the second-best choice (25).

General Budget Support (GBS) is an aid to Governments that are not earmarked to specific projects or expenditure items.
It is disbursed through the Government’s financial management system including procurement, reporting and audit systems.

Currently, some of the partners supporting the MOHCC are using the pooled funding model.

The HDF is a good example of pooling of funds locally.

The Health Development Fund (HDF) brings together partners to support one common goal under the ministry leadership.

“Pooling” of funds for some entities is done at the international level.
Global Fund is a partnership between governments, civil society, the private sector and people affected by the diseases designed to accelerate the end of AIDS, tuberculosis and malaria.

Gavi, the Vaccine Alliance brings together public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s poorest countries.
The Global Health Facility (GFF) is a newcomer to funding institutions joining the existing major funders such as the Global Fund, Health Development Fund, GAVI, USG, DFID just to mention a few.

The GFF supports governments to bring together key partners in a country platform that focuses on prioritizing high-impact and underinvested areas of reproductive, maternal, new born, child and adolescent health and nutrition (RMNCAH-N), described in a country Investment Case.
It then supports the development of a prioritized health-financing plan to support the implementation of the investment case.

The Global Health Facility comes in at an opportune time as it presents an opportunity to strengthen coordination amongst funding sources.

Some funding mechanisms/institutions prefer to have a structure within a ministry to manage its resources e.g.

the PCU in the Ministry of Health and Child Care is charged with the responsibility of managing Global Funds on behalf of PS.
The establishment of one structure to manage resources from various funding institutions helps in reducing friction and fragmentation within the Ministries.

It is therefore recommended that the Ministry works towards having one structure to manage all the funding from the different Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 75 institutions such as the HDF, Gavi, GFF and GF mechanisms, under one roof and avoid establishing additional structures.
Within the Ministry there is need to clarify roles between Department of Finance and Administration and the entities managing resource mobilization & coordination of funding mechanisms.

There is also need for ministry officials, especially program officers and the partners to be fully aware of the requirements of the Ministry of Finance and Economic Development spelt out in the 2019 Development Cooperation Policy.

4.13.3.
4.13.3.

Recommended action points to strengthen budget support to the health sector • Encourage all partners to work towards General Budget Support.

• All external funding coming into the MOHCC shall reflect in the MOHCC Budget.

• Document and later audit to check if all resources given to the health sector reach the intended beneficiaries.
• All funding mechanisms fall under one fund coordinating structure • Clarify the roles of the Department of Finance and Administration and the entity managing resource mobilization & coordination of funding mechanisms.

• Operationalize the provisions in the Zimbabwe National Health Financing Policy (38, 39) Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 76 05| 5.
Implementation Modalities One of the functions of the MOHCC is the coordination of health activities.

The Division of Policy, Planning, Monitoring and Evaluation has the mandate of supporting and facilitating coordination and consolidation of planning, monitoring and implementation in the health sector.

The division will, therefore, take the lead in strengthening coordination activities in the health sector.
The capacity of the office of the Chief Director Policy Monitoring and Evaluation will be strengthened in fulfilling its role of effectively coordinating health activities.

Among the initial activities to be undertaken by the division, is to raise awareness of the importance of coordination in the health sector (both within the MOHCC, between MOHCC and MDAs and also between the MOHCC and development partners).
Government services are often cross-sectional, interlinked and complementary particularly in the areas of education, agriculture, women affairs and environment.

All the eight Government ministries that attended a stakeholder workshop on Health Sector Coordination indicated that they contribute to health development in different ways.

Eleven ministries that responded to a questionnaire on Health Sector coordination indicated that they have focal persons dealing with health issues.
The missing link seems to be a platform for Ministries to meet and discuss health development issues in a coordinated manner.

The message from the stakeholder workshop that “inter-sectorial coordination will not take off without full support from top management in the different ministries” is in line with findings in global literature on inter-sectorial/ multi-sectorial coordination.
To that end, it is proposed that the MOHCC shares the Health Sector Coordination Framework document with other Ministries and the relevant office in the Office of the President and Cabinet with the aim of working towards creating a permanent health development coordination structure and a regulatory framework to promote inter-ministerial coordination.

The ultimate goal will be to have a systematic integration of health considerations into the processes of all ministries i.e.
promoting a “Health in All Policies Approach” (40).

