A Process Evaluation of the National Development Strategy 1(NDS1) 2021 – 2025 on Health and Wellbeing Promotion in Matabeleland South Province, Zimbabwe

A Process Evaluation of the National Development Strategy 1(NDS1) 2021 – 2025 on Health and Wellbeing Promotion in Matabeleland South Province, Zimbabwe

Marvelous Ndlovu¹*, Retsanang Thabang Nyathi²

¹Department of Postgraduate Studies and Research, Chreso University, Lusaka, Zambia

²Department of Development Studies, Lupane State University, P.O Box 170, Lupane, Zimbabwe

DOI: https://doi.org/10.51244/IJRSI.2025.121500060P

Received: 30 March 2025; Accepted: 04 April 2025; Published: 08 May 2025

EXECUTIVE SUMMARY

Matabeleland South Province is one of the 10 provinces in Zimbabwe. The province has suffered from a higher disease burden culminating in high incidence and prevalence rates. The country has adopted the National Development Strategy 1 (2021-2025) which considers public health as an important component in realising an upper middle income status by 2030. The main goal of the NDS1 health priority area is to improve the quality of life of the general population through programme financing, WASH promotion, prevention and control of diseases, and increasing competence in the health sector. Annual targets have been set that determine progress towards NDS1 goals.  This document is a report of a process evaluation that was conducted to measure the NDS1implementation in Matabeleland South. The main objective of the process was to measure the programme implementation and determine factors influencing achievement so as to improve the programme and align it towards achieving its goal. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was employed in the evaluation process.  The evaluation design employed was an utilisation focused evaluation ensuring that evaluation findings are used to improve the development strategy. Convenient sampling was used to incorporate key informants into the evaluation. The programme framework was analysed using qualitative thematic reasoning. The evaluation established that the programme has universal coverage within the area and population. The effectiveness of NDS1 (health and wellbeing priority area) in Matabeleland South Province presented a constant progress with limited unintended outcomes. Implementation analysis indicated a higher programme quality, adherence to programme theory, a higher programme dose and average participant responsiveness. Programme maintenance was compromised by reliance on external funding and skilled worker attrition. On this note, it was recommended that the province should leverage staff capacity, increase social and behaviour change interventions, improve local programme financing, adopt a community based management system, and create an integrated disease management system for programme objectives to be realised.

Keywords: Process evaluation; National Development Strategy 1; Health and wellbeing.

INTRODUCTION

The National Development Strategy 1 (NDS1), implemented by the Government of Zimbabwe from 2021 to 2025, is a key strategy aimed at achieving inclusive growth and sustainable development across various sectors, including health. NDS1 builds on the gains of the previous Zimbabwe Transitional Stabilisation Programme (TSP) 2018 to 2020 and aligns with Vision 2030, which seeks to transform Zimbabwe into an upper-middle-income country. Various evaluations of the TSP concluded that significant progress was made in the implementation of its various pillars (Zimbabwe Coalition on Debt & Development ZIMCODD, 2022).  The next and current step towards attaining the objectives of Vision 2030 is guided by the interventions undertaken through the National Development Strategy 1 (NDS1) 2021-2025. The NDS1 is a first 5-year Medium Term Plan aimed at realising the country’s Vision 2030, while simultaneously addressing the global aspirations of the Sustainable Development Goals (SDGs) and Africa Agenda 2063. The NDS1 was built on the successes, while addressing challenges met during the TSP (Chiyanike, 2023. It outlines the strategies, policies, legal and institutional reforms and the programmes and projects that will be implemented over the five-year period, 2021 -2025, to achieve accelerated, high, inclusive, broad based and sustainable economic growth as well as socio-economic transformation and development. The NDS1 has 14 priority areas in its implementation. One of the primary objectives of NDS1 is to enhance public health outcomes by addressing systemic weaknesses and improving service delivery, particularly in underserved areas like Matabeleland South (NDS1, 2020-2025).

Matabeleland South is a largely rural region that faces significant health challenges, including high rates of communicable diseases (such as HIV/AIDS and tuberculosis), under-nutrition, and maternal and child health issues (Mhlanga et al, 2023). According to Mhlanga et al, (2023), evaluating the progress of NDS1 in meeting its health targets in this region requires an in-depth analysis of implementation strategies, resource allocation, healthcare delivery systems and community engagement mechanisms. This reasoning qualified the need for a process evaluation to assess programme implementation for programme improvement. The main objective of the evaluation was to measure the fidelity of the intervention to the programme strategy and plan. Adherence was considered as the essential bottom-line measurement of implementation fidelity. This was done with the intent to link progress to the achievement of programme outcomes.

Project Description

Programme Goal

The goal of the programme is to improve the quality of life of the people in Matabeleland south province in order to sustain an economically active population that can work on its pre-dispossession to develop its area hence contributing to the achievement of an upper middle income status.

Programme Objectives

Public health and wellbeing outcomes include;

• Increased domestic funding for health
• Improved human resource performance in the health sector
• Increased access to availability of essential medicines
• Increased access to water, sanitation and healthy environment
• Improved infrastructure facilities and critical equipment for health service delivery
• Improved enabling environment for health service delivery.
• Reduced morbidity and mortality due to communicable and non-communicable diseases
• Improved reproductive, maternal, new-born, child and adolescent health and nutrition.
• Improved public health surveillance and disaster preparedness and response
• Improved access to primary, secondary, tertiary and quaternary health care services.

Programme Activities

Programme operational activities are classified into 3 categories which include providing an enabling environment for health, human health promotion and critical support system. Interventions implemented in obtaining an environment suitable for health promotion include water and sanitation projects. Specific activities in this sector are the construction of sanitation facilities to increase sanitation coverage, drilling new boreholes and rehabilitation of old ones to increase access to safe water thereby reducing waterborne and diarrhoeal diseases. Disaster preparedness and response is fundamental in the creation of a health promotion environment (Mayanike, 2023). It allows for early detection of outbreaks and their prompt control when they are still localised. The main activities done under human health protection include the prevention and control of both communicable and non-communicable diseases through which morbidity and mortality are reduced. Other activities in human health promotion are aimed at improving reproductive, maternal, new born, child and adolescent health and nutrition. These include peri-natal care, maternal care, use of modern contraceptives and child nutrition and care.

Critical support systems involve strengthening the supply chain management for successful procurement, planning, stock and information management for bi-annual end user verification exercise. Specific activities include the supply of essential medicines, securing critical equipment such as x-rays, construction of health facilities and improving dilapidated structures. Also, improved human resource performance is a critical support factor in health service provision. This involves hiring, training and providing professional development courses for health workers to keep them in purr with modern technologies in health prevention and control. Continuous programme surveillance; monitoring and evaluation activities are key to provide timely strategic information for programmatic decision-making, supported by internal and external audits (Mayanike, 2023).

