MTR report Zimbabwe 13 September 2016 PDF

Mid Term Review report

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Acknowledgements Special gratitude goes to Sydney Machafa (HAI regional monitoring and Evaluation officer) and Marck Chikanza (CCDS Director) for guiding the whole process. Special thanks go to the enumeration team in the five districts of Zvishavane, Mutoko, Gwanda, Mberengwa, and Goromonzi for the data collection process. In Gwanda; Monalisa Nhengu, Daniel Mukonto, Cacious Ncube, James Ndebele, and Julia Phiri. In Mutoko; Melody Mack, Nyaradzai Gomwe, Willard Nyamunokora, Albert Muzanenhamo, Yanano Mugarisawa, Solomon Kanyon’o, and Lovemore Mupaza. In Zvishavane; Elias Masendu, Ngonidzashe Sharara, Progress Phiri, Idah Sumbureru, and Moreblessing Chaibva. In Goromonzi; Debrah Chiedzo Muzadzi, Moffat Kaludzu, Patience Matsuro, Patricia Nyatsanza, and Shingirai Gwatiko. In Mberengwa; Daniel Mukonto, Ngonidzashe Koke, Ngonidzashe Sharara,Tracy Mugandani, and Walter Mutenheri. Furthermore, I would also like to acknowledge with much appreciation the crucial role of Daniel Mukonto and Dexter Madawo for data entry and data analysis. Special mention goes to the report writing team of Dexter Madawo and Willard Nyamunokora, led by Lovemore Mupaza. Hands up to Moreblessing Chaibva and Nyarai Majoni for their immense contribution in editing this document. Last but not least, many thanks go to the older people, Older People Associations (OPA), Older Citizen Monitoring (OCM) groups, Ministry of Health and Child Care for the support, provision of staff to facilitate local level mobilisation of Village Health workers and various key Informants – DMO, DNO, Sister in Charge at various health facilities.

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EXECUTIVE SUMMARY Better Health for Older People in Africa (BHOPA) is a three-year programme which commenced in July 2014 and will run until June 2017. It is funded by DFID and is currently being implemented in Mozambique, Zimbabwe, Tanzania, and Ethiopia. Its overall aim is to make poor older people (OP) and their households less vulnerable to illness and worsening poverty through the provision of better access to health and care services. The programme’s overall approach has two complementary strands namely: i. A supply-side strand that seeks to increase access and availability of age-appropriate health and HIV services for older people through interventions at service and policy levels; ii. Demand-side interventions that seek to raise older people’s capacity to monitor delivery of services and policy and advocate for their rights and entitlements. It intends to reach 19 770 older people, in Zvishavane, Mutoko and Gwanda districts through a variety of services. We are half way through project implementation, hence the need for a midterm review (MTR). The major objectives of this mid-term review were to analyse and critically assess the relevance, efficiency, effectiveness, and sustainability of the BHOPA thus far. Relevance refers to the extent to which the Better Health for Older People in Africa (BHOPA) programme is suited to the priorities and policies of the target group. Efficiency on the other hand measures the outputs (qualitative and quantitative) in relation to the inputs. Programme effectiveness measures the extent to which the BHOPA programme is attaining its objectives. Sustainability is concerned with measuring whether the benefits of an activity are likely to continue after donor funding has been withdrawn. The mid-term review was conducted through a mixed approach using both quantitative and qualitative means. The research team went through a process which included fieldwork and data collection, data analysis, and report writing. A lighter version of the quantitative tool sed in other countries implementing BHOPA was administered to each of the districts using questionnaires. Few questions from the original tool were customised to suit the Zimbabwe context while others were totally dropped so that the tool could be administered within the available time and budget. The questionnaires were administered to programme beneficiaries and non-beneficiaries who acted as control group. The qualitative data was gathered through conducting key informant interviews (KIIs) and focus group discussions (FGDs) in each of the districts using purposive sampling.

Findings: Respondents to this study were aged between 56 and 98 years. Of the 245 respondents, 38.4% (94) were males and 61.6% (151) were females. Three wards in each district were randomly selected from where respondents to the quantitative tool were randomly picked. Two FGDs with OCM groups were organised in each district. The OCM groups were randomly picked from the same wards where quantitative tool respondents were selected. At least one FGD with VHW in each district was also organised from the selected communities. The bulk of respondents (43.7%) to the quantitative tool were aged between 60 and 69 years, followed by those in the 70-79 years age cohort who constituted 29.8%. One hundred and forty eighty (148) of these older persons (OP) were beneficiaries whilst the other 97 were non beneficiaries from the control group. iii

Most Older Citizen Monitoring (OCM) groups highlighted that chronic illnesses are a key area of concern. Twenty-one comma two percent (21.2%) of all OP were suffering from arthritis. Hypertension was the second most prevalent at 15.5%. Some of the chronic illnesses identified included knee problems, eye conditions, backaches and diabetes. Findings reveal that the project is on track towards meeting its ultimate target. For instance, the 2016 project milestone is to reach 58% of older people with improved access to age appropriate health and HIV services. This mid-term review indicates that 62.4% have instead benefited from this service. Older people’s Associations (OPA), OCM groups, Village Health workers (VHW) and health worker trainings were relevant, efficient, effective and sustainable. The project has demonstrated impact in several areas. However greater impact can be achieved with an improved policy environment, particularly in terms of operationalising existing policies and developing multi sectoral policies to enable access to health for OP. Elder abuse remains a common phenomenon although the project has reduced its occurrence in project sites through awareness raising. Non beneficiary OPs were the most abused standing at 37% compared to beneficiaries who stood at 28%. There has been a noticeable decrease in cases of discrimination against older women and men in health services and OP now testify of the high priority they receive at health facilities. Interaction between VHW, OCM groups and OP has increased knowledge of the specific health needs of older women and men in communities under intervention. Advocacy efforts have increased awareness amongst most OP who now understand their rights and entitlements, and are able to claim them and voice out their concerns if they cannot access them. Findings suggest an improvement in health seeking behaviour among project beneficiaries. Seventy-seven percent (77.6%) of all OP remarked that they first go to community health centres when they fall ill. However, the absence of age friendly infrastructure in several health centres is an area of concern, especially in non-programme districts. Lack of health services designated for the elderly makes it difficult for OP to access some facilities. MTR findings also indicate an increased awareness of OP rights and entitlements and positive results from this. The study has revealed that OP are financially responsible for raising grandchildren below the age of 18. Of all OP respondents, 79 females and 64 males (58.4%) were financially responsible for raising grandchildren below the age of 18 and this compares well with other studies. In addition, a significant proportion of OP (33.1%) are primary care givers of an ill family member. Despite this huge burden, 40% of OP depend on subsistence agriculture as their main source of income. OP continue to farm beyond retirement age according to this MTR. MTR findings show project impact in the form of higher satisfaction with services at local health centres. For the older people who visited a health facility in the past six months more iv

beneficiaries were very satisfied with the services they were offered than non-beneficiaries. This is attributed to the training of health professionals and level of awareness about OP rights and entitlements by concerned stakeholders.

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TABLE OF CONTENTS Acknowledgements............................................................................................................................. ii EXECUTIVE SUMMARY ........................................................................................................................... iii LIST OF TABLES ....................................................................................................................................... vi LIST OF FIGURES .................................................................................................................................... vii Acronyms ......................................................................................................................................... viii 1.

INTRODUCTION ............................................................................................................................... 1

2.

BACKGROUND TO THE STUDY......................................................................................................... 2

3.

OBJECTIVES OF THE EVALUATION.................................................... Error! Bookmark not defined.

4.

METHODOLOGY .............................................................................................................................. 5

5.

FINDINGS ......................................................................................................................................... 7

QUALITATIVE FINDINGS ........................................................................... Error! Bookmark not defined. FINDINGS FROM VHW FGD ................................................................................................................... 22 RECOMMENDATIONS ........................................................................................................................... 43 CONCLUSION............................................................................................ Error! Bookmark not defined.

LIST OF TABLES Table 1 Outputs........................................................................................ Error! Bookmark not defined. Table 2Details of KIIs and FGDs per district ......................................................................................... 5 Table 3 Number of Focus Groups administered per district................................................................... 6 Table 4 Number of quantitative tools administered by site ................................................................... 6

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LIST OF FIGURES Figure 1 Age of OP interviewed .............................................................................................................. 8 Figure 2 Marital Status of OP ................................................................... Error! Bookmark not defined. Figure 3 Level of Education of OP ............................................................ Error! Bookmark not defined. Figure 4 Health Conditions of OP ............................................................................................................ 8 Figure 5 OP Primary Caregivers .............................................................................................................. 9 Figure 6 Employment Status of OP ......................................................................................................... 9 Figure 7 Sources of Income of OP ............................................................ Error! Bookmark not defined. Figure 8 OP Abuse ................................................................................................................................. 10 Figure 9 ADA Participation by OP............................................................. Error! Bookmark not defined. Figure 10 Treatment Centre..................................................................... Error! Bookmark not defined. Figure 11 Health Status of OP ............................................................................................................... 11 Figure 12 Level of Difficulty against Beneficiary Status ........................................................................ 12 Figure 13 Ability to SeekMedical Care Alone ........................................................................................ 12 Figure 14 Access to IEC Material .............................................................. Error! Bookmark not defined. Figure 15 Improved Acessibility to Health ............................................................................................ 13 Figure 16 Affordability of Health Care ..................................................... Error! Bookmark not defined. Figure 17 Health Facility Visits ................................................................. Error! Bookmark not defined. Figure 18 Satisfaction with Services...................................................................................................... 16 Figure 19 Reasons for Dissatisfaction ................................................................................................... 16 Figure 20 Consultation Fee Payment .................................................................................................... 17 Figure 21 Access Denial............................................................................ Error! Bookmark not defined. Figure 22 Affordability of Medicines........................................................ Error! Bookmark not defined. Figure 23 Accessibility of Medicines ........................................................ Error! Bookmark not defined. Figure 24 Age Friendly Equipment ........................................................................................................ 18 Figure 25 AMTO Application Knowledge ................................................. Error! Bookmark not defined. Figure 26 HIV/AIDS Knowledge ................................................................ Error! Bookmark not defined. Figure 27 HIV Stigmatisation ................................................................................................................. 19 Figure 28 Knowledge on where to Seek HIV Treatment .......................... Error! Bookmark not defined. Figure 29 HIV Servics Ease of Access .................................................................................................... 20 Figure 30 HIV related Services .............................................................................................................. 20 Figure 31 OP visited by CHBC/VHW ......................................................... Error! Bookmark not defined. Figure 32 CHBC/VHW Helpful to OP ..................................................................................................... 20 Figure 33 Community NCD Treatment..................................................... Error! Bookmark not defined. Figure 34 Same Rights .............................................................................. Error! Bookmark not defined. Figure 35 Gender Difficulty amongst OP in getting medicine.............................................................. 21 Figure 36 Patient (Mrs Sibusisiwe Ncube) consulting the nursing sister (Doreen Rafamoyo) at Simbumbumbu Rural Health Centre, Zvishavane district. ....................... Error! Bookmark not defined.

