DOI: 10.5255/ukda-sn-857310
title: Multimorbidity and Knowledge Architectures: An Interdisciplinary Global Health Collaboration (KnowM): Qualitative Dataset, Zimbabwe (2021-2024)

description: Multimorbidity, commonly defined as the co-occurrence of two-or-more long-term conditions in one individual, has been argued to be among the greatest global health challenges of our time. Health systems remain largely organised around specialist rather than generalist knowledge, which in many African nations translates into ‘siloed’ organisation of care, fuelled by ‘vertical’ single-disease programming. Multimorbidity has recently emerged on the health agendas of many lower-income countries, including in Africa. Yet with its conceptual origins in higher-income settings the global North, its meaning and utility in lower-resource settings remains abstract.

KnowM (2021-2024) was an interdisciplinary research collaboration to characterize the meaning, significance, and transformative potential of the concept of multimorbidity within a global health context, centred on a case study of Zimbabwe. In Zimbabwe, KnowM brought together stakeholders from across the country’s health system to critically interrogate the concept of multimorbidity and co-produce a formative agenda for responding to it in this setting. The specific objectives were: to understand how multimorbidity is being defined and framed as a global health challenge; to describe concepts, experiences, and responses to multimorbidity across different spaces within Zimbabwe’s health system; and to co-produce a conceptual framework and formative agenda for responding to multimorbidity in Zimbabwe.

The study was conducted in four provinces of Zimbabwe, including Harare, Bulawayo, Mashonaland East, and Matabeleland South, to represent both urban and rural settings. Within a participatory ethnographic study design, specific research methods included a health facility survey, participant-observation, in-depth interviews, audio-visual diaries, and participatory workshops. Through this holistic, bottom-up approach, KnowM sought to push thinking beyond the single disease paradigm and to open new conceptual pathways towards more integrated systems of research, training, and care in Zimbabwe, Africa, and wider field of global health. 

The data deposited include the health facility health facility survey (n=30 surveys), in-depth interviews (n=45 transcripts), and fieldnote summaries from participant-observation and other stakeholder engagements during the study (n=23 fieldnote summaries). Data collection commenced with a survey of 30 health facilities at different levels of care, and included questions about services, staffing, and resources; about specific services and capacity related to multimorbidity, and more specific questions about care for particular non-communicable diseases (NCDs). Following the survey, participant-observation and in-depth interviews were conducted with a range of healthcare professionals in 10 facilities purposively sampled from the surveyed facilities. In parallel, we conducted interviews and audio-visual diaries with PLWMM (the latter not deposited for ethical reasons) to capture understandings, experiences, and challenges of (self-)managing multimorbidity and accessing care. To gain a perspective on multimorbidity beyond the patient and service delivery level, participant-observation and in-depth interviews were conducted with policymakers and public health practitioners, clinical academics and medical educators, health informaticians and data experts, and non-governmental organisation (NGO) representatives. Finally, participatory workshops (not deposited for ethical reasons) were held to collaboratively interpret and reflect on preliminary findings and draw out their significance and implications.

Findings suggest that multimorbidity, while a relatively new and emerging concept, revealed and amplified key tensions within the health system and wider field of global health. Participants described multimorbidity as complex, multifaceted, and rising, particularly among people living with HIV and among the elderly. However, it is currently challenging to respond to – or fully understand – due to various interconnected factors. These include disease-specific programme guidelines and monitoring and evaluation (M&E) systems; the considerably greater funding and visibility of HIV, TB and malaria compared to NCDs and mental health; and a fragmented, disenabling policy environment. While participants considered multimorbidity a meaningful and useful concept, with capacity and momentum to address multimorbidity currently concentrated within the HIV programme, there was concern that multimorbidity could itself become verticalized, undercutting its transformative potential. Participants agreed that responding to multimorbidity requires a decisive shift from vertical, disease-centred programming towards more integrated, person-centred approaches across the health system. Specific priorities included reinvigorating comprehensive chronic care at primary level; building multimorbidity into routine health information and M&E systems; fostering engagement and learning across disease programme areas; and strengthening ties between academia, policymakers, and ground-level experience to foster continuous, contextually-attuned learning.