By Michael Gwarisa
A landmark ethnographic study has raised urgent questions about Zimbabwe’s capacity to manage rising rates of multimorbidity, a growing health challenge defined as the coexistence of two or more chronic conditions in a single individual. Conducted by a multidisciplinary team of researchers from Zimbabwe and the United Kingdom, the study explores how this issue intersects with systemic gaps in healthcare delivery, funding, policy, and frontline services.
Published in PLOS Global Public Health, the study involved more than 130 participants, including patients living with multiple chronic conditions, healthcare professionals, policymakers, academics, and data managers. Using a participatory ethnographic approach, the researchers sought to understand the potential and limitations of elevating multimorbidity as a national health priority.
Multimorbidity is increasingly recognized as a pressing issue worldwide. In Zimbabwe, the challenge is compounded by a dual burden of disease. On one side, long-standing epidemics like HIV and tuberculosis continue to strain the health system. On the other, the country is experiencing a rapid rise in non-communicable diseases such as hypertension, diabetes, asthma, and depression.
The study shows that Zimbabwe’s health system, once one of the strongest in Africa, is now ill-equipped to meet these complex demands. Much of the current infrastructure is organized around “vertical” disease-specific programs, particularly for HIV, which has received substantial international funding. While this structure has enabled effective HIV care, it has also contributed to fragmentation, making it harder to deliver integrated, person-centered services for those with multiple conditions.
Patients Struggling Under the Weight of Multimorbidity
The lived experiences of patients in the study reveal stark disparities between how different diseases are managed. HIV care is generally free, accessible, and nurse-led at the primary care level, thanks to decades of investment and decentralization. In contrast, patients with NCDs often face user fees, medication shortages, and poor access to specialist care.
Those living with both HIV and NCDs described the healthcare system as disjointed and difficult to navigate. Patients reported long waiting times, frequent referrals, fragmented follow-up, and the need to visit multiple clinics to manage their different conditions. Many were forced to prioritize one illness over another due to cost or time constraints, leading to delays in treatment, complications, and added financial and emotional burden.
Systemic Fragmentation from the Top Down
The study attributes much of this fragmentation to the structure of global health funding and governance. Disease-specific funding streams—especially those tied to HIV, TB, and malaria—have shaped how departments within the Ministry of Health and Child Care are organized and resourced. HIV programming, for example, benefits from dedicated personnel, infrastructure, and data systems at every level. Meanwhile, departments handling NCDs or mental health operate with fewer resources and minimal capacity.
Despite national policies that call for integrated service delivery, implementation on the ground remains limited. Health professionals interviewed during the study described how their efforts to offer holistic care were undermined by siloed training, performance metrics, and data reporting requirements. At the community level, primary care nurses—once seen as the backbone of integrated care—are now overwhelmed and under-supported, dealing with an increasing volume of patients with multiple health issues.
A Crisis in Training and Workforce Distribution
The research also highlights a shift away from generalist medicine, which is essential for managing multimorbidity, toward narrow specializations. Medical education in Zimbabwe increasingly emphasizes advanced specialisms, often requiring training abroad. While this might benefit elite institutions and urban centers, it does little to support rural and primary care facilities where generalist skills are most urgently needed.
At the same time, training programs in family medicine and public health remain under-resourced and under-enrolled. Nurses, who historically served as generalist frontline providers, now struggle with limited in-service training, outdated equipment, and a lack of clear protocols for managing coexisting chronic diseases. The burden is particularly severe in rural areas, where health workers must act as de facto generalists while managing multiple roles across underfunded programs.
A Broken Data System
Another barrier to effective multimorbidity care lies in the country’s health information systems. According to the study, patient records and data collection tools are still largely disease-specific, making it difficult to track patients with multiple conditions or coordinate their care. Electronic health records (EHRs) have been introduced in some public sector facilities, but coverage is limited and often dependent on connectivity, electricity, or donor priorities.
The study also points out that data reporting remains focused on vertical program requirements. Health workers face the constant burden of completing multiple registers for HIV, TB, or maternal health, with little room for capturing multimorbidity. This not only affects the quality of care but also limits the system’s ability to recognize emerging patterns or make evidence-based decisions. Nurses and facility managers expressed frustration at the growing demands for paperwork that, in their view, contributed little to improving service delivery or patient outcomes.
A Case for Reform: Toward a Learning Health System
Rather than proposing entirely new models, the researchers argue that Zimbabwe could improve its response to multimorbidity by reviving and strengthening its original vision of comprehensive primary healthcare. This would mean resourcing the “already-integrated” primary care nurse, who historically managed a wide range of conditions under one roof.
The study recommends embracing a “learning health system” model—an adaptive approach where policy, practice, and research are closely integrated. This would involve empowering frontline health workers, decentralizing decision-making, strengthening domestic research and data systems, and encouraging more collaborative policy development.
While models from countries like Malawi, Uganda, and South Africa offer useful lessons on integrated chronic care clinics, the researchers caution against one-size-fits-all solutions. Any reform, they suggest, must be context-sensitive and grounded in Zimbabwe’s own historical strengths and challenges.
Conclusion
This participatory study offers a sobering but constructive roadmap for transforming Zimbabwe’s health system in the face of growing multimorbidity. It makes clear that treating patients as whole persons, rather than as a collection of disconnected diseases, will require not only new clinical models but also a rethinking of funding, training, data management, and institutional culture.