Table 1.1 Logframe Matrix

Programme description	Verifiable indicators	Targets				Means of verification	Risk/Assumptions
GOAL To contribute to the improvement of the quality of life for the people of  Matabeleland South Province by 2025	Life expectancy at birth in years	2021	2022	2023	2024	Population statistics records	Strong systems will persist to prevent local transmissions of communicable diseases and reduce incidence of NCDs
		61.5M 65F	62M 66.5F	63M 67.5F	64.5 69F
Outcomes 1.     Improved human resource performance in the health sector 2.     Improved access to availability of essential medicines 3.     Increased access to water, sanitation and healthy environment 4.     Improved infrastructure facilities and critical equipment for health service delivery 5.     Improved enabling environment for health services delivery. 6.     Reduced mortality and morbidity due to communicable and non-communicable diseases 7.     Improved reproductive, maternal, new-born, child and adolescent health and nutrition 8.     Improved public health surveillance and disaster preparedness and response 9.     Improved access to primary, secondary, tertiary and quaternary health care services	Overall vacancy rate % HRH competence (# of MDLs) % of availability of selected tracer medicines (VEN) % Population using safely managed drinking water % population using safely managed sanitation services % health facilities with functional equipment % of new or renovated health facilities Proportion of audit reports with adverse observations Malaria incidence rate per 1000. TB incidence HIV incidence per 1000 Bilharzia incidence Hypertension incidence/100 000 Diabetes incidence/ 100 000 Cervical cancer Institutional maternal mortality ratio Perinatal mortality rate Modern contraceptives Cure rate for children with severe acute malnutrition % outbreaks detected within 48 hours % outbreaks controlled within 2 weeks Service availability ndex Client satisfaction index	14.1 12000 55 79 69 44 15 0 0.18 185 1.23 48 23 98 26 68 70 100 60 50 76	12 15000 62 83 73 51 25 0 0.10 167 1.07 285 161 45 19 86 22 70 75 100 70 57 77	10.3 16000 70 85 75 60 30 0 0.05 154 0.94 280 150 41 14 73 19 73 75 100 75 62 78	8 17000 74 87 78 66 42 0 0.03 150 0.76 275 140 37 11 60 15 75 75 100 86 68 79	HR records Training reports Procurement forms Demographic Health Surveys Demographic Health Surveys Inspection reports Health centres inventory Audit reports Out patients registers TB registers Art registers Out patients registers Out patients registers Out patients registers Cancer registers Maternity forms/ reports Post natal care registers Family planning attendance registers. Post natal and child care registers Disease notification forms Outbreak management reports Audit forms/reports Client feedback reports	More health workers increase health coverage. Competent staff is more effective and efficiently. Essential medicines improve on disease control through treatment. Access to safe water and improved sanitation and hygiene are critical in preventing the spread of diarrhoeal diseases such as amoebiasis. Functional equipment will allow for correct diagnosis hence care. Renovated facilities will provide health and safety assurance to patients and staff members. Conducting service audits will influence health workers to work effectively and efficiently. Reduced incidence of communicable and non-communicable diseases lead to reduced disease prevalence, hence reduced morbidity and mortality Improved maternal care reduces maternal mortality. Use of modern contraceptives improves maternal health. Early disease outbreaks detection allows to contain them locally hence effectively control them. Effective outbreak control reduces epidemics and pandemics hence reduced morbidity and mortality. If the health service is available and people are satisfied of its quality their health seeking behaviour improves.
Outputs 1.     Enabling environment for health promotion 1.1  Constructed sanitation facilities. 1.2  Established new water sources. 1.3  Built new health facilities. 1.4  Renovated dilapidated health facilities 2.     Human health promotion 1.1  Tested malaria clinical cases and pregnant women 1.2  Administered malaria therapy 1.3  TB examination and treatment done 1.4  HIV testing and treatment done 1.5  Bilharzia cases screened and treated. 1.6  Hypertension patients screened 1.7  Cancer screenings done 1.8  Diabetes patients screened and treated 1.9  Peri-natal and post natal care provided 1.10     Implemented child nutrition project 2.     Critical support system 1.1  Hired health workers 1.2  Trained health workers. 1.3  Procured and supplied programme commodities. 1.4  Conducted internal and external programme audits. 1.5  Gathered and analysed programme strategic information	% sanitation facilities constructed. % water sources established Number of health facilities constructed and/or renovated. Number of people tested % pregnant women tested % confirmed cases treated Number of population screened and proportion of treatment initiated. Number of pregnant mothers registered. % children on nutrition care Number of health workers hired and/or trained. Number and types of procured commodities. Number of audits done. Availability of a programme information system or database.					Community mapping registers Health centres inventory Clinical records Pre-natal records Out patients registers Out patients registers Maternity forms Beneficiary registers Human resource registers Stock cards Audit reports Programme database and reports	The achieved outputs will contribute to strong disease prevention and control systems. Water and sanitation facilities increases on coverage and improve access to water and sanitation services. Built facilities increase health access. creening improves on detection and early treatment of communicable and non-communicable diseases Registered pregnant mothers are most likely to receive maternal care. Nutritional care will improve child health Recruiting more staff reduce work burden and training improves on competence. Available medicines leads to treatment Audits highlight work anomalies. Programme data allows for programme monitoring and evaluation hence improvement.
ACTIVITIES 1.     Enabling environment for health promotion 1.1  Constructing sanitation facilities. 1.2  Establishing new water sources. 1.3  Building new health facilities. 1.4  Renovating dilapidated health facilities 3.     Human health promotion 3.1  Testing malaria clinical cases and pregnant women 3.2  Administering malaria therapy 3.3  TB examination and treatment 3.4  HIV testing and treatment 3.5  Bilharzia screening and treatment. 3.6  Hypertension screening and care 3.7  Cancer screening 3.8  Diabetes screening and care 3.9  Providing peri-natal and post natal care 3.10     Implementing child nutrition project 4.     Critical support system 1.5  Hiring more health workers 1.6  Training and providing refresher courses to health workers. 1.7  Procuring and supplying programme commodities. 1.8  Conducting internal and external programme audits. 1.9  Gathering and analysis of programme strategic information	Sanitation facilities constructed. water sources being established Number of health facilities constructed and/or renovated. Malaria screening and treatment Population being screened and confirmed cases treated for communicable and non-communicable diseases. Number of pregnant mothers registered. % children on nutrition care Number of health workers hired and/or trained. Number and types of procured commodities. Number of audits done. Creation of a programme information system or database.					Community mapping registers Health centres inventory Clinical records Pre-natal records Out patients registers Out patients registers Maternity forms Beneficiary registers Human resource registers Stock cards Audit reports Programme database and reports	The achieved outputs will contribute to strong disease prevention and control systems. Water and sanitation facilities increases on coverage and improve access to water and sanitation services. Built facilities increase health access. Screening improves on detection and early treatment of communicable and non-communicable diseases Registered pregnant mothers are most likely to receive maternal care. Nutritional care will improve child health Recruiting more staff reduce work burden and training improves on competence. Available medicines leads to treatment Audits highlight work anomalies. Programme data allows for programme monitoring and evaluation hence improvement.
Inputs	Human resources (EHPs, nurses, laboratory technicians, spray operators, VHWs), DT kits, microscopes, injections, PPE (gumboots, overalls, safety hats, respirators, gloves, goggles), essential medicines, funding