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Acronyms ADA

Age Demand Action (campaign) Acquired Immune Deficiency Syndrome

AIDS ARV

Antiretroviral Therapy

BHOPA

Better Health for Older People in Africa (Programme)

DMO

District Medical Officer

FGD

Focus Group Discussion

HBC

Home‐based Care

HDI

Human Development Index

HIV

Human Immunodeficiency Virus

HOT

Health Outcomes Tool

IGA

Income Generating Activity

KII

Key Informant Interview

M&E

Monitoring and Evaluation

MEL

Monitoring, Evaluation and Learning

MoHCC

Ministry of Health and Child Care

NCD

Non-communicable Disease

OCM

Older Citizen Monitoring (Group)

OPA

Older People’s Association

OVC

Orphans and other Vulnerable Children

VHW

Village Health Worker

WHO

World Health Organization

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1. INTRODUCTION/ CONTEXT ANALYSIS The world’s population is ageing. Virtually every country in the world is experiencing growth in the number and proportion of older persons in their population. Population ageing, described by many scholars as the increasing share of older persons in the population, —is poised to become one of the most significant social transformations of the twenty-first century, with implications for nearly all sectors of society, including labour and financial markets, the demand for goods and services, such as housing, transportation and social protection, as well as family structures and intergenerational ties (Mary Robinson (2007). The 2002 Madrid International Plan of Action on Ageing (MIPAA) highlights the need to consider older persons in development planning, emphasizing that older persons should be able to participate in and benefit equitably from the fruits of development to advance their health and well-being, and that societies should provide enabling environments for them to do so. According to Robinson (2007) as populations become increasingly aged, it is more important than ever that governments design innovative policies and public services specifically targeted to older persons, including those addressing, inter alia, housing, employment, health care, infrastructure and social protection. According to data from World Population Prospects: the 2015 Revision (United Nations, 2015), the number of older persons—those aged 60 years or over—has increased substantially in recent years in most countries and regions, and that growth is projected to accelerate in the coming decades. Between 2015 and 2030, the number of people in the world aged 60 years or over is projected to grow by 56 per cent, from 901 million to 1.4 billion, and by 2050, the global population of older persons is projected to more than double its size in 2015, reaching nearly 2.1 billion. Over the next 15 years, the number of older persons is expected to grow fastest in Latin America and the Caribbean with a projected 71% in the population aged 60 years or over, followed by Asia (66 per cent), Africa (64 per cent), Oceania (47 per cent), Northern America (41 per cent) and Europe (23 per cent). Globally, during 2010-2015, women outlived men by an average of 4.5 years. As a result, women accounted for 54 per cent of the global population aged 60 years or over and 61 per cent of those aged 80 years or over in 2015. In the coming years, average survival of males is projected to improve and begin to catch up to that of females so that the sex balance among the oldestold persons becomes more even. The proportion of women at age 80 years or over is projected to decline to 58 per cent in 2050. The older population is growing faster in urban areas than in rural areas. At the global level between 2000 and 2015, the number of people aged 60 years or over increased by 68 % in urban areas, compared to a 25 per cent increase in rural areas. As a result, older persons are increasingly concentrated in urban areas. In 2015, 58 per cent of the world’s people aged 60 years or over resided in urban areas, up from 51 per cent in 2000. The oldest-old are even more likely to reside in urban areas: the proportion of people aged 80 years or over residing in urban areas increased from 56 per cent in 2000 to 63 per cent in 2015. 12 1

The Zimbabwe older persons’ act defines an older person as someone who is aged 65 years and above. This study adopted the UN definition which considers anyone aged 60 years and above as an older person. According to 2012 census, older people aged 60 and above constitute 5.5% of the total population. In Zimbabwe the Assisted Medical Treatment Order (AMTOS) which is meant to assist vulnerable people (older people included) access health services is run by two different ministries making it difficult for older people to understand and access. The Older Persons' Act is meant to provide a framework for the country but this is not funded. There are also no policies to operationalise it. Other policies have not been adjusted to complement it. It therefore remains just a blueprint. There also remain fundamental contradictions between the Older Persons’ Act, other Acts as well as international charters. In Zimbabwe, according to the 2012 census, 29.2% (27.7% males: 30.3% females) of older people in Zimbabwe live with disabilities compared to 4% of the general population. Disability prevalence among older persons increased by almost 50% from about 20 percent in 2002 to 29.2% in 2012, with insignificant variations by sex. The Centre for Disease Control notes that 90% of adults aged 65 and older have one chronic condition and 70 percent have two or more. Other estimates have in Zimbabwe determined that 35 percent of the population aged 65-79 have more than one chronic condition and 70 percent of adults aged 80 and older have more than one chronic condition. The core of the Better Health for Older Persons in Africa (BHOPA)programme is its concern for the health of the increasingly older population in the world today. Ensuring a more secure, healthier, and happier life for the older person is crucial to the programme.

2. BACKGROUND TO THE STUDY Better Health for Older People in Africa (BHOPA) is a three-year programme (July 2014– June 2017) funded by DFID implemented in Mozambique, Zimbabwe, Tanzania, and Ethiopia. Its overall aim is to make poor older people (OP) and their households less vulnerable to illness and worsening poverty through the provision of better access to health and care services. The World Health Organization (WHO) identifies income and social status as key determinants of health status. According to WHO research, whilst HIV and malaria are still major diseases affecting older people, projections indicate that by 2020 the largest increases in Non-Communicable Diseases (NCD) deaths will occur in Africa and that NCDs will become the most common causes of death by 2030.1 1

UK AID Match Proposal Form (2014), HAI document.

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The programme’s overall approach has two complementary strands: (1) a supply-side strand that seeks to increase access and availability of age-appropriate health and HIV services for older people through interventions at service and policy levels and (2) demand-side interventions that seek to raise older people’s capacity to monitor delivery of services and policy and advocate for their rights and entitlements. It intends to reach 19 770 older people, in Zvishavane, Mutoko and Gwanda with various services in the package. Objectives of the study: The mid-term review was geared towards analysing and critically assessing the relevance, efficiency, effectiveness, and sustainability of the Better Health Programme thus far. Relevance-The extent to which the BH programme is suited to the priorities and policies of the target group, recipient, and donor:  Is the BHOPA programme targeting the right beneficiaries and catering to their needs?  Is the project design and approach suitable for the local context in each of the countries?  Are the objectives of the programme still valid?  Are the project indicators (as defined in the log-frame) appropriate in each of the countries?  Are the activities and outputs of the programme consistent with the overall goal and the attainment of its objectives?  Are the activities and outputs of the programme consistent with the intended impacts and effects?  Are the monitoring and evaluation mechanisms appropriate at the country and regional level?  Is the choice of inputs (financial and human) appropriate in each of the countries? Efficiency- measures the outputs -- qualitative and quantitative -- in relation to the inputs.  To what extent are activities implemented as scheduled, and how economically were resources used to lead to results (simple value for money analysis)?2  Were activities cost-efficient?  How regularly and well are the country activities monitored and are corrective measures applied as necessary?  Is the monitoring and data collected accurate and of good quality, and is the information gathered used for learning?  How adequate was the baseline information?

2

This will depend on access to HelpAge financial data as well as whether other similar organizations are willing to share their data.

3

Effectiveness- A measure of the extent to which the BH programme is attaining its objectives.  

To what extent were the objectives achieved / are likely to be achieved? What were the major factors influencing the achievement or non-achievement of the objectives?  What monitoring and evaluation systems are in place for the BH programme and how effective are they?  What systems are in place for lessons learning and how it is replicated within country offices and regionally?  Are there are programmatic synergies and coordination among implementing partners within the same country, among programme offices across the four countries, as well as with the regional office? This is in light of the view that the BH programme chose the range of countries and activities so as to allow for regional learning and impact;  Did older people and other stakeholders participate in the design and implementation/monitoring of the BH programme? Sustainability- concerned with measuring whether the benefits of an activity are likely to continue after donor funding has been withdrawn.  Can the benefits of the BH programme be continued/maintained once the programme has ended in terms of policy support and capacity building measures?  Are the services being provided affordable and likely to remain so after the funding has stopped? The mid-term review therefore sought to test the progress of the programme towards realizing its broader theory of change in terms of ensuring better health and reduced poverty for older men and women in the country. This involved analysing the extent to which the programme is meeting its defined outputs and outcomes which are highlighted below: Outcome: 19770 older people (60% female, 40% male) have age –appropriate health and HIV services Output 1: Training curricula developed and 110 health staff trained on age appropriate health and HIV services Output 2: 105 care workers trained and older people receive community and home based care Output 3: Technical and policy support for greater access to social protection and health entitlement Output 4: Older people trained to monitor and advocate locally for access to health, HIV and care services and entitlement Output 5: HIV and social protection policies/strategies in Zimbabwe and within the region include recommendations made by the programme 4

In addition to assessing the current level of achievement vis-à-vis the initial goals, the midterm review sought to: 1. Identify challenges encountered in meeting the defined programme objectives; 2. Provide recommendations for change based on the assessment findings in order for the project to realize its medium and long-term outcomes and impact.

3. METHODOLOGY The mid-term review was conducted through a mixed approach using both quantitative and qualitative means. Fieldwork was conducted in Mutoko, Zvishavane, Gwanda, Mberengwa and Goromonzi. Mberengwa and Goromonzi were used as control districts. Each survey team comprised CCDS, Ministry of Health and Child Care and Island Hospice and Health care personnel. In each of the districts, both qualitative and quantitative tools were administered.

