District level implementers training on the Public Health Act Chapter 15:09

TRAINING WORKSHOP REPORT

Training and Research Support Centre (TARSC)

Ministry of Health and Child Care

(MoHCC)

9-10 May 2016 Bulawayo, Zimbabwe

With support from Open Society Initiative of Southern Africa

Table of Contents

1. Background ............................................................................................................................. 2

2. Opening, introductions, delegate expectations .................................................................. 4 2.1 Introduction to public health and the training course ............................................................. 5

3. Participatory exercise: Public health challenges and opportunities in Bulawayo ......... 8

4. Functions, rights, duties and powers in the Public Health Act ......................................... 9 4.1 Duties, functions, powers of government, private sector and communities .......................... 9 4.2 Duties, functions, powers of local government and City of Bulawayo public health regulations .................................................................................................................................. 11 4.3 Rights, duties, roles and functions of other sectors of government .................................... 12

5. Provisions relating to water, sanitation, housing and infectious disease control ....... 13 5.1 Ensuring healthy urban environments in Bulawayo and in Zimbabwe ................................ 13 5.2 Provisons relating to infectious dieasease control and port health ..................................... 15

6. Provisions on food safety, nutrition and smoking control .............................................. 15

6.1 Provisions relating to food safety ......................................................................................... 15 6.2 Food labelling and smoking control regulations .................................................................. 16 6.3 Overview of public health regulations .................................................................................. 20

7. Implementation of the Act ................................................................................................... 21

7.1 Actors, roles, duties and incentives ..................................................................................... 21 7.2 Role of the Zimbabwe Republic Police ................................................................................ 21 7.3 Proposals for Action to strengthen implementation ............................................................. 22

8. Final sessions ....................................................................................................................... 24

8.1 Proposals for the review of the Act ...................................................................................... 24 8.2 Course evaluation ................................................................................................................ 25 8.3 Closing ................................................................................................................................. 25

Appendix 1: Programme ............................................................................................................. 27 Appendix 2: Participants’ list ..................................................................................................... 28 Appendix 3 : Evaluation results ................................................................................................. 29 List of Acronyms.........................................................................................................................31

Cite as: Training and Research Support Centre (TARSC), Ministry of Health and Child Care (MoHCC) (2016) District level implementers workshop on the Public Health Act, Bulawayo, May 9 -10 2016, TARSC Harare. Acknowledgements The report has been prepared by Artwell Kadungure. Many thanks to Dr Rene Loewenson (TARSC), Mr G Mangwadu (MoHCC) for the technical design of the training and review of the report; Mr A Chigumbu (Public Health Consultant) for expert inputs to most of the sessions and presentations, Mr P Ncube, Mr M Moyo, and B Kaim for the presentations. Thanks to Zvikie, Jacob and Francis for the administrative support. The financial support from OSISA is acknowledged. C over photograph: Part of the participants to the PHACt training course working on the follow up

actions and roles as a group in Bulawayo, Zimbabwe © TARSC 2016

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1. Background During the review of the Public Health Act in Zimbabwe in 2011, it was evident that awareness of the Act’s provisions was low and that its implementation would be improved by private and public sector stakeholders having improved knowledge of its contents and application. During the stakeholder meetings and community level discussions, few people had accessed the Act or were aware of its specific contents. While inspectorates in local government and Ministry of Health and Child Care (MoHCC) may be versed with the provisions of the PHAct, lower levels of wider knowledge reduces the role of the many social and institutional actors that have a role to play in knowing and implementing the Act to protect public health. Proposals were thus made to hold follow up awareness raising and training on the Public Health Act. In 2012, a proposal was made to divide the training into two parts, first a high level one day meeting for top management of different sectors of the state, civil society, parliament, private sector, traditional, church and other institutions, to obtain their support for a more sustained programme of training, and then a three day training for field level personnel from the same institutions who have a role in the implementation of the Public Health Act later. Both these two workshops were held in 2012. During the first top level workshop, participants noted that such training be designed to include representatives from government, local authorities, civil society organisations, private sector, law enforcement agents, professional bodies and other international agencies. This is the fourth time the implementers training course was held, the first second and third having been held in 2012, 2013, 2014 and 2015 respectively (see Table 1 and Figure 1 for details of participants trained to date)

Table 1: Distribution of participants trained by type of organization and sex: 2012-2015