Critic of the Project Design

A programme theory consists of a set of programme activities that are linked to its objectives and results. The development strategy in Matabeleland south is well articulated as it form part of the NDS1 being implemented nationwide. The NDS1 was drafted to conform to the regional development strategy. The strategy was tested by the African Union and it has proved to achieve its intended ultimate goal of economic development. Numerous implementation of the programme in various places has however proved that, the programme can be affected by area specific factors. It is therefore important to conduct context and stakeholder analysis before implementing the programme and align it to the contextual and stakeholder needs for it to be a success. The programme design is so simple and straight forward. Hummelbrunner (2015) stated that the beauty of a programme theory lies in its simplicity as classifies programme activities into three categorical classes for easy management.

Evaluation Questions

Main Evaluation Question

The main question for this evaluation was;

• To what extent has the implementation of public health and wellbeing interventions under NDS1 been progressing towards achieving its intended targets and outcomes?

The evaluation sought to answer the following key questions;

1. Are health interventions reaching and benefiting all intended populations, especially vulnerable groups?
2. Are the planned activities being carried out as intended to achieve short term health and wellbeing programme objectives (annual targets)?
3. Were there any external factors (economic, environmental or political) that influenced the progress of health related initiatives?
4. To what degree does the implementation of the NDS1 in Matabeleland South province aligned with the programme strategy?
5. Are the health programmes under NDS1 well maintained to allow for their sustenance after the NDS1 time line?

Evaluation Methods

Study Area

Matabeleland South Province has a population of 760 345 (Zimstat 2022). It is the country’s least populated province after Matabeleland North.  Matabeleland South and Matabeleland North were established in 1974, when the original Matabeleland Province was bifurcated. The province is divided into seven districts. Gwanda is the capital, and Beitbridge is the province’s largest town. Matabeleland South is bordered by Bulawayo and Matabeleland North to the north, Midlands to the northeast, Masvingo to the southeast, South Africa to the south, and Botswana to the west. It has an area of 54,172 square kilometres, equal to 13.86% of the total area of Zimbabwe. It is the fourth-largest of the country’s ten provinces in area. Matabeleland South sits on the edge of the Kalahari Desert, giving it an arid climate not hospitable to agriculture. The Human Development Index as according to 2018 Zimstat records stood at 0.537. It is considered very low and the 6th province in the country (Zimstat, 2022). As a result, there are Tswana, Sotho/Pedi, Venda, Shangani (Tsonga) and the Khoisan speaking people in the province. The other languages that are native in the province are Ndebele and Kalanga. Its economy is largely centred on subsistence farming and livestock farming. Droughts and a lack of economic opportunities have resulted in widespread poverty and migration out of the province (Zimstat, 2022).

The study area has an average annual temperature of 18.5 °C. The month of June has the lowest annual average temperature at 13 °C. The mean maximum temperature ranges from 22.5 °C in June to 32.2 °C in October (Mhlanga et al 2022). Matabeleland South experiences three broad seasons, including a warm, wet period between November and April; a cool, dry winter from May to August; and a hot, dry period from August to early November. The area receives rainfall from October to April with an average rainfall of 644 mm per year and the most rainfall falls in January with no rainfall received from June to August; August is the driest month in a year. Matabeleland South Province boasts of a high coverage of health facilities. The province has a total of 133 health facilities. Combined efforts to provide health care services across the province have emerged from the government, RDC, churches, local town council and private actors. The government provided a larger share with 51 health facilities, followed by the RDC with 54 health facilities. There are 13 church mission ran health centres, 8 private health facilities and the municipality having the least share with 3 health facilities. These health centres are the ones that oversee health programmes done in the province.

Area Map

Figure 3.1 Matabeleland South Map

Source: Zimstat, 2022

Evaluation framework

This evaluation used the RE-AIM Framework by Glasgow et al (2019). The RE-AIM framework, which stands for Reach, Effectiveness, Adoption, Implementation and Maintenance, is useful in evaluating public health interventions. Using this approach, the process evaluation assessed how well NDS1 initiatives were reaching underserved populations in Matabeleland South, and the effectiveness of these interventions in improving health. According to Glasgow et al (2019), this framework is particularly useful in process evaluations where the goal is not only to assess outcomes but also to understand how well an intervention is implemented and sustained in different contexts. Holtrop et al (2021) adds that as the RE-AIM framework continues to evolve, it is well-suited to address the realist evaluation question of what intervention components are effective, with which implementation strategies, for whom, in what settings, how and why, and for how long?

Reach refers to the number, proportion and representativeness of individuals who are exposed to or participate in the intervention. This dimension evaluates how well the intervention reaches the target population, particularly those who are most at risk or underserved. Evaluating reach involved assessing whether the health interventions for example HIV treatment and maternal health programmes were accessible to rural populations and what barriers prevented people from using these services. Effectiveness focused on the impact of the intervention on key health outcomes, both positive and negative. It included not just the primary outcomes such as the reduction in disease prevalence but also secondary outcomes such as improvements in quality of life, adverse effects, or unintended consequences. Evaluating the effectiveness measured how health indicators such as HIV rates or maternal mortality have changed since the strategy’s implementation in Matabeleland South.

According to Glasgow et al (2019), Adoption refers to the uptake of the intervention by settings for example clinics, hospitals and by providers or stakeholders. This dimension focused on how widely the intervention was adopted across various organizations or regions and the willingness of institutions to implement the intervention. It looked at how many health facilities in Matabeleland South have incorporated new services or protocols introduced by the strategy and whether healthcare workers are trained and willing to implement these changes. Furthermore, the implementation dimension assessed the fidelity, quality and consistency of the intervention’s delivery. It focuses on how well the intervention was carried out as intended, including any adaptations made to fit local contexts. In Matabeleland South, implementation was evaluated by examining how well the NDS1 health policies were being executed in clinics, including whether they have the necessary resources, staffing and infrastructure to provide quality care.

