Haley Connie A, Vermund Sten H, Moyo Precious, Kipp Aaron M, Madzima Bernard, Kanyowa Trevor, Desta Teshome, Mwinga Kasonde, Brault Marie A
Vanderbilt Institute for Global Health, Departments of 2Medicine and 3Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.
University of Zimbabwe-University of California San Francisco Collaborative Research Programme, Harare, Zimbabwe.
Health Policy Plan. 2017 Jun 1;32(5):613-624. doi: 10.1093/heapol/czw162.
Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwe's critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwe's persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study.
尽管在降低全球五岁以下儿童死亡率方面取得了显著进展，但撒哈拉以南非洲大多数国家进展不足，阻碍了千年发展目标4（MDG#4）的实现，即在1990年至2015年期间将五岁以下儿童死亡率降低三分之二。关于一些非洲国家未能实现MDG#4的潜在因素的国家级评估尚未发表。由于津巴布韦在实现MDG#4方面进展相对缓慢，该国被纳入了一项四国研究，该研究考察了2000年至2013年间五岁以下儿童生存的障碍和促进因素。对国家卫生政策和战略文件的审查以及定性数据分析表明，津巴布韦卫生工作者严重短缺，专业培训和教育机会减少，这是一个首要挑战。此外，在研究期间，卫生人力不足严重限制了为孕妇和儿童提供的救生卫生服务的可及性、质量和利用。这些挑战的影响在津巴布韦持续居高不下的新生儿死亡率中最为明显，政策差距可能加剧了这种情况，这些差距未能授权助产士实施救生干预措施，并确保卫生工作人员在婴儿出生后不久进行产后家访。同样，缺乏一项授权较低级别的卫生工作者提供基于社区的肺炎治疗的国家政策，导致这种有效干预措施的覆盖率低，儿童死亡率高。津巴布韦最近开始通过全面的政策和战略来应对这些挑战，这些政策和战略旨在改善经验丰富的高级医疗人员的招聘和留用，并将基本的孕产妇、新生儿和儿童保健服务的责任转移给需要较少培训、地理分布广泛且成本效益更高的较低级别的干部和社区卫生工作者，然而，在本研究的范围和时间框架内，无法评估这些干预措施的影响。