Strengthening health sector coordination will be achieved through implementing the action points that are listed under each coordination mechanism in this document.

The recommended action points are collated and presented as Table 5.

It is advisable to periodically review and report on the implementation progress of the action points.
Ministry of Health & Child Care Republic of Zimbabwe 77 Table 6: Action points and indicators Action Indicator (process) Intra-ministerial coordination and committees • Consider reviewing the MOHCC structure • Rationalized committees in light of changes that have taken place in the Ministry with some of the functions transferred to other MDAs.
• Reviewing and rationalizing committees based on the MOHCC structure • Reviewed MOHCC structure • Improve the efficiency and • Adherence to standardized TWG template effectiveness of committees through guideline approved use a standardized Terms of Reference template and guidelines for TWG committee • Availability of a generic orientation manual for committees • Number of committees that have updated their TOR to be in line with standardized TWG template • Adherence to crosscutting guidelines for governance and management of committees under section 4.2.1 of this document • Minutes produced within 48 hours after a meeting/ workshop • Number of committee self-evaluation reports Opportunities for strengthening multi-sectorial and inter-sectorial collaboration include • Involve of other sectors during planning • Proportion of MDAs engaged during health and budgeting meetings.
(18, 19) sector planning and budgeting sessions • MOHCC to seek for opportunities to • Number of planning and review meetings that participate in planning and budgeting MOHHC participated in meetings of other MDAs • National Advisory Board on Public Health • Operationalize the Public Health Act appointed • Annual National Consultative Forum in line with Public Health Act held Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 78 Opportunities for strengthening multi-sectorial and inter-sectorial collaboration include • MOHCC lobby OPC to put in place a • Availability of a position paper on permanent national health development determinants of health articulating their inter-sectorial collaboration platform importance and role of inter-sectorial • MOHCC will engage OPC to facilitate collaboration discussion on health determinant and • National inter-sectorial collaboration coordination in permanent secretaries’ guidelines developed party • Permanent national health development inter-sectorial platform established • Availability of a document with roles and responsibilities of each MDA in health development • Leverage on existing platforms with • Availability of a generic lecture/paper on opinion leaders such as the Annual Chiefs the health determinants and the role of the Council Conference, the Parliamentary community and MDAs for presentation to Portfolio on Health and Provincial appropriate gatherings Councils to share and advocate for health • Number of platforms identified annually and as a developmental issue.
used to promote health Partner Coordination • Minister of Health and Child Care to • Updated HDPCF terms of reference in place convene biannual Health Development and adopted Partners Coordination Forum meetings • Number of HDPCF meetings • The HDPCF and Sector Working group to • Number of MOHCC Sector Working group conduct annual self-evaluations meetings • HDPCF annual self-evaluation report • Sector Working group to convene quarterly meetings and submit reports to the HDCPF.
• Minutes of quarterly MOHCC Sector Working group meetings • Annual calendar of HDPCF and Sector working group meetings in place.

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 79 Integrated Results-Based Management (IRBM) • Annual calendar of key events such as major meetings, conferences, visits etc.
•Availability of an annual calendar for : a.DHT, PHT and MODO meetings shared with shared with MDAs and partners at the beginning of the year and reminders before start of every quarter of the year MDAs and partners b.Integrated Supportive Supervision (ISS) visits, Integrated M&E visits and Joint Review Missions (JRM) •Number of MDAs participating in DHT, PHT, CHT and MODO meetings •Number of MDAs participating in Integrated Supportive Supervision (ISS) visits, Integrated M&E visits and Joint Review Missions (JRM) •Training of managers and subordinates • Number of directors, deputy directors and in the MOHCC in the IRBM and team building approaches.
program managers trained in IRBM • A Number of directors, deputy directors and program managers trained in team building • Availability of MIPA, HIPAs, DIPAs by December each year • Performance contracts and individual work plans signed each new year • Availability of Annual performance appraisals reports for all staff • All training/workshops to be conducted • All trainings, workshops and major meetings during a particular year should be in the approved annual training/workshop plan.
• The annual training plan/workshop plan should be in the approved MIPA, HIPA and DIPA.

part of the MIPA, DIPA and Workplan • All attendees to training, workshops and major meetings approved by HOD or program manager (no hangers-on) • Annual and quarterly calendar of training, workshops and major meetings shared • MOHCC to ring fence funds for key events • Availability of funding for MODO, PHT, CHT, such as major meetings, conferences, DHT meetings visits etc.
• Availability of funding for Integrated Supportive Supervision (ISS) visits, Integrated M&E visits and Joint Review Missions (JRM) • The secretariat for the MODO, PHT.