Maintenance refers to the long-term sustainability of the intervention at both the individual and organizational levels. It examines whether the positive outcomes of the intervention are sustained over time and if the intervention continues to be implemented after the initial phase (Glasgow et al, 2019). For NDS1, maintenance involved assessing whether the health improvements for example lower maternal mortality and the structures supporting the interventions such as continued funding and health worker retention are sustained beyond the initial period of implementation. The use of the RE-AIM framework provided a robust structure for evaluating health programmes, offering insights into not only the success of the interventions in improving health outcomes but also the processes that lead to successful implementation and sustainability. Evaluating these dimensions will help identifying areas for improvement to ensure that health strategies have a lasting, meaningful impact.

Table 2.1 Evaluation questions

EVALUATION CRITERIA	KEY EVALUATION QUESTION	SPECIFIC EVALUATION QUESTIONS	DATA SOURCES	DATA COLLECTION METHODS
Reach	What factors influenced participation?	What was the geographic and demographic reach of the program? Were vulnerable and underserved populations adequately targeted and served? How accessible and affordable were the health services to the intended beneficiaries?	Programme documents Key informants	Document review Interviews
Effectiveness	What were the perceived benefits or drawbacks of the program?	Did participants notice improvements in health outcomes? What was the gap between outcome mechanisms? What were the major factors influencing achievement of short-term objectives?	Programme documents Key informants	Document review Interviews
Adoption	What facilitated or hindered program adoption? Were staff adequately trained and supported?	To what level were stakeholders involved in program planning and execution. To what extent were evidence based approaches utilised in designing health programs under NDS1?	Programme documents Key informants	Document review Interviews
Implementation/ Fidelity	Does implementation align with the programme plan? What challenges arose and how were they addressed?	To what extent did contextual factors affected NDS1 implementation? To what level are participants engaging in the programme? Are the implemented activities aligning with programme theory?	Programme documents Key informants	Document review Interviews
Maintenance	Was the NDS1 program well sustained? Are participants continuing the behaviours promoted by the program?	What capacity building activities were conducted for healthcare workers ad systems? Were community health structures strengthened to ensure long term sustainability? How well were local resources integrated into the interventions?	Programme documents Key informants	Document review Interviews

Evaluation Philosophy

This process evaluation was underpinned by interpretivism research philosophy, focusing on actionable insights to inform policy and practice. Interpretivism philosophy in evaluating programs focuses on understanding the subjective experiences, cultural contexts, and meanings that people attach to their behaviours and the interventions they receive (Saunders et al, 2019). In Matabeleland South, where sociocultural dynamics significantly influence health outcomes, this philosophy provided valuable insights into how health programs are perceived and experienced by the local population. The evaluation acknowledges the complexity of health systems and the interplay of multiple stakeholders, resources, and socio-economic determinants. It views health outcomes as shaped by dynamic interactions between policies, communities, and environmental factors within the Matabeleland South context. Qualitative insights from health service providers, and policymakers, shed light on lived experiences, systemic barriers, and local adaptations.

The evaluation employed an inductive research approach which involves starting with gathering qualitative data to build patterns, themes, or theories about the effectiveness and impact of these programs. This method aligns with the interpretivist philosophy by allowing insights to emerge from the data rather than testing pre-existing hypotheses. Qualitative data collected was analysed to identify recurring themes, ideas, and patterns. The final step involved formulating conclusions or theories about health program dynamics in Matabeleland South.

Yin (2023), stated that a research strategy is the overarching approach or plan that a researcher adopts to conduct a study and answer specific research questions. This evaluation employed a case study design using Matabeleland south as a case. Using a case study approach in the evaluation of health programs allowed for an in-depth exploration of the health program within its real-life context (Yin, 2023). This targeted approach evaluates how the team contribute to the implementation and outcomes of NDS1 goals while identifying strengths, gaps, and systemic challenges.

The evaluation embraced a cross sectional case study design, focusing on provincial health service providers in Matabeleland South. A cross-sectional study is a type of research design in which data is collected from many different individuals at a single point in time. In cross-sectional research, you observe variables without influencing them. Wang and Cheng (2020) defined cross-sectional studies as observational studies that analyse data from a population at a single point in time. They are often used to measure the prevalence of health outcomes, understand determinants of health, and describe features of a population. Barker and Osmond (2020) stated that unlike other types of observational studies, cross-sectional studies do not follow individuals up over time. It provides a snapshot of the characteristics of the population, such as health status, disease prevalence, attitudes, or behaviours, at a specific moment

Evaluation Population

The provincial office (PMD) was the main focus of this evaluation as it consolidated all progress made by health programmes in the whole province. The provincial health team in Matabeleland South province had 10 departments that included the Provincial Health Office, Provincial Epidemiology and Disease Control Office, Provincial Environmental Health Office, Provincial Nursing Office, Provincial Health Services Administration, Provincial Accounts office, Provincial Family and Child Health Office, Provincial Pharmacists, Provincial Nutritionists and the Provincial Health Promotion Office with a combined population of 56 workers. These workers were key informants in this evaluation as they provide technical and management support to the district level, coordinate planning, oversee the implementation of national standards and guidelines, train health personnel, and monitor and evaluate health interventions in the entire province. This means that they are the information rich population ideal for this evaluation.

Sample Size

The sample for this evaluation was calculated using Cochran formula;

Where;

n₀ = Initial sample size (for an infinite population)

Z = Z-score corresponding to the desired confidence level (that is, 1.96 for 95%)

P = Variability assumption (proportion), in this case, 0.2 for 20%

e = Margin of error (desired precision level, that is, 0.05 or 5%)

Since the population is finite, the sample size is adjusted using the finite population correction formula below where n₀ is adjusted for N = 56 (sampling frame)

The adjusted sample size is approximately 46 health workers. This is the number of interviews needed to achieve a 95% confidence level with a ±5% margin of error.

Sampling Technique and Procedures

Purposive sampling was used to incorporate the key informants. Hossan et al (2023) described purposive sampling as where subjects are selected because they possess some characteristics to achieve a certain goal. The provincial health team was purposively selected because of the essential service it provide in the programme planning, implementation, monitoring and evaluation, and an overall strategic management of health programmes within the province. Convenient sampling was then used, where the evaluator interviewed available and willing to participate team members until the total needed sample number was reached.

Data Collection Methods

The main data collection tool used in this evaluation is key informant interviews. The researcher was guided by an interview guide to avoid deviating from the evaluation subject. The proceedings of the interviews were recorded down and analysed and interpreted to form some conclusions.

RESULTS AND DISCUSSION

Data Analysis and Presentation

Qualitative data was analysed using thematic analysis in order to extract key insights, patterns and contextual factors influencing performance. Responses from open ended questions were placed into themes, which were assigned codes and then classified according to the number of responses obtained for each theme. Facts, opinions, and feelings from the respondents were narrated and analysed with inductive and deductive reasoning. Data was analysed as per objective/theme.