Description

2012 2013 2014 2015 Grand Total A B Total

No

Total %

B B B

No No No % No % No % No %

Total Trained 29 24 53 100 22 100 29 100 17 100 121 100

Type of Organization

Gvt dept, Local authorities, Parliament

15 12 27 50 9 41 13 45 4 24 53 44

Private Sector 3 6 9 25 3 14 7 24 2 12 21 17

CSOs, International Agencies

11 6 17 25 10 45 9 31 11 65 47 39

Sex

Male 15 12 27 50 14 64 18 62 11 65 70 58

Female 14 12 26 50 8 36 11 38 6 35 51 42

A = High level meeting for top management (held in April 2012 only)

B= Implementers training programme held in 2012, 2013, 2014 and 2015

Figure 1: Distribution of Number of participants trained by type of organization and sex: 2012-2015

0

20

40

60

80

High level Implementers Total Implementers Implementers Implementers

2012 2013 2014 2015 Grand Total(4 years)

Num

be

r o

f p

art

icip

an

ts

Gvt dept, Local Authority (urban/rural), Parliament Private SectorCSOs, International Agencies MaleFemale

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The majority of those trained were from government departments, parliament and local authorities as well as civil society organisations and international agencies. Nearly a fifth (17%) of the total participants was from private sector. Males constituted slightly above half (58%) of the total participants. TARSC and the MoHCC implemented a formal evaluation of the PHAct training course in September-November 2015. The findings showed that the course was rated highly (82%) in terms relevance, given the priority public health issues the course was addressing in the discussions and presentations. Knowledge sharing was also rated as good with national level participants using the course in a CSO network for strategizing advancement of the new Act. From the evaluation exercise and internal review from TARSC and MoHCC, it was evident that strengthening the impact of the course required a more focused and targeted approach, with clear collective action plans after the training by the participants at the end of the training programme. In its current form, the participants were fragmented as they came from diverse districts across Zimbabwe. To address this gap, TARSC and MoHCC developed proposals and implemented a two day district level training course for Bulawayo district in May 2016. The resource persons were drawn from the MoHCC, TARSC, Bulawayo City Council and the Zimbabwe Republic Police. Participants were identified by TARSC and MoHCC based on their roles in the implementation of the PHAct in Bulawayo and from sites TARSC is implementing Participatory Action Research (PAR) in 2016 in Mangwe district. A total of 33 participants from state departments, civil society organisations, local authorities and private sector participated in the training programme. The aims of the two day Bulawayo district level training course on the PHACt were:

i. Building knowledge to support implementation of the Public Health Act and its regulations on key areas in terms of;

a. Public health in Zimbabwe and in Bulawayo b. An overview of current public health law and how it addresses key public health

concerns. c. The key areas, rights and responsibilities, duties and obligations, functions and

personnel involved in public health at community and institutional level and the role in implementing the Public Health Act and its regulations by ministries, other sectors, local authorities, private and community actors

d. The issues in implementation and enforcement of the Act, and co-ordination with other laws and authorities

e. Proposals for strengthening the implementation of public health measures

ii. Developing proposals for action to strengthen implementation of the Public Health Act in Bulawayo urban in terms of:

o The priority areas to address o The strategies to address the key priority areas including the networking and

collaboration required o The progress monitoring framework o Roles and responsibilities in the action plan

The programme is shown in Appendix 1 and the participants’ list in Appendix 2. The report has been compiled by TARSC. Participants were provided with soft copies of the presentations and background materials for the training workshop, including the Act and its regulations. The training included discussion sessions and only a summary of the issues that emerged from these is captured in this report.

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Box 1: Participants’ expectations Widening understanding of the Act and its regulations o To understand the purpose/functions of the PHACt, its custodian

and applications. o Provisions on infectious disease control including in work places o To learn more on the provisions of the Act o To understand provisions relating to food handling and food safety Sharing and networking, collaboration in public health, widening awareness on the Act o To know more about how the law can be applied in the community o To learn how other health programmes eg ART feed into the Public

Health Act. o To understand how the widening of understanding of the Act can be

done to community level o To understand how different players can work together for effective

implementation of the Act Roles, responsibilities, powers, functions in public health o Responsibilities of inspectorates o Role of Environmental Management Authority (EMA) o Learn on the role of the Zimbabwe Republic Police o To gain knowledge on the role of civil society organisations as well

as other non-state actors in the implementation of the Act.