CHT and DHT meetings shall be capacitated to strengthen their skills in managing meetings, writing reports etc.
• o o o • • Number of Secretariats capacitated in Managing meetings, workshops Report writing Resource availability (tools) Timeliness of meeting reports Quality of meeting reports Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 80 MOUs & Grant Agreements • Align all Contracts, Memoranda of • All Memoranda of Understanding & Grant Understanding & Grant agreements to National and Ministry strategic documents in consultation with relevant CEOs, PMDs and DMOs • Annual review of deliverables in existing MOUs agreements aligned to National and Ministry strategic documents • Availability of a generic Contract, Memoranda of Understanding & Grant agreement template • Number of renewed Contracts, Memoranda of Understanding & Grant based on performance reports • Develop simplified SOPs for memoranda of understanding documentation Events Management System • Improve the functionality of the MOHCC website and MOHCC twitter handle •Develop guidelines for the Events Management System and MOHCC website •Appoint DEVPROMIS Focal person to work with MOFED.
• Explore linking MOHCC Event Management System with MOFED DEVPROMIS • Functional MOHCC websites twitter handle • Number of visits to MOHCC websites • Functional Events Management System • Availability of an officer responsible for DEVPROMIS in the ministry • Availability of guidelines for Event Management System, DEVPROMIS and the MOHCC website Health Information and Monitoring and Evaluation Systems • MOHCC to facilitate use of one National Health Information, one Performance Monitoring and Evaluation System and one electronic health information system by all key stakeholders including partners.
• All officers dealing with health information or monitoring and evaluation should fall under the respective official MOHCC department.
• Number (%) of stakeholders/partners not using the National Health Information and Performance Monitoring and Evaluation System • All MOHCC facilities using the MOHCC Electronic Health Record (EHR) • All HIS officers under EDC director and assigned to program as per need • All M&E officers under M&E director and assigned to program as per need • All accounts officers under Finance and Administration director and signed to program as per need • All procurement officers under Procurement department and assigned to program as per need Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 81 Reporting health sector events •A committee to review all studies and • Availability of a standing committee to researches in the MOHCC should be set up.
approve studies, researches and surveys • A clause indicating that a report shall be submitted to the library included as part of the approval process • Number of new studies, researches and surveys captured in the MOHCC library •Have all studies and researches conducted within the MOHCC archived in the ministry library and website.
Strengthening service delivery coordination • Promote the use of the MOHCC Essential • Availability of an Essential Community Community Package of services at community level package of services • Chief Directors convene quarterly divisional meetings • Quarterly divisional meetings • Ensuring all hospitals have quality • All hospitals with quality management teams management teams.
• Regular holding of mortality meetings with special emphasis on the perinatal and maternal death audits • Frequency of Mortality meetings • Regular hospital staff meetings.

• Frequency of Hospital staff meetings • Consider adopting and adapting the WHO Framework on integrated people-centred health services • WHO Framework on integrated people-centred health services adopted and adapted to local situations Strengthening Communication • Develop an overall MOHCC Communication strategy.
• Availability of a communication strategy • MOHCC should have a policy on the • Guidelines on the use of social media and use of social media and internal email etiquette as one of the mechanisms for internal coordination internal email etiquette • All MOHCC employees that go for both • Internal and external trip reports submitted in-country and external trips, shall provide trip reports through respective Chief Directors within 48 hours • Institutions that are visited shall submit • Feedback reports from visited institutions reports on the value of visits Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 82 Legal Requirements • Division of Policy Planning Monitoring and Evaluation to track all Health-related International and regional multi-sectorial commitments • Log book or register with Health-related International and regional multi-sectorial commitments • Each department shall identify, track and submit progress reports of health-related International and regional multi-sectorial commitments that fall within their jurisdiction.
• Quarterly submission of progress report on Health-related International and regional multi-sectorial commitments • Report shared with MDAs • Departments should identify and track • List of outstanding inter-sectorial activities implementation of health-related provisions in statutes (e.g.