Qualitative data was gathered through conducting key informant interviews (KIIs) and focus group discussions (FGDs) in each of the five districts. Respondents of KII were identified using purposive sampling as illustrated in the table below: Table 1: Details of KIIs and FGDs

Number of KIIs Number of FGDs District Medical officers OCM groups District Nursing officers Village health workers 4 Sisters in charge of local clinics 8 12 Table 2 Details of KIIs and FGDs The aims of the KIIs were to gain perspectives from stakeholder groups who have an important role in improving access to health services for older people in the areas where the different target groups of people are likely to have specialised knowledge. CCDS were responsible for organising the KIIs with key stakeholders in the field. KIIs were held with the following stakeholders: i) District Medical Officers ii) District Nursing Officers iii) Sisters in charge of rural health centres (RHC) or clinics The aims of the FGDs, which had between six and ten participants, were to assess, from the perspective of programme beneficiaries, indicators of quality in service provision and involvement in programme design and monitoring. In addition, the FGDs aimed to obtain greater depth, detail, and voice on aspects of particular interest such as service delivery and participation. The table below summarises FGD guides which were administered to different groups:

5

OCM groups

Number of FGD guides administered per district Mutoko Zvishavane Gwanda Total 2 2 2

VHW

2

2

2

6 6

Total

12

Table 2 Number of Focus Groups administered per district

Groups of trained and active OCM members were constituted in a ward randomly selected for the study. Each group was made up of older men and women aged 60years and above. FGDs were also administered to VHWs. Groups of between 6 and 10 VHWs were drawn from the same community with OCM groups.

Quantitative data collection: The survey was conducted in Zvishavane, Mutoko, Gwanda, Mberengwa and Goromonzi and quantitative tools were administered by enumerators who do not interact with the programme. Questionnaires were administered to programme beneficiaries and non-beneficiaries who acted as control group. Table 4 below summarises the number of quantitative tools administered by site.

Male # beneficiary quantitative tool respondents

Mutoko Female 23

Beneficiaries Zvishavane Gwanda Male Female Male Female

28

15

31

16

35

Male

Total Female 54

94

40

57

94

151

None beneficiaries Goromonzi Male # non beneficiary control group quantitative tool respondents

Mberengwa

Female 20

GRAND Total

27

Male

Female 20

30

Table 3 Number of quantitative tools administered by site

Through a quantitative tool, 245 (94 Males: 151 Females) older people programme beneficiaries were interviewed to assess programme impact in terms of knowledge, attitudes, and practices, as well as its relevance, efficiency, and sustainability. Programme beneficiaries were randomly selected from programme registers kept by village health workers, community home based care givers and Older People Associations (OPA) and Older Citizen Monitoring (OCM) groups through a multi layered randomisation process. At district level wards were randomly selected, from where beneficiaries were drawn. 97(40M: 57F) non-programme beneficiaries were also randomly selected from adjacent districts of Groromonzi and Mberengwa.

Data analysis: Raw quantitative data was entered on Excel by data entry clerks and exported to SPSS for coding and analysis. Before exporting the data to SPSS, the data was sorted and cleaned for any errors in entry; however there were isolated cases owing to the experienced enumerators who collected the data. The data was coded for SPSS to be able to produce accurate analysis to support the qualitative analysis. Descriptive statistics were run to get the 6

column totals, missing entries and frequencies, to give an overview of the study results. The data was then analysed using cross tabulation, to try and infer and test if there was a relationship between the different responses and respondent’s profiles. Qualitative data was analysed at basic/ manifest level and at latent level to infer deeper meaning of responses. This was achieved by grouping common responses into various themes. These themes were then used as narrative of the findings.

Study Weaknesses/ limitations Due to old age, it was difficult for some respondents to provide specific ages. Although one could easily conclude that the respondent perfectly fell inside the age group of interest, ages remained unspecified by some older people. The tool combined a question on access to general health services with access to HIV and AIDS services. Responses purporting that there has been an improvement are contaminated by combining the two because there is significant difference between level of access to HIV and AIDS services and access to services for other general conditions of OP. Goromonzi district which was considered one of our control districts has some degree of contamination because Island Hospice and Health Care is implementing a health programme there. The only difference is that the intervention in Goromonzi is not targeted at older persons.

4. FINDINGS Respondents to this study were aged between 56 and 98years. Of the 245 respondents, 38.4% (94) were males and 61.6% (151) were females. The bulk of respondents (43.7%) were aged between 60 and 69 years, followed by those in the 70-79 years age cohort who constituted 29.8%. The number of respondents was inversely related to age. Most (50.2%) older people interviewed were widowed. This exposes surviving spouses, especially older women, to several vulnerabilities. This is exacerbated by the fact that most men are bread winners and own means of production in most households. The other respondents were married (46.1%) which comprised 38 females and 75 males. 4 females and 1 male (2%) were divorced, 1 male was engaged (0.4%) and 1 female was in a stable relationship (0.4%).

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Zimbabwe boasts of a reasonably good literacy rate. 102 females and 66 males (68.6%) of older persons interviewed had primary Level of Education school as their highest level of education. Primary school does not Percent imply that one completed primary 68.6 school. Instead it means one has been to primary school but whether or not 19.2 they completed was outside the scope 10.2 1.2 .4 of this study. 98 females and 9 males (19.2%) never went to school. Only 9 females and 16 males (10%) proceeded to secondary school while 2 females and I male (1.2%), went as far as college/University/post graduate level of education. Again, secondary school means one has gone beyond primary school. Whether secondary school education was completed or not was outside the scope of this study. A close analysis of these findings suggests that most older people in the rural areas are limited in terms of education when attempting to access formal employment. This further exposes them to financial vulnerabilities.

Figure 1 Level of Education of OP

Fi g ur e

The largest group of study participants (21.2%) made up of 34 females and 18 males were suffering from arthritis. Hypertension followed at 15.5% with 29 being females and 9 males. Eye conditions stood at 15.1% (18 females and 19 males). Osteoporosis accounted for 6.9% (11 females and 6 males) of all conditions among older persons while HIV accounted Figure 2 Health Conditions of OP

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for 8.2% (11 females and 9 males). Other conditions were COPD (4.5%) with 8 females and 3 males, hearing loss (3.7%) with 7 females and 2 males, diabetes (4.9%) had 9 females and 3 males, immobility (1.6%) with 4 females and 0 males and urinary incontinence (3.3%) with 2 females and 6 males. Cancer and mental illness were the least prevalent illnesses (0.4%).

Of all OP respondents, 79 females and 64 males (58.4%) were financially responsible for raising grandchildren Primary Caregiver (%) below the age of 18. In Primary Caregiver Not Primary Caregiver addition, 48 females and 33 males (33.1%) 41 of OP were primary care givers of an ill 25 family member. Of the 20 33.1%, 11% comprising 14 17 females and 10 males were caring for their sons/daughters, Male Female followed by those who cared for a spouse (10.2 comprising 8 females and 17 males. 5.7%, 12 females and 2 males were looking after grandchildren. 5 females (2%) were taking care of a parent and 5 females (2%) were taking care of a sister /brother. Older persons therefore constitute a significant proportion of the total population who have a primary caring role. Figure 3 OP Primary Caregivers

Most of the OPs cited farming as their major source of income (39.2%), followed by family support (28.4%), Employment status of OP private pensions Percent (12.7%), and 40.8 employment (12.7%). Other 22.4 sources constituted 16.3 13.1 the balance. 6.1 The majority of OP 1.2 (40.8%) made up of Employed Retired Subsistence Domestic Other Nill 67 females and 33 farming work males who participated in this study cited subsistence farming as their employment status. The next category was retired (22.4%) with 10 of the OP being females and 45 males. OP Figure 4 Employment Status of OP

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who retire continue to practise farming as a core business., The remainder were doing domestic work (13.1%), 29 females and 3 males or doing other unspecified jobs (16.3%). Six comma one percent (6.1%) did not specify their employment status.

31.8% (49 females and 29 male) of all OP reported that they had suffered abuse in the past six months. Non beneficiary OPs were the most abused standing at 37% compared to beneficiaries who stood at 28%. This finding demonstrates programme impact in districts where the programme is being implemented, as older persons and other community members are more aware of the subject of elder abuse and the need to discourage it. Older persons associations and OCM groups were responsible for sensitising communities on this subject. Of the OP who did not face any form of abuse on the other hand, beneficiaries had a higher percentage than non- beneficiaries at 72%. NonFigure 5 OP Abuse beneficiaries stood at 62%. Again this is attributed to increased awareness of OP abuse, through efforts by trained OCM groups. Of the 31.8% abused, the most dominant form of abuse was emotional/ verbal, which was cited by 16.7% (26 females and 15 males), followed by financial abuse and witchcraft accusations (4.5%) with 5 females and 6 males. Physical abuse (2.4%) with 5 females and 1 male and isolation (2.0%) with 4 females and 1 male followed. Sexual abuse was the least dominant (0.8%) with only 2 females. 13.9% of all OP beneficiaries were members of the older people’s association (OPA) of whom 19 were male whilst 15 were female, 7.3% of whom had participated in ADA campaigns.

Contrary to general beliefs, the bulk of OP in this study group (92.2%) visit some form of health facility compared to only 7.8% who first consult traditional/ faith healers. Within the health facility 10

Figure 6 treatment Centre

category, community health centre dominated the first port of call for OP with (77.6%) made up of 117 females and 73 males. The study also shows that more beneficiaries (87%) than non-beneficiaries (63%) go to community health centres. This can be partly explained as a programme impact where health seeking behaviours were promoted among OP. This was testified to in focus group discussions with village health workers and Older Citizen monitoring (OCM) groups where they agreed that one of their major roles is to offer health education. The package of health education includes promotion of health seeking behaviour through utilisation of local health facilities. Despite absence of drugs, OP continue to visit health facilities as an attention seeking behaviour and also as a response to the motivation from VHW and health professionals. Only 11 females and 8 males (7.8%) of all OPs said they consult traditional/ faith healers first. Of these OPs 7% were beneficiaries compared to 9% of them being non beneficiaries. 10.6% (16 females and 10 males) of the OPs posited that they first go to a district health facility. These were made up of 4% of all beneficiaries compared to 21% of all nonbeneficiaries. Of the 0.8% (2 females) who go to a provincial facility, 1 was a beneficiary. An area for further research is to establish why some OP go straight to district or provincial health facilities first against government policy to start at the lowest level.

All OPs were asked to rate their feeling on the day of the survey. Most beneficiaries (87%) were healthier in one way or the other compared to 81% of non-beneficiaries who said the same. The work of trained VHW assisted to address physical, emotional and spiritual needs of OP and contributed to the relatively superior health status of OP among programme beneficiaries. 12% of all beneficiaries claimed to be very healthy with only 11% of non-beneficiaries being in the same state. 45% of all beneficiaries were somewhat healthy compared to 36% of non-beneficiaries. 30% of beneficiaries claimed that they were healthy with 33% of non-beneficiaries saying the same. Figure 7 Health Status of OP

For the 23 females and 14 males that said they were not healthy, 13% of them were beneficiaries whilst 19% were non beneficiaries.