Table 3.2 Data Analysis

Dimension	Explanation	Data analysis	Codes
Reach	Focused on the population reached by the program	Identify themes related to participant demographics, barriers to participation, and strategies that enhanced inclusion	Access barriers, community outreach, target population engagement
Effectiveness	Assessed the outcomes of the program in terms of health benefits and unintended consequences	Use thematic analysis to identify perceived changes in health behaviours, outcomes, or quality of life. Include unintended negative effects.	Improved health outcomes, participant satisfaction, unintended outcomes
Adoption	Examined how well the program was adopted by staff and organizations	Focus on organizational readiness, staff engagement, and factors influencing uptake. Analyze perceptions of training and resources provided	Staff motivation, organizational support, training adequacy
Implementation	Evaluated how well the program was delivered according to plan.	Identify themes related to fidelity, adaptations made during implementation, and logistical challenges.	Implementation fidelity, challenges in delivery, resource constraints
Maintenance	Assessed the sustainability of the program over time at both the individual and organizational levels	Explore themes related to on-going program participation, organizational support for continuation, and long-term impact.	Program sustainability, long-term engagement, resource dependency

Reach

Reach is defined by Glasgow et al (2019) as the extent to which the health interventions reach the target population, particularly the marginalized groups. The NDS1 has improved access to healthcare in Matabeleland South through decentralized service delivery, with provincial hospitals, district hospitals, and rural health centres extending coverage. HIV/AIDS services such as prevention of mother-to-child transmission and ART programs have achieved significant reach, supported by partners like MSF and OPHID. Immunization campaigns have targeted underserved populations, improving vaccination rates among children. This evaluation found out that there has been a notable increase in the provision of essential medicines for the province. Since the year 2022 to 2024, Matabeleland South has retained the stock of medicines above its annual targets. It was also found out that 96% of health centres in the province had at least 80% of essential medicines in stock. Although certain stock-outs were noted in remote rural areas, the PMD for Matabeleland South concurred that the stocks of essential medicines such as anti-malarials, ARVs and anti-TB medicines remained adequate since the year 2021 to 2024.

Access to health services is a critical factor considered by the NDS1 as crucial for improved health promotion. There has been a great improvement in accessing health service in the province with a constant rise recorded from 2020 to 2024. The province surpassed the 2024 target which is a great success. Much of the achievements in health services were attributed to the Result Based Financing and the Health Resilience Fund (HRF). This funding has provided for health outreach programs including HIV, Sexual reproduction health, vaccinations, mobile x-rays, OPDS and eye care close to the homes of the people. These outreach programmes were accessed for free thereby maximising uptake. This improvement in service led to an increased client satisfaction index in the province. It has also increased on service coverage and allowed people to access health services as possible, whenever needed and on affordable means. Mhlanga et al (2023) found out that persistent high rates of malnutrition, stunting, and poverty-related health issues undermine overall health gains. This is the same scenario with Matabeleland South province where malnutrition is rampant exposing many to nutrients deficient illnesses especially in children less than 5 years.

This evaluation observed that there still exist a persistent water and sanitation crisis in Matabeleland South. Although water coverage falls short to meet the annual targets, this evaluation has noted that there has been a great progress in clean water access within the province. The province largely benefited from the Presidential borehole drilling scheme which drilled numerous boreholes and established 32 piped water schemes across the province. It was observed that improvements in water provisions did not only brought health benefits but also unlocked the province’s untapped economic potential at the same time cushioning a majority of the population from drought. This is because they are now able to run nutrition gardens, irrigation schemes and provide drinking water for domestic livestock.

A highest proportion of the population still practise open defecation, however, the proportion of households accessing sanitation services that hygienically separate human excreta from human contact (improved facilities) has slightly improved since 2020. The evaluation discovered that lack of awareness is one of the reasons that keep open defecation on, where people lack quality credible information on the dangers of open defecation and on strategies to address it. It was also noted that poverty also prohibits families from prioritising constructing latrines over sourcing food staff. Also, the price of building materials becomes more expensive with the distance from the CBD, making it less likely affordable to the rural poor. This evaluation also noted that the appreciation of proper health correlates with the level of education. Minimum access to basic sanitation services and open defecation contribute to the spread of diseases such as diarrhoea and bilharzia. Maphosa (2024) concluded that, “access to toilets is one of the definers of civilisation and modernisation, but unfortunately our communities will continuously be labelled as primitive and backward.” He drew this conclusion remarking the prejudice met by rural people due to lack of good sanitation and cleanliness. This is exacerbated by the lack of clean water needed to maintain sanitation and hygiene. Prioritising rural communities in development, fiscal and policy planning is essential for the realisation of the NDS1 health outcomes.

Provincial targets on the construction and renovation of health facilities were fairly progressing. A number of health facilities were constructed and some renovated in the province from 2020 to 2024. The UHC strategy aims to ensure that health facilities are within the reach of people as possible, therefore constructing more clinics increase on coverage and reach to health services. WHO (2022) recommends that health facilities should have a 5km radius coverage allowing patients to travel not more than 5km to reach health facilities. Matabeleland South PMD conquered that quality health care service delivery is one of the critical requirements for the country to attain an upper middle class economy by 2030. Renovations of health facilities can improve on health care service delivery by reimagining operational space, incorporating of new technologies and enhancing the patient experience. They can also make health facilities to appear modern hence attracting more patients to seek care there by improving on health care seeking behaviour among community members. Great improvement was also noted in the provision of medical equipment so that health centres have functional equipment needed to deliver health services. The Pan American Health Organisation (2024) puts on point that medical equipment is an essential component of the health system. The equipment is useful in the prevention, diagnosis, treatment and rehabilitation of illness and disease in a safe and effective way. These equipment need to be maintained so that they remain functional. These improved facilities with functional equipment help health care professionals provide high quality care to patients. This equally increase on service availability and improves on client satisfaction.

The UHC approach was adopted by the province in maximising health service coverage throughout the province. The health team determined programme sprawl, by considering 5 factors that include discrimination, the place of residence, socio-economic status, governance and vulnerability to shocks. This assists in improving coverage by understanding who is affected and why hence coming up with strategies to engage them through breaking existing community barriers. With the noted engagement and whole of province approach which emphasised on leaving no one and no place behind, Matabeleland south successfully achieved UHC.

The challenges facing the NDS1 health service coverage in Matabeleland South province included remote and sparsely populated areas that remain underserved due to poor infrastructure, inconsistent transportation and long distances to health facilities. Also, vulnerable groups, including migrants and border communities, faced difficulties in accessing health services. To mitigate these challenges the province has adopted the grassroots approach where it uses local people such as village leaders and VHWs to deliver preliminary health services.