Public Health Act; Health Service Act).
teased out from the Public Health Act • Teased out activities followed through & report submitted Resource mapping • Participation in the national Resource mapping exercise shall be one of the conditions to be included in MOU’s and other agreements Budget Support • Providing information for Resource mapping included in Contracts, Memoranda of Understanding & Grant agreements • Encourage all partners to work towards • Proportion of partners using parallel General Budget Support, implementation structures • Reflect all external funding coming into the MOHCC in the health sector budget.
• Clarify roles of the Department of Finance and Administration and the entity managing resource mobilization & coordination of funding mechanisms • Operationalize the provisions in the Zimbabwe National Health Financing Policy (31, 32) • Proportion of development partners using the Government public financial management systems • Proportion of development partners using the Government procurement system • Proportion of development partner support coming on budget (AID recorded in MOHCC budget) • Document clarifying roles and responsibilities of the Health Financing department and the Donor Coordination Unit in the PPM&E division • Number of the Zimbabwe National Health Financing Policy recommendations implemented.
• Health sector Public Private Partnership structures and regulations established Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 83 Health Sector Coordination Framework 06| Annexes Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 84 Annex 1| List of Specialized Technical Working Groups (Committees) 1.

Budget committee 2.

Procurement and supply management committee (Medicines and medical supplied committee) 3.
Human Resources for Health Technical Working Group 4.

Health Financing for Universal Health Coverage Technical Working Group 5.

Health System Research Technical Working Group 6.

Strategic Information Technical Working Group 7.


National RMNCH-A (Reproductive Maternal Neonatal Child and Adolescent Health) Technical Working Group Ministry of Health & Child Care Republic of Zimbabwe Annex 2| Technical Working Group Terms of Reference Template 85 TECHNICAL WORKING GROUP TERMS OF REFERENCE REVIEW TOOL Review section Review questions 1.Background/context 1.1.

Does the TOR indicate the rationale behind the formulation of the TWG?

2.
2.

Membership alternates and Co-opted members 2.1 Does the TOR indicate which departments or organizations will be represented on the TWG?

2.2.

Does the TOR indicate a list of members and their alternates?

2.3.

Does the TOR indicate the method of selecting the chair and deputy?

2.4.

Does the TOR indicate the roles and responsibilities of the chair and the deputy chair?

2.5.

Does the TOR indicate the roles and responsibilities of the TWG members?

2.6.

Does the TOR mention co-opted members?

3.


Secretariat 3.1.

Does the TOR indicate who the secretariat is?

3.2.

Does the TOR specify the roles and responsibilities of the secretariat?

4.

Frequency and length of meetings 4.1.

Does the TOR specify periodicity of meetings?

• The frequency of meetings 4.2.

Does the TOR make mention of extraordinary meetings.

4.3.

Does the TOR indicate how long the meetings should last?

5.Agenda items 5.1.
5.Agenda items 5.1.

Does the TOR indicate the process of coming up with agenda items?

6.

Quorum requirements 5.2.

Does the TOR indicate who will prepare the agenda and minutes, and when will these be circulated to members?

6.1.

Does the TOR indicate the quorum requirements?


• How many members are needed for the committee meeting to go ahead and • How many members are required to be present for decision-making Ministry of Health & Child Care Republic of Zimbabwe 86 TECHNICAL WORKING GROUP TERMS OF REFERENCE REVIEW TOOL Review section Review questions 7.

Governing Principles 7.1.

Does the TOR indicate a code of conduct?

8.

Purpose of the TWG 8.1.

Does the TOR clearly articulate the purpose of the TWG?

9.
9.

Objectives of the TWG 9.1.

Does the TOR clearly articulate the objectives of the TWG?

10.Deliverables 10.1.

Does the TOR specify the deliverables of the TWG?

(Output) 11.Scope of work/ Jurisdiction 12.Governance 11.

Does the TOR indicate the bounds of responsibility and authority (Mandate) of the TWG?

12.1 Does the TOR indicate how decisions are made within the TWG?

Is it by consensus?

Two-thirds majority??

12.2.

Does the TOR indicate to whom TWG report to?

13.


Relationships with other committees 13.1 Does the TOR mention its relationships to other TWG?