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Figure 8 Level of Difficulty against Beneficiary Status

Due to the Ops’ health status, it was more difficult for non-beneficiaries to do work or household activities than beneficiaries. Only 24% of beneficiaries compared to 27% of non-beneficiaries (42 females and 19 male) found it very difficult to do work or household activities. Also, only 23% of beneficiaries found it difficult compared to 35% of non-beneficiaries (48 females and 20 males). 28% of beneficiaries and 28% of non-beneficiaries (41 females and 27 males) found it slightly difficult.

It was less difficult for beneficiaries (24%) to do work or household activities compared to non-beneficiaries (9%). The BHOPA programme in Zimbabwe has lived up to its expectation of improving access to health for OP through the work of VHW in palliative care.

There is no significant difference between programme beneficiaries and non-programme beneficiaries in their ability to seek medical care alone. While 22% of all beneficiaries were not able to seek medical care alone, 21% of non-beneficiaries could not do the same. Figure 9 Ability to Seek medical care alone

Most of the older people, 76% of all beneficiaries and 79% of all nonbeneficiaries (111 females and 79 males) were capable to seeking medical care alone.

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More beneficiaries (79%) than non-beneficiaries (68%) remarked that health care and HIV services in the community have improved in the last one year. This is consistent with the programme’s objective of improving access to age friendly health and HIV services. Justifications for an assessment that health services had improved are several. Health facilities have become more accessible because of the existence and efforts by VHW and CHBC. They have been collecting drugs on behalf of patients. This has reduced defaulting rates and increased adherence as noted by some health staff. A very small percentage of beneficiaries (14%) thought that health care and HIV services did not improve at all compared to 22% of non-beneficiaries. Figure 10 Improved Accessibility to Health

Quite a significant number of the OP interviewed were of the opinion that health care has become more affordable in the last six months. A very small proportion of OP thought that health care has not become affordable. Of the OPs who thought that health care has become more affordable, most were programme beneficiaries (70%) compared to 60% of all programme non beneficiaries Figure 11 Affordability of Health Care

Factually nothing much has changed except raising awareness that OP do not have to pay. As OP demanded their right of exemption from paying consultation fees and service providers operationalising policy provisions there was meeting of minds resulting in the perception on improved affordability. Affordability has also been viewed by some OP in light of ART programmes which have been massively rolled out through support from Global Fund.

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51.4% (81 females and 45 males) of all participants stated that medication has become more affordable over the past six months. However, 40.8% (56 females and 44 males) were of the opinion that medicines have not been more affordable. More beneficiaries (55%) thought medicine has become affordable compared with 45% of all non-beneficiaries who expressed the same opinion. As in the case of general health care, nothing much from service providers has changed over the reference period in connection with affordability of medicines. Instead, the perception is driven by programme HBC kit drugs which contributed to a health system where OP do not have to pay for them. Figure 12 Affordability of Medicines

The majority of OPs 54.7% (82 females and 52 males) mentioned that medicines have become more accessible in health facilities over the past six months. 38% of OPs (56 females and 37 males) thought that medicines have not been more accessible For those who thought medicine has become more accessible, most Figure 13 Accessibility of Medicines of them were beneficiaries (57% of all beneficiaries) as compared to non-beneficiaries (51%). Responses of beneficiaries were 14

motivated by programme intervention to supply medicines in health facilities for onward transmission to VHW based in communities. Although the medicines were inadequate, they went a long way to close the existing gap.

Figure 14 Affordability of Medicines

69.4% (111 females and 59 males) of all OPs reported that they had visited a health facility in the last 6 months. Only 38 females and 30 males (27.8%) never visited a health facility in that period. There is no significant difference between level of visit by beneficiaries and non beneficiaries. A slightly higher proportion of programme beneficiaries (72% of all beneficiaries) visited a health facility in the last 6 months compared to 65% of non benefiaries. The difference can be attributed to the work of VHW who were responsible for referring OP to their nearest health facility whenever they felt there was need. One health staff member had this to say “OP are now visiting the clinic on a regular basis. The service at the clinic is now better in terms of the time they spend to be attended to. There is some change as we now see some older persons coming to the clinic just to have a routine checkup. In general, the reception at the clinic is now very welcoming for older persons as they are now served as first priority’’ More women are going for HIV, diabetes and hypertension testings. Fewer beneficiaries (25% of all beneficiaries) did not visit a health facility whilst non-beneficiaries (32%) never visited at all in that period.

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For the older people who visited a health facility in the past six months more non beneficiaries (60%) were very satisfied with the services they were offered than beneficiaries (34%). This is attributed to the level of awareness about OP rights and entitlements. OP programme beneficiaries know their rights and entitlements; hence they are not satisfied by services which do not match certain standards. However, all Figure 15 Satisfaction with Services programme beneficiaries had some level of satisfaction with services compared to non-beneficiaries, 8% of whom were not satisfied. Health staff in programme areas were trained to offer age friendly services and contributed to the positive rating of health facility services by OP. All the OPs who said they were not satisfied or not very satisfied were female non-beneficiaries, women.

Both beneficiaries and non beneficiaries had various reasons for not being satisfied with services. Programme Reason for not being satisfied beneficiaries 53 60 (53%) were more 40 50 worried about 30 40 24 30 lack of funds to 12 10 12 10 10 20 finance their 0 10 0 health needs compared to 30% of non beneficiaries. On the other hand non beneficiaries Total Beneficiaries

Figure 16 Reasons for Dissatisfaction

Total Non Beneficiaries

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(40%) were mostly concerned about the unfriendliness of services at health facilities compared to only 12% among beneficiaries. Health staff trainings successfully achieved what they were meant to. Some health facilities have reportedly displayed written notices that older people should not queue.

Fewer beneficiaries (7% of all beneficiaries) than nonbeneficiaries (16% of all non-beneficiaries) mentioned that they paid a consultation fee when they visited the health facility. Zimbabwe policy exempts all people aged 65 years and above from paying consultation fees. This figure is therefore composed of people below 17 Figure 17 Consultation Fee Payment

the age of 65. Some health centres levy all patrons of their facilityirrespective of age, a health centre development fee. This was mistaken by most OP for consultation fee. Majority of both beneficiaries (89%) and non-beneficiaries (71%) did not pay a consultation fee in line with government policy. Access to essential health services has been denied to only 4.9% (12) of the OPs with the majority (91%) never being denied access. For those who were denied access fewer of them were beneficiaries (2%) than non-beneficiaries (9%).

A very small percentage of OP (25.7%) 33 of them being females and 30 males remarked that health facilities are not better equipped for older people. However, the majority (64.1%), composed of 100 females and 57 males, mentioned that health facilities are better equipped for the elderly. For most of the OP who feel that the facilities were better equipped, most of them were beneficiaries (73%) whilst only 51% of all non-beneficiaries felt the same. During baseline study, 37% of health facilities were found to be age friendly. This contrasts with an improvement to 73% in the midterm review. The reason for the Figure 18 Age Friendly Equipment perceived improvement is that health centres were manned by trained health staff, more age friendly toilets were constructed and age friendly policies like jumping queues were operationalised, among several other changes. Fewer beneficiaries (18%) than non-beneficiaries (37%) thought that health facilities were not better equipped. Respondents in the control districts were assessing health facilities with generic provisions from government. 18

Zimbabwe has a social protection scheme for vulnerable groups, including older persons, to access medical treatment. Only 21 females and 18 males (15.9%) of the older people knew how to apply for Assisted Medical Treatment Order. 126 females and 26 males (80.8%) were unaware of the programme and how to benefit from it. Surprisingly, more beneficiaries (86%) than non-beneficiaries (73%) were unaware of this intervention. Social welfare officers in one of the control districts, Mberengwa, made deliberate effort to sensitise potential beneficiaries about the intervention during some of their outreach programmes. A significant percentage of respondents (89.4%, 131 females and 88 males) posited that they have heard of the virus called HIV or the illness called AIDS. A very small percentage (10.2%, 19 females and 6 males) have never heard about HIV or AIDS. Most of the OPs who have heard about HIV are beneficiaries (95% of all beneficiaries)

Figure 19 HIV Stigmatisation

compared to non-beneficiaries (81% of all non-beneficiaries). This is a result of the efforts of community workers whose role was to offer health education to OP. For those who have never heard about HIV, only 5% were beneficiaries whilst the other 18% were non-beneficiaries. Most of the participants (62.9%) thought that there is no stigma facing older people living with HIV in the community. Only 17.1% thought that older people living with HIV are being stigmatised. 17% (43) of the older people were not sure whether people living with HIV are being stigmatised. More beneficiaries think that there is no stigmatisation than nonbeneficiaries. The majority of older people who mentioned that there is no stigmatisation are 76% beneficiaries compared to 43% non-beneficiaries. Education on stigma and discrimination was cascaded through VHW and OCM groups to OP and to the community at large. Very few participants (12.7%, 21 females and 10 males) did not know where to seek treatment for HIV/AIDS. The majority (84.9%, 128 females and 80 males) knew where to seek HIV/AIDS treatment. Beneficiaries know where to seek HIV treatment better than nonbeneficiaries: 87% of all beneficiaries stated that they know where to seek treatment compared to 81% of non-beneficiaries.

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Only 9.4% (13 females and 10 males) of older people think that HIV/AIDS treatment services are not easy to access. The majority (80.8%, 124 females and 74 males) were of the opinion that the treatment services are easy to access. Those who thought that services are easy to access were made up of more beneficiaries (85 Figure 20 HIV Services Ease of Access of beneficiaries) than non-beneficiaries (74%) For the OPs that think HIV/AIDS treatment is not easy to access, 2 females (0.8%) had insufficient information, 1.2% faced cost challenges, 1 male (0.4%) had language problems, 5 females and 4 males (3.7%) had physical location problems and transport difficulties and 1.2% had other challenges. The majority of older people (72.2%) stated that there has been an improvement in HIV-related health services and care in the past month. Most of these OPs were beneficiaries (76% of all Figure 21 HIV related Services beneficiaries) compared to 66% of all nonbeneficiaries. Besides receiving support in form of drugs from a national programme, beneficiaries received care and support from BHOPA trained VHW. They were more aware of how to access these services from local VHW. Only 2.2% (6) older people think that there has been no improvement at all. 22% (56) older people were not sure whether there has been improvement or not.

Very few OPs (36.7%) have not been visited by a CHBC/Village Health Worker whilst most of them (62.4%) have been visited in the past six months. For those who have been visited by a CHBC/Village health worker in the past six 20

Figure 22 CHBC/VHW Helpful to OP

months, quite a significant percentage (37.1%) were very satisfied with the care they received, 20% were satisfied, 0.8% were moderately satisfied, 0.8% were not very satisfied and 0.4% were not satisfied at all. A very significant percentage (79.2%) of OPs think that community care workers are very helpful. 4.9% (12) of them think that community care workers are somewhat helpful. 9% (22) are of the opinion that community care workers are not helpful at all.