Effectiveness/ Programme Progress

Effectiveness in this case of a process evaluation, assessed the outcomes of the programme in terms of health benefits and unintended consequences (Glasgow et al, 2019).  Matabeleland South has made a great achievement in the prevention and control of communicable diseases. It has made impressive gains in the reduction of TB incidence from 2020 to 2024. It was considered that the TB pandemic in Matabeleland South is HIV driven and had a notable co-infection. The province therefore prioritised HIV testing in TB patients giving collaboration between TB and HIV health services within the province. A majority of TB patients got HIV testing and more than 95% of HIV positive TB patients were on ART by 2024. It was established that investment in new diagnostic technologies such as the Xpert MTB/Rif Assay and Digital Radiology has led to improved diagnosis and treatment of both ordinary TB and drug resistant TB. This effort on TB prevention and control in Matabeleland South has surely contributed to the reduction of the national TB burden which saw Zimbabwe being removed from the 30 high TB burden countries in 2023.

Although Matabeleland South has managed to reduce new HIV cases (incidence) from 2020 to 2024, records review indicated that the province still suffer higher HIV prevalence burden with approximately a fifth of its population living with HIV. This translates to 1 in 5 persons living with HIV in Matabeleland province. Respondents lamented the proximity of the province to high HIV burden countries like Botswana and South Africa. They also said that spousal separation where one parent is across the border and the other one being left home might also be a factor contributing to high HIV burden in the province. This might be true considering that the most affected districts were border districts Bulilima and Beitbridge. Bulilima was even considered as the most HIV burden district in the country (DHS, 2022). The province has thus employed several strategies in the control of HIV such as perinatal care, treatment as prevention and more; run under the mantra “Closing the gate of new HIV infections”.  A remarkable percentage of people living with HIV are receiving ART, thereby reducing their chances of spreading the infection. Compliance to medication also might be another attribute to the continuously declining AIDS mortality. The main objective of these strategies was to reduce HIV incidence, morbidity and mortality.

The province has successfully managed to control malaria and bilharzia to levels below the annual targets set in the NDS1 health priority area and the NHS. It has managed to eliminate malaria and has entered the eradication stage. The control of malaria and bilharzia might have been a success due to the dry spell hitting the area thereby affecting the life cycle of these diseases as they are supposed to have some life cycle stage in water bodies. Most of the malaria cases reported in the province are imported cases mainly from South Africa. According to CDC (2022), reducing disease incidence helps to reduce morbidity and mortality thereby contributing to the improvement of the quality of life of the people. Although Matabeleland South province has made significant strides in the fight against communicable diseases, however, there exist a serious emerging challenge in the management of NCDs such as hypertension, diabetes, mental health and cancer. According to the WHO (2020), NCDs are likely to surpass the combined statistics of communicable diseases, maternal, neonatal and nutritional diseases as the leading cause of death by the year 2030. Although health documents reviewed showed a very low reduction in NCDs incidence, health teams appeared to be amused as they claimed that the fight against NCDs has started to gain momentum in the province. The Matabeleland South Provincial Medical Directorate applauded the combined efforts of the MOHCC and CHWs gratifying the grassroots approach lately adopted in the province to have proven essential in providing health education on NCDs and promoting early diagnosis and treatment. The province is however let down by the shortage specialist care needed to treat those with complicated health issues or emerging diseases. It was established that health teams in Matabeleland South province had a hope that their on-going efforts in the fight against NCDs will improve health care outcomes and bring a brighter future for the people in the province. This commitment to addressing NCDs reflects a broader dedication to the health and wellbeing of the people.

Life expectancy has significantly improved among females than among males. The PEHO for Matabeleland South, in the Provincial Health Strategy Performance Report (2021 -2024) exclaimed that this improvement might be due to the availability of essential medicines in hospitals. He reasoned that the difference between males and females might be attributed by the difference in health seeking behaviours, where females frequent health services than their male counterparts.

The province has also made strides on paediatric health. The monthly report for October 2024 recorded an annual institutional maternal mortality of 71 cases per 100 000 live births. The reduction in maternal mortality according to the comment on the reviewed programme document concurred by interview respondents was attributed to the promotion of maternity waiting shelters/homes. At waiting homes, mothers can access maternal health easily since nurses and doctors are readily available to attend them in case labour pains occur. In these maternity homes, pregnant mothers are also taught how to handle babies and how to prevent mother to child HIV infection (Mhlanga et al, 2022). There was also a notable reduction in the number of babies who die during parturition. This might be attributed to the improvement in capacity of health personnel and the availability of functional equipment.

Using contraception is the best way to prevent pregnancy. The use of traditional methods such as lactational amenorrhea, coitus interruptus, calendar or rhythm methods still exists in Matabeleland South although they lack credibility from a scientific point of view. According to CDC, (2024), the only effective traditional contraception is abstinence but is not likely practiced by married couples. The use of modern contraception therefore becomes important in preventing unwanted pregnancies. Matabeleland south reported an improvement in the uptake of modern contraception from 2020 to 2024. Most used contraceptives included the pill, IUD, condoms and jadelle. The most used modern contraceptive were male condoms followed by the family planning pill.

Malnutrition is another persistent health burden in Matabeleland South Province mostly affecting children. One of the targets of NDS1 was to improve the cure rate for children with severe acute malnutrition. Matabeleland South province has made efforts in the improvement of the nutritional status and treating severe acute malnutrition. The province engaged a care group approach to deal with severe acute malnutrition where people check malnutrition among their children using Mid-Upper Arm Circumference (MUAC) tapes to detect early signs of malnutrition. The above achievements made by the health strategy in Matabeleland south has increased the health service index leading to an increased client satisfaction level. The above realised progress made by the health sector in Matabeleland South province indicate the commitment the province has in achieving NDS1 health targets.

Adoption

Adoption measures the extent to which NDS1 health initiatives are adopted by health institutions, communities, and stakeholders. Provincial and district health institutions have integrated NDS1 objectives into operational plans, with emphasis on resource allocation and service delivery. Community health programs, including health education campaigns, have gained widespread adoption, supported by traditional leaders and local organizations. This evaluation unearthed that resource-constrained institutions like most rural clinics struggle to fully adopt new initiatives due to inadequate funding, staff shortages, and limited technical capacity. Matabeleland South is struggling with an austere human resource predicament through from 2021 to 2024 which arrest the provincial efforts to fully adopt a viable National Development Strategy. Rural areas often experience a shortage of skilled personnel, particularly in specialized fields. This has compromised the province’s capability to deliver passable health services to its populace. Although the province has tried to recruit more health workers to reduce the vacancy rate, this evaluation has found out that the province is hardly hit by the medical brain drain. It was discovered that a quantifiable of health workers have left the province since 2020 presenting a notable attrition rate. The PMD lamented that this exodus of health workers has created a vicious cycle where the ministry continuously recruit and train new health workers but fails to retain them and this continue to weaken the health sector. Matabeleland South province has made efforts to fight human resource crisis by engaging more village health workers and establishing community health teams in a bid to increase maximised reach throughout the province by health services thereby achieving Universal Health Coverage (UHC). This community centric approach adopted by the programme promoted a culturally sensitive health promotion which increased programme adoption and participation by the community. The Results Based Management (RBM) approach adopted by the government also motivated health staff to take action on programme implementation.