14.

Reporting guidelines or Reporting lines 13.2.

Does the TOR indicate coordination mechanisms with other TWGs 14.1.

Does the TOR indicate to whom the TWG reports to?

14.2 Does the TOR indicate how the TWG reports?

14.3.

Does the TOR indicate how often the TWG reports?

15.

Communications 15.1.

Does the TOR have a mailing list?

15.2.


Does the TOR indicate the method of reporting?

15.3.

Does the TOR indicate how quickly the members of the TWG should respond?

(Timeframe for reporting) 16. Review of the Terms of Reference 16.1.

Does the TOR make mention of the amendment, modification or variation of the TOR?

16.2.

Does the TOR indicate how often the terms of reference will be reviewed and updated if needed?

17.

Structure and Institutional arrangements 17.1.


Does the TOR indicate how the TWG fits into the ministry’s organization structure?

17.2.

Does the TWG function under the MOHCC or other entity?

Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 87 TECHNICAL WORKING GROUP TERMS OF REFERENCE REVIEW TOOL Review section Review questions 18.

Administrative arrangements 19.

Evaluation/Key Performance Indicators 20.

Accountability 18.1.


Does the TOR indicate administrative arrangements?

(transport allowance, accommodation etc) 19.1 Does the TWG have an M&E framework?

• • How the TWG will self-evaluate and how often How the TWG will follow up its recommendations 20.1 Does the TWG TOR have evidence that senior management approved its existence?
• management will sign The terms of reference should have a section where senior Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 88 07| 7.

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Zimbabwe Inter-Censal Demographic Survey (ICDS) report 2017 2.

National Health Strategy for Zimbabwe, 2016 – 2020: Equity and Quality in 3.

4.
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“Capacity Development Resource Guide: Multi-sectorial Coordination.” Washington, DC: Futures Group, Health Policy Project.

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Ministry of Health and Child Care - Health Sector Resource Mapping Report 2018 7.

8.

Public Health Act of Zimbabwe [CHAPTER 15:171 Zimbabwe Health Sector Performance Monitoring and Evaluation Policy Guidelines and Strategy (MOHCC 2018), 9.

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Declaration of Alma-Ata: https://www.who.int/publications/almaata_ declaration_en.pdf 16.

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County Health Rankings Key Findings 2019.

20.


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NAM Perspectives.

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https://nam.edu/social-determinants-of-health-101-for- health-care-five-plus-five.

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Global action on the social determinants of health.

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MOHCC – Structure, Organization and Functions of District Health Services in the Midlands Province 1994 24.

MOHCC – Structure, Organization and Functions of Provincial Health Services in the Midlands Province 1994 25.

Zimbabwe Development Cooperation Policy Procedures Manual 26.

Zimbabwe Joint Ventures Act {Chapter 22:223) 27.


The Government-Donor Coordination Committee (GDCC) and Technical Working Groups (TWGs) in Cambodia - Kingdom Of Cambodia 28.

Carter McNamara - Basic Guide to Conducting Effective Meetings 29.

Planning Basics: A Guide for Developing Community Long-term Care Options - Section IV Managing Meetings 30.

Ministry of Health and Child Care “Guidelines for Conducting Workshops/ Training Programmes 31.
Ministry of Health and Child Care Integrated Supportive Supervision Standard Operating Procedure (SOP) 32.

Government of Zimbabwe National Monitoring and Evaluation Policy 33.

Jamison, D. T., H. Gelband, S. Horton, P. Jha, R. Laxminarayan, C. N. Mock, and R. Nugent, editors.

2018.

Disease Control Priorities: Improving Health and Reducing Poverty.

Disease Control Priorities (third edition), Volume 9.

Washington, DC: World Bank.

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WHA69.24 Strengthening integrated people-centred health services 35. WHO Framework on integrated people-centred health services ;https://www.

who.int/servicedeliverysafety/areas/people-centred-care/framework/en Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector 90 36.

Ministry of Health and Child Care Health Sector Resource Mapping Report 2016 37.
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WHO, Government of South Australia, Adelaide 2010.

41.

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Republic of Uganda – Ministry of Health- Guidelines for Governance and Management Structures – January 2013 Ministry of Health & Child Care Republic of ZimbabweCoordination Framework for the Health Sector