Quite a substantial percentage (69%, 106 females and 63 males) remarked that older people have the same rights as others. However, 29% (41 females and 30 males) are of the opinion that older people do not have the same rights as others in society.

Figure 23 Gender Difficulty amongst OP to get medicine

A very small percentage of older people (7.8%, 10 females and 9 males) think that it is more difficult for older women to get medical care than older men. Most of the older people (78.4%, 121 females and 71 males) think that it is not more difficult for older women than men to get medical care. 18 females and 11 males (11.8%) are not sure whether it is more difficult for women to get medical care than men.

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Findings from VHW FGD

Key concerns of older persons During focus group discussion with OCM members, they were asked to identify some key concerns of older persons in their respective areas. The most common areas of concern included; lack of age friendly services, ageism, food shortage, financial constraints, access to health facilities, OVC burden, chronic illnesses, shortage of drugs and OP equipment, abuse, and pensions. Lack of age friendly infrastructure: According to OCM the absence of age friendly infrastructure is an area of concern. For instance the toilets at the local clinics are Blair ventilated pit latrines and OP have difficulties in using these. Lack of health services designated for the elderly makes it difficult for OP to access some facilities. They also highlighted that VHWs are not very active in some wards which means their services are not utilised by some OP. Ageism: OCM noted that younger people are benefiting from food aid whilst the elderly are not. OP are excluded from drought relief programmes and this is a major concern in most areas. Older people’s committees (OCM) are not involved in selecting elderly beneficiaries. OP are not being given preferential treatment at some health facilities, e.g. queuing at some clinics. Food shortage: Food shortages induced by drought is another area concern that has economic and health implications for OP especially limited access to safe drinking water. OCM noted that there is conditional distribution of food to the elderly e.g. food for work. Financial constraints: OCM highlighted that financial constraints limits access to services for OP. In most cases there is the inability to raise funds to buy medicines that have been prescribed at hospitals for most OP. Some even highlighted cases where OP lose property as they fail to pay the council. Access to health facilities: Failure to reach designated places e.g. food distribution, churches, and health facilities due to distances is a key concern for most OCM. They highlighted the poor spread of health facilities, forcing OP to travel long distances. In some cases, OP travel long distances to fetch water (3-4km).

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OVC burden: OCM highlighted that looking after OVC and inability of OP to pay fees for OVC is an area of concern. OP have to depend on their grandchildren on the Food for Work programme. OP like other people are expected to receive grain on condition that they provide labour for community works irrespective of their age. It is the same grandchildren who are then made to provide labour for Food for Work programmes. Chronic illnesses: With age the body tires and is susceptible to a number of ailments. Most OCM highlighted that chronic illness is a key area of concern. Some of the chronic illnesses identified include, hypertension and knee problems, eye conditions, backaches, diabetes. Shortage of drugs & equipment: Lack of drugs at local clinics and health centres e.g. Ibrufane was also identified as an area of concern in OCM focus group discussions. The unavailability of equipment for OP at health facilities e.g. machines to test diabetes, was also highlighted. Pensions: Lack of non-contributory pensions is a sour area for most OP according to some participants in the FGD. Abuse: According to most participants in the FGDs, abuse – both physical and emotional, is a major area of concern amongst OP. OP are at risk from various forms of abuse from close family members as highlighted in the FGD.

Experience at the Older Citizen’s Monitoring (OCM) training provided by HelpAge. Topics trained. Participants were asked to highlight the topics that they were trained on and how they are relevant to their respective communities. The most common responses included; OP monitoring, OP abuse, issues affecting OP, and advocacy. OP monitoring: Monitoring of older people's issues and identifying OP challenges are topics participants emphasized. Members feel that they are now able to identify OP in need and facing challenges. They said they were trained to meet regularly and do proper record keeping and that there is now co-operation between OCMs. OP abuse: OCM were trained on the forms of abuse and how to identify them in their community and how to work with OP. They were also trained how to assist an abused, neglected OP. Issues affecting OP: Participants also highlighted that one topic they were taught which was relevant in their communities was on the challenges faced by OP e.g. looking after orphans, queuing at health facilities and other general OP problems. They also stressed the rights and entitlements of OP. According to some participants, training also covered issues affecting OP including drought, health, education and these topics are very relevant.

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Advocacy: According to participants, the training also taught them advocacy. This was relevant according to OP because it enabled OP to advocate for the rights of older people. Through advocacy efforts, OPA are now known by authorities.

Usefulness of training. To assess the impact of the training, participants were asked if the training was useful or would they rather have a different one. Most if not all participants felt that the training was useful, and they highlighted some of the reasons which included, improved health seeking behaviour amongst OP, OP monitoring skills, rights awareness, and counselling skills. However, some felt that there is need for refresher trainings on some of the concepts. Improved health seeking behaviour: OP are now motivated to visit health facilities as a result of advocacy work of OCM and there has been a noticeable increase in the volume of OP visiting health facilities. According to participants, OP are moving away from traditional medicine and this may be credited to advocacy efforts by OCM. OP monitoring: The training was useful according to participants because they are now able to identify OP with need. There is relative improvement in targeting and selection of orphans under the care of OP although more still needs to be done. Thus OP now have a focal person to discuss challenges at community level and some of the challenges of OP are directly sent to OCM members. Rights awareness: According to participants, the training was useful as most OP are more aware of their rights and entitlements. The younger generation are now also more aware of OP rights through OCM efforts. However, some felt the need to implement other rights of the elderly especially at banks. Counselling: There is better access to counselling services.

Areas of improvement. Participants were asked to suggest ways in which the training could have been improved. Generally, most were satisfied by the way the training was conducted but some pointed out possible areas of improvement. The most common areas of improvement include; coverage, incentives, and more training at grassroots level. Training at grassroots level: Some participants felt that there is need for more training at grassroots level and trainings could be blended with community care topics. Coverage: According to some participants, more people per ward should have been trained. Incentive: Incentives for OCM members need to be considered.

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Refresher: Refresher trainings on the concept of OCM were encouraged. Some OP also wanted to meet with the trainers (CCDS/IHH) and be mentored as well, on top of meeting with trained OCM members. Satisfied: Training met its objectives and no points for improvement were noted. The meeting was generally well conducted.

Change in perception towards the rights for older people and social and healthcare entitlements because of the training. Participants were asked if the training changed the way they think about rights for older people and social and healthcare entitlements and most of them confessed that it did. According to most participants, the training was eye opening as they are now more aware of their rights and are capacitated to demand respect for instance in health centres. Knowledge on rights of OP has increased. Participants emphasized that they now understand the welfare and challenges of OP much better than before. “We only used to know the welfare of our parents before the programme”. Increased awareness of international commemorations for OP and the ability to attend these events.

Monitoring and advocacy activities post training. The survey sought to explore some of the monitoring and advocacy activities that trained OCM groups have been involved in since the training. The most common advocacy activities among participants include; preferential treatment, food distribution, access to health, public transport, and BEAM. Preferential treatment: Since the training, some participants have managed to advocate for preferential treatment of OP in banks when collecting pensions and also at food distribution schemes. Some participants have managed to engage and advocate for OP with the local leadership for preferential treatment of OP. Councillors and chiefs are now engaged in promoting OP rights. Advocating for prioritisation of OP in community projects and at health facilities and engagement with Ministry of Health to have OP jump queues were some of the advocacy work done by the participants. Food distribution: Some participants advocated for the inclusion of OP on the food distribution list and this has worked since local councillors are now implementing the initiative. In one ward, OP have been exempted from travelling long distances to collect food aid. They can send representatives to collect the handouts on their behalf. Some village heads who are also OCM members prioritised inclusion of OP in some of their villages on the food distribution list. Access to health: According to participants, they have managed to advocate for improved access to health services for OP since the training. Participants advocated for inclusion of OP in the health centre committee. 25

Public transport: Advocating for better treatment of OP within the public transport sector was one effort some participants managed to perform after the training. BEAM: Since the training some participants managed to advocate for orphans under the care of OP to be on BEAM. Access to Basic Education Assistance Module programme for orphans under the care of OP would relieve the burden from OP who find it difficult to pay school fees.

OCM activities as change agents. When asked whether OCM activities can be successful in bringing about change in their respective communities, participants agreed that the activities do bring this about. Some of the noticeable changes they could identify include; awareness raising, improved health seeking behaviour, access to food, and reduced OVC care burden. Awareness raising: According to participants, effective OPA structures are critical in education and advocacy with the rest of the communities on OP issues. Educating the younger generations about caring for older persons can ensure success of OCM efforts. Improved health: Improved health seeking behaviour of OP can be credited to OCM activities for instance community sensitisation. Access to food: OCM activities have in some way improved access to food for OP for instance during food distribution programmes by representing them. OVC care: Orphans under the care of OPs will be able to attend school if they access BEAM as a result of OCM activities Engagement: According to participants the responsiveness of the community leadership to OCM efforts can ensure success of the project e.g. on needs of OP such as food aid.

Age Demand Campaign participation. During the OCM focus group discussions, participants were asked about their experience of Age Demand Campaigns if they were involved in any. Both groups in Mutoko said they had not been involved in any Age Demand Campaigns. In Gwanda the group was aware of campaign days e.g. Elder Abuse Awareness Day on 15 June, but had no resources to organise huge gatherings. In Zvishavane, ADA campaigns were conducted in a more organised way. However, the level of organisation is not uniform across communities. Although ADA campaigns are fairly well known, participation by OP is still quite low.

Forms of records kept from monitoring activities and whom they are shared with. The survey sought to understand the records that OCM keep from their monitoring activities and who they share the records with. The most common forms of records include; minutes, record books, data collection forms and OP registers. 26

Minutes: Participants highlighted that they keep minutes and attendance registers for every ward meeting held. These are shared with district staff and CCDS. Minutes of monthly meetings with the elderly are shared with us when we come on a quarterly basis. Record books: Some participant keep Ward record books of visits to OP which are shared with the community leadership, CCDS and VHW. OP registers: They also keep OP registers indicating numbers of older males and females. The registers are shared with local councillors and with CCDS. They are also shared with NGOs who need profiles of OP and their households. The registers are continuously updated by entering those who have turned 60 and deleting those who have did

Need for Psychosocial/counselling services. Most participants agreed that OP do need psychosocial/counselling services. Some of the reasons they cited included; isolation, abuse, and general wellbeing. Isolation: Some older persons live alone according to OCM groups and some are unable to walk and need company from time to time to prevent cases of depression and anxiety. Having someone to talk to is important for mental health as noted by some participants. Counselling: According to some participants, OP are comforted through counselling. OP open up to OCM of their challenges. It builds the relationship between OCM & OP. Counselling provides OP with someone to confide in. Abuse: OP are abused by young children who don’t understand them and therefore the OP need psychosocial services. Various challenges: Participants felt that psychosocial support is indeed needed because a lot of older people have challenges that need psychosocial support especially those who are not being cared for by their children e.g. not being taken to health facilities medical problems, hunger, shelter, children being chased away from school etc. Psychosocial support helps to comfort OP and helps them face their challenges. Improved wellbeing of OP: According to some participants, psychosocial support is needed for the improvement of the wellbeing of OP.