It was established that broader issues such as fragmented HR management, the effects of past crises, and a lack of cohesive strategies between faith-based organizations and government health services continue to hamper human resource performance. Streamlining policies and enhancing collaboration could mitigate these challenges. Moyo et al (2020) specified that to optimise human resource performance, greater emphasis is needed on equitable deployment, improved working conditions, targeted training, and robust HR management strategies. Addressing these areas in Matabeleland South might ensure more effective service delivery and better health outcomes for the region.

It was also found out that traditional beliefs and practices influence the uptake of health programmes in Matabeleland South. Cultural beliefs and practices, which hold reliance on traditional cultures and norms mostly among the San people in Bulilima-Mangwe have affected their acceptance of modern medical interventions. Moyo et al (2023) support the above point as they argued that some community members become hesitant to embrace new health programmes if they conflict with traditional beliefs. They also pointed out that social stigma and taboos around certain health issues, such as HIV/AIDS, mental health, and sexual health, can prevent individuals from seeking treatment. This cultural barrier can significantly undermine efforts to address these health issues, especially if people feel ashamed or fearful of social exclusion. The WHO (2022) suggested that grassroots approaches are critical to influence health programme adoption in culture and traditionally immersed communities. Involving community members and local leaders in health programme design and implementation ensures that health messages are culturally appropriate and more likely to be accepted by the target population and when local leadership supports health initiatives, they are more likely to succeed.

Implementation

The strategy was implemented through a number of programmes all aimed at improving the quality of life such as the TB strategy, health strategy, WASH and more. The programme held the national mantra of “leaving no one behind”. According to the UN (2020), this is a commitment by its member states and a core principle of the SDGs. This slogan played a crucial role in promoting universal participation throughout Matabeleland South in rolling out NDS1. It looked on both area coverage where no area was left behind since those areas left out act as disease epidemic pots and also on universal population coverage. By so doing, this mantra evoked an unequivocal commitment among health staff and programme implementers in eradicating barriers that climax discrimination, exclusion, inequalities and vulnerabilities that leave certain groups of people behind. The Universal Health Coverage strategy also increased on programme reach as it emphasised the availability of health services as much as possible whenever needed at minimal cost. Also the records reviewed depicted a whole of province reporting which clearly show that the whole province was fairly reached by the health programmes. Mobile clinics and grassroots approaches brought health services closer to the users leading to increased attendance. It can therefore be concluded that the closer the service to the people the higher the health service consumption rate. Similarly, the cheaper the services, leads to increased access.

Implementation of HIV/AIDS programs, immunization campaigns, and maternal health initiatives has been relatively successful due to strong partnerships with NGOs and international organizations. Community health worker programs have supported implementation in remote areas. The main challenge pointed out by this evaluation was inconsistent implementation of programs due to frequent stock-outs of essential medicines and supplies in remote health centres.

Detecting and controlling disease outbreaks within 2 weeks of their occurrence were another key result area of the NDS1 health targets.  In this area the province achieved much as it realised concurrent 100% achievements from 2021 to 2024. Outbreaks are hard to control because they occur as an emergency but at the same time they can be easily controlled if strategies adopted by Matabeleland South are prioritised. It sets its emergency preparedness team that deals promptly with outbreaks. Also the health seeking behaviour allows for early diagnosis, early detection and prompt treatment of cases.

Matabeleland south province never received any adverse audit reports during the period under review from the year 2020 to 2024. This means that there was no adverse event that negatively affected the implementation of the problem such as accidents and emergence disasters or theft of programme equipment. It also suggests that everything went well during programme implementation. Since they were no adverse reports recorded during the period under review, the province was expected to action its provincial health strategy without any disturbances and was expected to achieve set targets. This is because having no adverse reports commissions an enabling environment for health service delivery hence the achievement of health targets. Yin (2023) posits that the nil-adverse reports audit findings suggest that resources, such as personnel, equipment, and supplies are being managed effectively and efficiently, which is crucial for the success of health programs. It also suggest that the program is adhering to relevant laws, regulations, and internal policies, ensuring that the services provided meet established standards of quality. Consistently positive audits enhances the credibility of the health programmes, ensuring continued investment and resource allocation and help in building a track record of accountability, which can attract further funding and support from both national and international organizations. This reasoning suggest that positive audits are often a sign of good governance and proper management practices, indicating that the program is being implemented effectively, which can contribute to better health outcomes. Overall, nil adverse audits in health programs in Matabeleland South are a strong indicator of proper program execution and financial stewardship, ensuring that resources are used efficiently and in line with the intended goals.

Distribution of essential medicine was another implementation strategy adopted in the province. Mostly the shortage of essential medicines in remote clinics was mainly due to bureaucratic delays and logistical challenges thereby limit program efficiency, especially in rural areas. Poor monitoring and evaluation systems were another challenged identified which hindered timely identification and resolution of gaps. Some challenges were pictured by the respondents as the main causes hindering the achievement of the broader NDS1 targets to include resource shortage, minimum coordination among stakeholders, widely spaced population and limited funding. Therefore strategies to improve health strategy implementation should include addressing systemic resource constraints, reaching more remote populations, and sustaining funding for health initiatives. Continued investments and coordination among stakeholders are crucial for sustained progress toward universal health coverage and improved health outcomes in the province.

Although the strategy faced some challenges in its implementation, evaluation findings show that it was implemented according to the programme plan. It depicts the fidelity of the programme as it is being implemented with determination to produce results which is according to the RBM approach emphasised by the NDS1. This approach was also evident in that the activities (strategic areas) considered by the health strategy aligned with the health sector target areas. It also observed the principle of UHC that emphasise on leaving no one and no place behind, which also is a key component of the NDS1.

Maintenance

Maintenance measured the ability of Matabeleland south as a province to sustain health interventions and outcomes over time. The decentralized healthcare system in the province comprising of the presence of provincial and district hospitals, along with rural clinics, ensures healthcare delivery even in remote areas. The provincial health team’s commitment saw untiring efforts in aligning programs under the Ministry of Health and Child Care with NDS1, which enhanced service delivery, particularly in maternal and child health, HIV/AIDS and other priority areas. Health services in Matabeleland south also benefit from NGO and International Support. Partnerships with organizations like MSF, OPHID and UNICEF provided critical funding, technical expertise, and program implementation, filling gaps left by limited government resources in the province. Community-Based Approaches adopted by the province included involvement of traditional leaders and community health workers helps in sustaining health programs at the grassroots level, ensuring better uptake of services. It was figured out that the rural and sparsely populated nature of the province increases the cost of delivering health services and makes consistent access of health services difficult. Also, many health programs in Matabeleland South are heavily dependent on donor funding such as Global Fund, USAID and World Bank, raising concerns about long-term continuity if external funding diminishes. Another threat to sustainability realised was the high staff turnover and the outmigration of skilled healthcare workers which affect the quality and availability of services. Also the rising disease burden characterised by high prevalence of communicable diseases like HIV/AIDS and TB, and the emergency of NCDs compounded by limited preventive healthcare, places additional pressure on an already strained system.