Focus group discussion with VHW findings.

Type of services provided by community health workers. When asked the type of services CHWs offer to older people the most common response included; capacity building, counselling, psychosocial support, education, collection and administering of drugs, advocacy, referrals, OP monitoring, physical care, and home visits. Capacity building primary care givers: Activities include, discussing good caring practices with care givers, education to primary health carers on dealing with patients, including 27

encouraging them to be friendly and sensitive when dealing with OP and supporting primary care givers Counselling: CHW Counselling Services to OP especially for the isolated and rejected and bereavement counselling. VHW also encourage OP to keep going to counselling sessions. Another counselling service VHW provide is to counsel the caregivers, monitoring them to avoid any abuse of OP. Psychosocial support: VHW offer psychosocial support including household chores, especially for men who have lost their wives and general support to patients such as fetching water for them. They also help build relations and mend bridges between family members and the patient. Health education: Another vital service VHW provide for OP is health education to care givers on the rights of the OP. VHW provide health education on hygiene and nutrition. They teach patients about drug adherence and remind them to take drugs on time. Collection & administering drugs: Collection of medicines from health facilities for chronic conditions in OP. Assisting those older persons who take medicines for chronic conditions such as hypertension. Administering first line drugs - sometimes they issue OP with painkillers if have them and skin creams. Advocacy work: Advocating for assistance for OPs e.g. drought relief. VHW assist them to get food from the Department of Social Services. Referrals: VHW encouraging OP to go for treatment. They also refer to the next level of care and remind OP of review dates. VHW also encourage sick patients to have a friend to remind them to take drugs.

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Case study: Older people and HIV and AIDS

Mrs Agnes Makombe is a village health worker who resides in ward 5 of Mutoko district. She stays with four grand children. In 2015, Mrs Makombe was trained in palliative care under BHOPA. She was equipped with knowledge and skills to interact with older persons, including skills to offer psycho social support and physical support. She was supplied with a home based care kit and a bicycle to ease her work. After the training she started identifying older people in her community who needed support. Currently, she is caring for 18 older persons. On average, she visits them twice a month. In May 2016, Mrs Makombe identified a woman who is 68 years old. The woman has been frequenting Mrs Makombe's place for paracetamol drug to ease pain since 2015. After realising the recurrent nature of pain and suspicion that the woman could have contracted HIV during her misinformed caring role for her HIV and AIDS daughters, Mrs Makombe encouraged the woman to visit a health facility for HIV testing. Besides caring for her HIV positive daughters who are now late, she also assisted one of them to deliver at home. She was initially too shy to go for HIV testing because of her age. The woman complied after several sessions of encouragement from Mrs Makombe who then assisted her with $5 for bus fare. Upon return from the clinic, the woman confirmed that she had tested HIV positive and added that she was comfortable this seemingly sensitive issue with Mrs Makombe of the bond which had been created OPdiscussing monitoring: Visiting OP and the sick, identifying theirbecause challenges and monitoring the during the period of interaction. She has since commenced treatment with ARV drugs. Mrs Makombe's role is toconditions offer psycho support. living ofsocial OP e.g. exposure to abuse are some of the services VHW provide for OP.

They also monitor adherence to drugs of those of chronic conditions. Home visits and physical care: VHW assist OPs in dressing wounds, physical care and hygiene.

Challenges faced in providing HBC support to older people. Some of the challenges faced by VHW while providing HBC support to OP include; poor health seeking behaviour by some OP, misconception of VHW roles, shortage of supplies, knowledge gap, financial constraints, neglect and isolation, poor access to health facilities and food shortage. 29

Poor health seeking behaviour: Some OPs refuse to go to health facilities because they are just given paracetamol. A limited number of OPs refuse to go to clinics/ hospitals e.g. some who have cancer prefer to visit traditional healers. They believe that cancer can be cured traditionally using herbs. Shortage of supplies: There are not enough kits to facilitate issuing of paracetamol. VWH are accused of selective administration of limited drugs. VHWs are quickly running short of drugs to administer to patients. This implies the need is high and the intervention is relevant. Financial constraints: Financial burdens prevent OPs from going to the clinic. OP fail to go for treatment and also fail to buy medications which sometimes leads them to default. Some OP cannot afford to go to health centres for further investigations e.g. x-rays. Access to health facility: The distance to the clinic is long and this poses a challenge to most OPs especially to those who are becoming frail. Misconception of VHW roles: Expectations of some OPs from VHWs are sometimes beyond the scope of the project. Some OPs that are visited expect VHWs to give them some food. They always argue that VHW talk about adherence which requires them to take medicines after meals. They argue that they do not have the food to take before drugs. Some isolated false expectations of OPs are beyond the work of VHW. An example is the washing of a deceased person in preparation for body viewing. The VHW can only provide guidance on how this should be done for instance in cases where one has died from diseases such as cholera. Some OPs expect VHWs to transport them to the clinic. Some of the OP initially felt that the VHWs were too young and there was risk of them lacking sensitivity to OP issues. Knowledge gap: Some older persons fail to visit the clinic when they fall ill and would rather suffer at home waiting for the review date. Some OP were not aware that they could visit the clinic whenever they fall ill and others simply think that they are not allowed to visit the clinic any time before a given review date. VHW are working to ensure that this gap is closed. Some OP do not understand drug adherence and so they skip doses so that their medicines can last longer. This is when health education becomes relevant. Neglect and isolation: Some of the OP live alone and the VHW are not able to be there 24/7 for them. VHW are forced to visit them more often in order to assist with their household chores. Others however isolate themselves by choice. Some OP known by VHW are being abused by family members or even by their children and refuse to allow VHW to assist them. If by any chance VHW manage to visit these OP, it becomes a really big issue and sometimes VHWs get threats from the family members. VHW and OP structures were trained to refer complicated cases to the Department of Social Services. Food shortage: Inadequacy of food for patients makes it difficult for VHW to assist sufficiently and recovery of patients also becomes difficult. Lack of food also affects drug adherence since some medication requires food before its consumption. Communication breakdown as some OP have dementia. 30

Frequency of supervisory home-visits to the elderly. When asked about the frequency of their home-visits to the elderly, response ranged from high care (3 times a week) to low care (twice a month). Frequency of home visits depended on; personal needs of VHW, request/needs of the patient, mobility of the patient, and condition of OP. VHW personal needs: Some VHWs visit OPs once a month so that they have some time to handle their own personal chores. There is a need to balance voluntary work and economic activities at home. Request/need: Some OPs are visited twice a month if they request more frequent attention. Mobility of patient: The ones who are bed-ridden or are no longer mobile are visited twice or even three times a month. Those who are mobile and are able to go to the clinic by themselves are visited once a month. OP visits are done once a month for those who are not bedridden and more often for those who are handicapped. Condition of OP: The frequency of OP visits depends on the condition or situation of the patient. Mostly OP are visited twice a month depending on the condition of the person or up to three times a month depending on the demand to attend to other personal responsibilities by VHW.

Need for more training and continued education. VHW were asked if they needed more training and continued education to better treat older people. Most of them agreed that care wokers do need more training and continued education. They were also asked to identify areas in which they required training/continued education. Such areas include; refresher courses on areas they were taught, counselling and communication skills, palliative care training of additional VHW, establishing rapport when engaging with OP,and increased training coverage. Refresher courses: There is need for refresher courses to keep abreast of current trends. VHW also need refresher courses and new knowledge on signs and symptoms of conditions most affecting OP. VHW require training on the subject of the dying process. Continous support: Need for support and supervision visits to get feedback on performance. VHW require trainers to continue mentoring them because it helps them to correct whatever mistakes they may have made on the ground. They need continuous support. Counselling and communication skills: VHW need counselling skills and they need more information on counselling because this service is in particular demand. They need more training on: communication skills, counselling Skills, how to approach patients. They also require special skills of communication e.g. to deal with the blind, deaf or dumb. VHW also need to learn more about bereavement counselling. 31

Palliative care training of additional VHW: VHW want implementing partners to train additional VHW who were not trained in palliative care because cascading information to them is posing challenges: some of them feel that they are getting second hand information whilst the initial group got first hand information from the trainers. Training of additional VHW will increase programme coverage. Raport: VHW need better skills for building relationships with OP in order for them to be able to gain trust and be able to open up about their challenges and personal issues. It is important to establish rapport when approaching the OP and educating the people who stay with OP is key to preventing issues of neglect and abuse. Training coverage: Some HPs did not receive training and they require this same training if adequate care for OP is to be maintained. Specific training: VHW were of the opinion that it would benefit them if they were trained to dress a cancerous wound because they currently do not have adequate knowledge on how to handle such cases. .

The most common illnesses facing older people who receive home-based care and specific common illnesses faced by elderly women. The most common illnesses facing older people who receive home-based care include; arthritis, eye conditions, ear problems, hypertension, diabetes mellitus , stroke, mental illness, cancer of the prostate and cervix, chronic backache, HIV and AIDS. The most common illnesses amongst older women include; diabetes, lower abdominal pain, eye conditions, chronic headaches, stroke, cancer, aArthritis, stomach pain, leg ,problems, asthma, hypertension particular to women, mental illness, urinary continence, dementia and chronic backache. Challenges faced by older people in accessing healthcare. VHW were asked to describe some of the challenges faced by older people in accessing healthcare based on their professional experience and observations. The most common challenges included accessibility of health facilities, lack of family support to assist OP access health facilities, lack of finances to access medication, unavailability of medicine, non-adherence to medication, lack of age- friendly equipment and services at health facilities, and false perceptions that affect negatively on health seeking behaviour of OP. Accessibility: Long distances to health centres and absence of cash for transport. Lack of transport to bring them to the clinic/hospital. Lack of family support: VHW noted that at times there is no one to escort the older person to the clinic when they fall ill. Neglect from children and relatives is a major area of concern and a barrier to OP accessing healthcare. 32

Financial constraints: Financial constraints restrict them from; travelling to health centres away from their localities and accessing vital medications which are paid for at pharmacies. They also lack finances to buy medicines that sometimes are not available at the clinic. Non-adherence: Some OPs stop taking medication because they feel they are not getting better. Unavailability of medicine: Unavailability of medicines for chronic conditions, e.g. hypertensive drugs from health centres, force OP to buy from expensive pharmacies. Shortages of medication in some cases result in older persons defaulting. Wrong perceptions: Misconceptions by the community that OP should not access drugs, including some OP themselves.