Partnerships with NGOs and donors have provided short to medium-term sustainability for key health programs, particularly HIV and maternal health services. Local ownership of community-based health initiatives, including involvement of traditional leaders and village health workers enhanced sustainability. Challenges to maintenance noted by this evaluation included heavy reliance on donor funding for critical programs which raised concerns about long-term sustainability if external support diminishes. High staff turnover and migration of skilled healthcare workers to urban areas or abroad create gaps in service continuity in Matabeleland South.

It was agreed that the community centric approaches that the province have adopted to leverage local leaders and VHWs for culturally sensitive health promotion have enhanced community buy-in and participation in health programmes. These also ensure continuity of health services in remote areas thereby sustaining health services in the province. It was however figured out that the province lacks local funding of health initiatives basing much on donor funds.

Sustainable health services including strengthening domestic funding for health services are essential to reduce reliance on external support and improve infrastructure and human resources (Moyo et al 2022). Innovative financing is crucial in raising community resources needed to sustain the smooth delivery of health services over the long-run. This can be achieved through exploring alternative financing mechanisms, such as public-private partnerships, which can help bridge resource gaps. Training and retaining healthcare workers, alongside investing in community health worker programmes, can enhance service delivery. Integrated service delivery through strengthening collaboration between government, NGOs and private providers ensures a coordinated and efficient approach to healthcare delivery. Mhlanga (2023) recommended an improved focus on preventive healthcare reasoning that expanding disease prevention and health education programs can reduce the disease burden and long-term costs.

In summing up it can be noted that Matabeleland South Province although it had failed to meet most of its annual health targets, it has made distinguished progress in all its health target areas. ZIMCODD (2024) was of the opinion that the NDS1 targets are very high with most of them being over ambitious. It is a golden rule that objectives must not be ambitious but practical. While setting overly ambitious goals may seem innocuous, it can lead to some lethal effects compelling programme implementers to doubt their competences and retire. This might mean that the government might fail to achieve them. Results from this evaluation evidently reveal that while NDS1 has made strides in health and wellbeing in Matabeleland South, particularly in expanding reach, adhering to implementation fidelity and addressing priority health issues, significant challenges remain in terms of long-term sustainability. Addressing these gaps will require Strengthened government investment in health services, enhanced resource allocation and monitoring systems and increased focus on preventive care and emerging health challenges like NCDs. With these adjustments, NDS1 can achieve more sustainable and equitable progress in Matabeleland South.

CONCLUSION

The NDS1 programme has universal coverage across the area and population in Matabeleland south. The effectiveness of the programme presented a constant progress with limited unintended outcomes. Implementation of the strategy, revealed a higher degree of engagement by both programme staff and the community (users). It showed a total adherence to programme theory with higher programme exposure/dose culminated by the UHC approach. High programme dose was achieved with some programme areas surpassing strategic boundaries. The programme quality was very good for main activities like WASH programmes, diagnosis of NCDs, Control of communicable diseases such as TB, malaria, and HIV. It was however, low in the management of diseases of emerging importance like mental illness. Implementation analysis indicated a higher programme quality, adherence to programme theory, a higher programme dose and average participant responsiveness. Certain priority targets like malaria and Bilharzia control received equals/more than 100% achievement rate, while some slightly failing to meet the target.  Programme responsiveness was another critical measure in implementation considered by this evaluation. People positively responded to the programme to a greater extent. Some were however obstinate to partake in the programme as evidenced by a low health seeking behaviour especially among men. This negatively retard programme effectiveness. The programme was implemented at provincial level but as a part of a national strategy with minimal discrepancy of programme activities to those implemented in other parts of the country where NDS1 is implemented. It was clarified much into a provincial strategy so that it embrace a local specific adopted health policy and strategy so as to effectively address local contextual factors and meet local stakeholder needs.

The sustainability of health services in Matabeleland South faces both opportunities and challenges shaped by resource availability, institutional capacity and stakeholder collaboration. While the current health service delivery system in Matabeleland South benefits from strong partnerships and decentralized structures, its sustainability is threatened by resource limitations, workforce challenges, and dependence on external funding. Programme maintenance was compromised by reliance on external funding and skilled worker attrition. A multi-faceted approach that strengthens local capacity, diversifies funding sources, and emphasizes preventive care is critical for ensuring long-term health service sustainability in the province.

The evaluation has noted a need to come up with all-inclusive solutions to improve health services in Matabeleland South Province. The following recommendations can be adopted to improve health care delivery in the province so as to achieve the sector and national health outcomes as stipulated in the NDs1 and National Health strategy;

1. There is a shortage of health workers in the province mainly due to diaspora attrition. Addressing the issue of continuous attrition of health workers will require comprehensive strategies that focus on increasing health worker satisfaction levels and managing ethical emigration such as improving working conditions, offering competitive salaries/incentives and creating a supportive environment for social development.
2. The province is facing a surging burden in managing NCDs. In order to effectively embrace NCDs into the composite health management system, there is a need to implement innovative strategies that leverage and integrate NCD services with the management of communicable diseases. This will act as a cost-effective way to maximise health service coverage within the province while improving access to care to patients with multiple chronic conditions.
3. The evaluator recommends health promotion professionals to maximize community engagement and knowledge impaction to improve their ability to draw unbiased inferences and act from their predispositions towards managing their own health. Collective approaches should be employed as they foster collective progress. Waterkeyn (2003) asserts that people change their behaviour if they are approached as a group rather than as individuals, they can determine their health standards together and make informed decisions based on common understanding. Collective approaches include Outreaches and Campaigns among other approaches. When people have adequate knowledge, they would be accustomed to embrace appropriate health promotion strategies.
4. Although led by the MOHCC, there are a number of actors that promote health in Matabeleland South province. To improve on health outcomes from these actors, there is a need for the PMD to implement a health sector coordination framework that will coordinate all efforts of stakeholders involved in a health related framework in the province. This will help to reduce duplication of efforts, improve resource management and increase accountability.
5. Community leaders and programme staff are recommended to promote a Community Based Management of the health programmes so that HHs can positively be involved in the programmes. Community Based Management promotes user ownership of interventions hence embracing sustainable services. This can be achieved through establishment of community NDS1 support teams and community health teams. These teams should be well trained to improve their skills and capacity, and they should take part in collecting data about the programmes so they can fruitfully note and embrace programme successes, avoid costly risks and correct failures.

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