Noticeable changes or improvements made in access and quality of healthcare for older people over the past year. To assess the impact of the intervention, VHW were asked to identify and describe any noticeable improvements made in access and quality of healthcare for older people over the past year. Improvements included availability of medicines, familiy support, improved counselling, improved relationships between VHW and OP, improved health seeking behaviour, preferential treatment of OP, and better care by care givers. Availability of medicines: Medications are now available e.g. Brufen has improved pain management or backache and arthritis. VHW are very helpful in collecting and administering medicines. Generally improved access to health care. Family support: Families are taking better care of older persons now that VHW make home visits. They are even allowing older persons to carry out small household chores if they request to do so. Families now also realize the importance of a little bit of exercise for older persons. Family education and support for people living with OP has improved. Families are better able to engage and consult with OP. Improvements in OP health and applying knowledge from the training has helped a particular OP to recover from stroke. Improved counselling: Counselling is improving the way of life, acceptance of health provisions and meaningful existence. OP are now hopeful and aware of their right to healthcare. Improved OP & VHW relationship: Change is also evident in the relationship between OP and VHW. There has been a mindsets shift in VHWs who are now more sensitive to OP. Cohesion and collaborative support exist between the VHWs and OPs. VHWs are now skilled in dealing with OP problems and care. Visits by VHWs motivate them- confidentiality is kept. OP are opening up to care givers more than ever before as a result of improved communication skills. Better relationships exist between OP and VHW who are sometimes invited to OP’s homes. 33

Improved health seeking behaviour: OP are now visiting the clinic on a regular basis. The service at the clinic is now better in terms of the time it takes for them to be attended to. There is some change as we now see some OP coming to the clinic just to have a routine check-up. In general, the reception at the clinic is now very welcoming for older persons as they are now served as first priority. More women are going for HIV, diabetes and hypertension testings. There is generally improved health seeking behaviour amongst male OP. Better care by care givers: Better care for OP by primary care givers as a result of health education efforts. Primary care givers visiting clinics more regularly to collect drugs on behalf of ill OP. Preferential treatment of OP: OP now receiving preferential treatment, improved services from HPs. The fact that they do not join the queue when they visit the clinic has motivated them to visit more often. Even on baby clinic days, nurses give preference to older persons.

Relevance of training in providing relevant knowledge that can be used by VHW. VHW were asked if the training provided by HelpAge provided them with relevant knowledge that they can use in their work. The general response was that the training was indeed relevant. Areas demonstrating relevance bordered around communication skills, counselling, improved OP care knowledge and skills, OP’s rights, and work plan development. Communication skills: Communication skills with OP means they open up more to VHW. They are also able to listen to OP when they talk. VHW testified that they are more patient with OP. The training increased the knowledge and skills of VHW so much that their relationship with older persons has also improved. Counselling: VHW are better able to offer counselling services to OP. Training on bereavement awareness helped VHW offer quality bereavement counselling. Improved OP care knowledge & skills: VHW are able to monitor OP drug adherence. “We are now able to explain the causes of some diseases and how to reduce the risk of having these diseases,” remarked one VHW. VHW are also applying their skills both at home and in the community. The programme has therefore had an impact at both personal and community level. OP rights: VHW are aware of OP’s rights and how to deal with OPS . Care givers have been sensitised to OP’s rights. Families and the community in general now realize that older persons have as much a right to live as anyone else. Work plan development: Training helped some VHW plan their work in such a way that they do not end up experiencing burn out. 34

Most useful training topics. Participants in the focus group discussion were asked to identify the most useful topics from the training with HelpAge for their work as community health workers. The most common topics included; bereavement counselling, OP abuse, palliative care, confidentiality, management of chronic illnesses, and OP rights. Bereavement counselling: VHWs can now easily discuss dying with patients and family, for instance allowing them to cry and to express their feelings. OP abuse: The topic was helpful to many VHW as it made them aware of various forms of OP abuse. Most were not aware that denying an older person some basic rights such as access to health or even not giving them food at a time they wanted it was some form of abuse. VHW are therefore better positioned to help them. The stigma and discimination topic helped VHW avoid exercising it against OP. Palliative care: OP conditions differ from other patients and they require specialized care. Confidentiality: This is one topic that most VHW confessed that they had never considered, but after the training they realized how important it was. It helped them to create long lasting relationships with patients Management of chronic illnesses: VHW indicated that they had learnt a lot about management of conditions. Concerning diabetes and hypertension, they agreed that OP learnt how to reduce their risks by eating the correct diet. One VHW had this to say “Cancer was most useful to me because it provided me with some information that I never knew about”.

Ways to improve the training. VHW identified areas where the training could be improved. These include; location of training, content of the training programme, need for practicals, and inclusion of more topics. Location: According to VHW, Low cost lodges are not ideal for training. They prefer having trainings at clinics and then get allowances as an incentive. VHWs prefer to arrange their own accommodation and then get allowances to pay where they can afford rather than be booked into low cost lodges. Training programme: It would be good to have fewer topics per day. There was too much to learn in a short space of time. Practicals: Topics should be immediately followed by a practical demonstration of palliative care delivery by the trainers. Although practicals were done, VHWs need more one on one practical sessions on palliative care through mentorship sessions.

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Including more topics: The counselling topic needs to be dealt with in greater depth. Ntrition education needs more information and the addition of sexual reproductive health issues in trainings is very necessary.

Need for psychosocial services by older people. The survey required the VHW’ perception of the need of psychosocial services by older persons. Most responded that OP do need psychosocial support, the reasons being; isolation, benefits of counselling, dependence and hopelessness. Isolation: Most OP share this issue and feel isolated to such an extent that they cannot trust anyone with their issues and problems. Most OP feel isolated as they grow older. Neglect usually comes from family members. Counselling: VHWs have the capacity to provide counselling; however, they feel there are some areas where they need mentorship, especially in bereavement counselling. Dependence: OP do need psychosocial services since most of them are dependent on other people (to fetch firewood and other chores). Hopelessness: In some cases, older persons are made to feel that life is no longer worth living. Providing them with psychosocial support rekindles that desire and gives them the willingness to live. Psychosocial services are important to OPs as they relieve the burden of their problems, according to VHW.

Findings from KII with health staff

Type of health facilities and services provide. Of the 8 health facilities interviewed, three are council clinics, two are government facilities, two church facilities and one a rural health centre. All these health facilities were established before Independence with the exception of one council clinic which was established in 2009. What all types of facilities have in common is the type of services provided which include; OPD, childcare, ART, EPI, chronic conditions, TB Lab, post-natal care, immunisation OI, PMTCT, outpatient services, family planning services, Jadelle insertion, maternity services – deliveries, HIV testing and counselling, PITC, VCT, and health education for male circumcision (actual circumcision is done by PSI).

Impact of the BH programme in various commun ities. Health staff were asked to assess the impact of the BH programme thus far in their respective communities. Possible answers ranged from “very significant, significant, average, and insignificant. The most common responses amongst health staff interviewed were “significant” and “average”. Those who felt the impact was significant based their responses on improved health seeking behaviour, improved service delivery, visibility, accessibility of

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health facilities, awareness raising efforts, and OP monitoring. Those who felt the impact was average based their responses on shortage of medicine, accessibility, and VHW-OP ratio. SIGNIFICANT IMPACT VHW work: Health staff emphasised that they now have VHW who were trained in the BH programme and have built a good relationship with OP. VHW assist OP with health problems and offer psychosocial support. There is improved care of OP by trained VHWs, including facilitating collection of drugs on their behalf therefore helping improve service delivery. There is better linkage between the facility and caregivers.

Figure 1 Patient (Mrs Sibusisiwe Ncube) consulting the nursing sister (Doreen Rafamoyo) at Simbumbumbu Rural Health Centre, Zvishavane district.

Mrs. Sibusisiwe Ncube is a 68 year old woman who lives with her husband and grandchildren. She visited her local clinic complaining of body pain and flu. Mrs. Ndlovu visit coincided with our mentorship and supervision at that clinic, (Simbumbumbu RHC). The nurse who consulted Mrs. Ndlovu is a palliative care trained nurse who was trained under the BHOPA Programme. During the interview, Mrs. Ndlovu expressed her gratitude on the way the nurses were handling older patients at the Centre. She said, “The nurses at the clinic are so good so much that she wishes they would not be transferred to any other Health Centre. I even make an effort to come and give them some of my produce from my fields as a way of appreciating them. These girls are well trained and well mannered, they really know how to talk to us and understand us. When we get here, they quickly serve us, we do not join the queue. They know that we are now old and our bones are now aging.’’

Improved health seeking behaviour: At clinic level health staff noticed that OP are now willing to go to the clinic because they know they can get treatment. OP are now motivated to

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visit the health facilities; thus health staff feel the BH programme has been very helpful to the community as the numbers of those visiting the clinic has increased. Improved service provision: Health staff highlighted that service provision has also improved after they got some medical supplies from Island Hospice (BHOPA Project). Results Based Fund (RBF) also assist in buying some of the medicines such as Nifedipine, Atenolol, Metfomin and other medicines for illnesses that are commonly found in older persons. They received drugs from kits supplied by CCDS and IHH which improved access to drugs. Visibility: According to health staff the project now known in the community. Preferrential treatment: Health staff pointed out that there is now preferrential treatment of OP at health facilities, for instance, not standing in long queues. Accessibility: Reduced distances to health facilities due to efforts by VHW and HBCW. This has reduced defaulting and increased adherence as noted by some health staff. OCM monitoring: Health staff also noted improved identification of OP in need of health services. Isolated people are better identified by VHW and HBCW. They are better positioned to follow up on OP in the community. Awareness raising: Efforts by the BH Programme according to health staff has increased knowledge on OP issues among the HCW and care has improved. AVERAGE IMPACT Shortage of medication: Shortages of medications for chronic condition hampers progress of BH Programme efforts according to some health staff.They felt OP are not getting all the services they need and the drugs which they require (hypertensive, pain killers). They strongly felt that partners like Island Hospice should assist them to buy some of the medicines that RBF could not buy for them. Accessibility: Lack of transport to health facilities for OP who live far from health facilities has a negative effect on health seeking behaviour according to health staff. VHW - OP ratio: Health staff highlighted that the project is still new and trained VHWs are few compared to the population in the catchment area.

Type of support and engagement between this health facility and the BH programme. The review sought to highlight the type of support and engagement that existed between health facilities and the BH programme. Health staff were therefore asked to describe the type of support and engagement. The most common responses included; equipment and skills, VHW and CHBC training, OP support, and OP monitoring.

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Equipment: Health facilities received medical supplies for OP and HBC kits for distribution to care givers from BH programme. VHWs were provided with referral forms which they use to refer patients in need of health care be they OPs or not. Some facilities also received technical support from BHOPA. VHW & HBCW training & support: BHOPA trained health professionals, VHW and HBCW to provide better OP care and the team has been conducting mentorship and support visits to the trained members. Frequent support and supervision for both the VHW and HPS is organised by the project. The health facility organises monthly meetings with VHWs to discuss BH project. VHW in turn submit monthly reports on OP care. The BH programme also provide support visits, mentorship and supervision of VHW at health facilities. The programme has trained Community Home Based Caregivers (CHBCs) and Village Health Workers (VHWs) who report to the health centre and visit patients on behalf of the health centre. They also observe the needs of OPs when they conduct visits and refer some patients who need special care. Most of the cases referred by CHBCs/VHWs are cases of continued backaches and BP. . The facility has an OPD register where they record OP patients seen who are aged above 60years. It also helps VHW to collect quality data and provides support to care givers and supervises their training.

OP support: Age friendly support to the patients is also being provided by the BH programme through health centres. OP monitoring: The health centre is identifying OP’s challenges, both health and others. It referrs OP to caregivers and OPA groups depending on the nature of their needs.

The main health challenges faced by the elderly. When asked what were the main challenges faced by the elderly in their communities, health staff identified drought and food shortage, accessibility, lack of resources and drugs, financial constraints, OVC burden, chronic conditions and isolation, Drought & food shortage: Hunger and poverty especially for those OP who live on their own is a major concern for OP health. Food shortage due to drought which results in malnutrition and hunger complicates health. Drought in Zimbabwe has affected most OP negatively. In some districts there are Food for Work programmes running but these are more suitable for the younger generations who are able-bodied and can perform the required tasks such as fixing roads. Drought has not spared the OP since gardening is the main means of survival for OP in some districts like Mutoko. The little rains that fell negatively affected gardening and therefore OP are struggling to access food. Sick OP are even worse off. Poor access to nutritious food is a major health risk. Accessiblity: Health staff identified accessibility to health facilities as a challenge. Transport challenges for those who live far from the hospital mean that OP cannot access easily health facilities when their health is compromised. 39

Lack of resources & drugs: Lack of OP resources at the hospital is a major concern for health staff and they identified it as a challenge to OP health. Limited access to drugs for chronic conditions is a challenge for OPs e.g. Hydro-chloronthiezide (HCT), Glibenclamide etc. Financial constraints: The cash crisis according to health staff is a challenge to older persons especially pensioners. Financial challenges mean OP cannot afford transport fees to reach health facilities, buy food and pay school fees for children under their care. OVC burden: Most OP are the carers of children who are left behind when parents or guardians pass on and yet in most cases these childern are sick and need an adult to care for them. Chronic conditions: According to health staff, chronic conditions which OP suffer from most include; backache; arthritis, hypertension. Isolation: Is a health challenge identified by health staff. Some OP have no one taking care of them (a number of them stay alone). No one is available to monitor nutrition and drug adherence . Some OPs have serious mobility problems which further hampers their access to health services.

Barriers faced by elderly in terms of access to health care. Generally, OP seek treatment when they fall ill. However, there are some barriers which hinder them from accessing health facilities. Health staff identified a number of challenges including access to medicine, access to health facility, cultural and religious beliefs and isolation. Access to medicine: According to health staff, consultation is free for OP aged 65years and above. However, some anti-hypertensive medications such as Nifedipine and slow K are expensive and OP have to pay for them. Shortages of drugs due to overwhelming needs at community level (some OP end up hesitating to visit health centres because they are not sure if they will get the medication they need. Therefore, they avoid travelling these long distances to health facilities). Some health centres according to health staff tried to close the gap by visiting patients (domiciliary visits) one day per month per health professional. VHW were encouraged to collect drugs on behalf of some patients but r the VHW – OP ratio is unfavourable. Access to health facility: Distance to health facilities is a barrier for the OP to access health care. Transport challenges due to bad road networks also means that OP find it difficult to access health care espeacially those who stay far away from health centres. Cultural & religious beliefs: According to health staff cultural and religious beliefs are sometimes a barrier for OP to access health care. In some religions it is forbidden to visit health facilities for any services. Some churches do not allow their members to be treated at hospitals. Although this is not widespread, it has a bearing on some OP. Health staff also noted that some traditional beliefs affect the health seeking behaviour of OP. Some who 40

suffer from cancer do not believe that cancer can be treated in hospital. This is not a widespread belief but needs to be corrected. Isolation: Is a barrier to health care access. Some OP live alone and when they fall ill they have no one to escort them to health facilities.

Frequency of OP visits to health facilities and main ailments presented. When asked if elderly patients visit health facilities for treatment, most health staff said they did. In some cases, OP visit once or twice a month depending on need and distance. According to health staff VHW efforts have improved OP health seeking behaviour. The main health ailments identified by health staff include; hypertension, painful lower limbs, backache, diabetes, arthritis, HIV, malaria, asthma, eye problems , cancer (cervical cancer in women and prostate cancer in males), urinary incontinence in men, and influenza – (depending on the weather). Free/subsidized programmes at health facilities. Health staff were asked if any of their programmes are free/subsidized for any segment of the population. At some health centres free services are offered to children under five years. Older persons aged 65 years and above receive free services subsidized by government in terms of exemption from paying consultation fees. At some centers OPD services are the only free services for OP offered by the health centres. According to some health staff maternity services are free – they are subsidized by Result Based Fund (RBF). However, in the absence of drug stocks, OP have to pay at pharmacies. Scanning is out sourced and they have to pay.

Changes made to facilities to make them more age-appropriate. Health staff were asked if they made any changes to their facilities to make them more ageappropriate and describe the changes if there were any. Health staff highlighted changes to the toilets and further stressed that there were some changes like OP prioritisation and free services for OP. OP prioritisation: Most health staff highlighted that health facilities are now giving priority to older persons, be it consultation or treatment. OP according to health facilities no longer stand in queues and are prioritized for treatment. Free OP services: According to health staff, OPD services for some facilities now free for some OP aged 60 years and above although the national policy talks of 65 years and above.

Type of training provided health workers and curriculum used.

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Another area the survey sought to explore was whether health facilities provide training to health workers. Palliative care training: Most health staff highlighted that they provide health workers with training information that they obtained from palliative care training from BHOPA. VHW training: Accordingg to health staff, VHWs are trained at district level, but the health centre educates them on key disease outbreaks such as malaria using a basic manual. They meet with VHWs every month and they discuss and support each other on case management.

Increase in number of older people attending the facilities for health services over the past year. The survey also sought to assess the impact of the programme in terms of improved health seeking behaviour. When asked if the number of older people attending the facilities for health services increased over the past year, most health staff agreed that the volume of OP visiting their health facilities has increased. Some of the reason for the incrase was credited to health education and advocacy, VHW efforts, improved service delivery, and free OPD services. Health education & advocacy: According to health staff, more OP now visit health facilities because of meetings which were organised by local leaders like councilors and health facility (soon after trainings) to sensitise OP on the need to utilise health facilities. Health seeking behaviour has improved because OP now receive health education and the involvement of chiefs and kraal heads have provided more buy in among the OP. Awareness campaigns to the OPs on health issues difinately helped. VHW efforts: The number of OP visits has increased according to health staff since VHWs are now vigilent and referring older persons to the hospital. Improved service delivery: The availability of medication for chronic conditions at some health centers has increased especially the number of OP visits. Improvement in services for the older person e.g. wheelchair at health facilities to assist OPs who can not walk and the prioritisvation of OP e.g not having to stand in queues.

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RECOMMENDATIONS 1. Older persons constitute a significant proportion of the total population which plays a primary care role for a sick person. Interventions should therefore consciously target older persons with health education programmes aimed at prevention of transmission of communicable diseases like HIV and AIDS. 2. Older persons are susceptible to multiple non communicable diseases. In the recent study arthritis was cited by most respondents. 57.4% of OP did not consider themselves fit on the day of interviews. Age friendly health facilities in terms of physical infrastructure and other dimensions including geographical spread of health centres need to be promoted by policy makers. 3. OP abuse remains a dominant phenomenon. Efforts by OPAs in programme districts have reasonably reduced the occurrence of abuses. The older people’s board, NANZ and other players in this sector should collaborate and roll out massive sensitisation drives, including identifying relevant champions at various levels nationwide. 4. OPA have made inroads towards sensitising members and community members on ADA campaigns as a tool for greater appreciation of OP issues. Participation at community level however is still low. The programme should consider recruiting influential community leaders as champions of ageing to accelerate uptake of the message. 5. The presence of community cadres to promote health seeking behaviours among older persons is an effective way of reaching to older persons and promoting access to health. Sound investment should be made to ensure that all VHW are trained in caring for OP. Besides improving access to health, the initiative is sustainable as it is housed within the ministry and can be carried forward beyond the project funding. 6. More programme beneficiaries were satisfied when they visited a health centre compared to those OP in the control districts. This is an indication of the effectiveness of an intervention to train health professionals on age friendly services. Trainings in the health professional curriculum should compulsorily include geriatric and palliatiative care. 7. Zimbabwe has a policy to exempt all older people aged 65 years and above from paying consultation fees and most rural health centres and clinics are upholding it. While this is providing relief to older persons, the policy should extend to other operations which demand more resources from older people. 8. The assisted medical treatment order (AMTO) is a noble government programme to improve access to health by vulnerable groups, including older persons. Besides lack of adequate funding, AMTO is little known by programme beneficiaries (80%). It is therefore recommended that OCM trainings include sensitisation on this and other programmes and policies which benefit older persons.

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9.

Financial constraints emerged as a major challenge militating against older persons accessing health care services. Social protection mechanisms, in particular universal pension policies must be put in place for OPs to help support their financial, health and social well-being needs. 10. Accessibility to medical facilities was cited as a major concern with transport and long distances as major reasons. The government should ensure that major systems, such as transportation, are responsive to the changing needs and capabilities of citizens as they get older. 11. The development and implementation of the national health and ageing strategy must be accelerated. The strategy must focus on creating a multi-sectoral age friendly society that provides ease of access to health care for the OP. It must help OP to be recognised, supported and enabled to live independent full lives.

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