2. Opening, introductions, delegate expectations Mr P Ncube, Bulawayo City Council, welcomed delegates to the training course. Delegates introduced themselves, noting the districts they were coming from and their roles. He noted that the Public Health Act is a key legal instrument for promoting health in the City of Bulawayo, in Zimbabwe at large and even beyond the borders of Zimbabwe through port health regulations. He hoped that participants would learn from each other and facilitators on the provisions of the PHAct and its regulations and that the training would help reduce conflicts and improve implementation of the public health law and regulations in Bulawayo. He thanked the participants for coming and reminded those who were from outside Bulawayo on the scenic attractions they could find in Bulawayo. He concluded by thanking TARSC and MoHCC for organising the training workshop and “bringing it to the city of Bulawayo”. The platform allowed for people to interact and it brings in people from outside the health sector who are also key in the implementation of the PHAct; relying on inspectorates from the city of Bulawayo and MoHCC was not enough as these cadres could not be everywhere at any given time. Thus effective implementation relies on support from other stakeholders and the community. “Collaboration is required for effective implementation of the Public Health Act. As stakeholders, we need to have a collective vision for public health in the City of Bulawayo” Mr P Ncube Mr G Mangwadu, MoHCC, gave the key note remarks. He thanked TARSC for partnering with the MoHCC to organise the training programme. The programme exposes various stakeholders to provisions of the PHAct. Effective implementation relies on efforts of different stakeholders and communities. Mr Mangwadu thanked Mr Chigumbu for his continued interest and support to the training programme since it started. He expressed his gratitude to the participants for showing their commitment to improving public health in Bulawayo and in Zimbabwe. He gave a brief background to the Act and that despite the current challenges in Zimbabwe, the Act has helped to protect public health and needs to be safeguarded. It was important that attitudes and behaviour of communities be changed for instance in areas like waste disposal and management to promote safe practices and clean environments for health. There was need to rethink enforcement of law in relation to food safety in urban areas as informal markets were now resorting to selling food products after the normal working hours of public health inspectors. He reiterated need to protect against cross border diseases like ebola, cholera, yellow fever and others through implementing port health regulations. Mr Mangwadu highlighted that the PHAct is being reviewed and that participants should build community awareness on the new provisions when they are enacted. Mr Kadungure, TARSC, expressed his appreciation for the financial support from the Open Society Initiative for Southern Africa (OSISA) for the training, and from delegate organisations. He gave the background to the course. Delegates’ expectations were compiled (see Box 1), and related to widening understanding of the PHAct, sharing, networking and collaboration in public health and understanding the functions, roles and responsibilities of actors in public health (state and non-state actors).

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2.1 Introduction to public health and the training course

Mr A Kadungure, TARSC, provided the background to the training course and outlined the objectives of the training programme as set out in the background section. He noted the other complementary areas TARSC is working in. Public health law is diverse; a number of regulations provide for regulation of specific areas of public health. He pointed out that the training would cover some of these regulations and the key areas in the Public Health Act. The training course looks at practical issues relating to implementation of the law, coordination with other sectors as well as proposals on the review of the Act. The aim of the course is to reach everyone who promotes public health and implements the law in Bulawayo. Mr Kadungure highlighted the course delivery methods and encouraged participants to share experiences, network and collaborate for the improvement of implementation of public health laws in Bulawayo He gave an overview of public health in Zimbabwe, and the key public health challenges, using a TARSC presentation. He provided the definition of public health as “the science and the art of preventing disease, protecting and promoting physical, mental and social wellbeing health of the whole community / population, and organising the conditions under which people can be healthy”. This definition of public health includes all those organised community efforts towards addressing the social factors causing disease, establishing a healthy environment, detecting epidemics, controlling disease , providing health education and promotion, organising health services for the early diagnosis and treatment of disease; and organising the care and rehabilitation.

What is Public Health? the science and art of disease prevention, prolonging life and promoting health and

wellbeing through organized efforts and informed choices of society, state and non-state

organizations, communities and individuals for the sanitation of the environment, the control of communicable diseases and non-

communicable diseases, the organisation of health services for the early diagnosis, prevention and management of disease, the education of individuals in personal health and the development of the social machinery to ensure everyone the living conditions adequate for the maintenance or improvement of health.

Public health is what we do to ensure the

conditions for people to be healthy, it includes the actions taken to create

conditions for and promote health, to prevent disease and prolong life. It includes the actions by health care institutions and those of other sectors of government, public and private organizations, communities and individuals, media, academia. He used the rainbow model (see Figure 1) to illustrate the determinants of health that are covered in public health that range from individual and lifestyle factors (eg diet, physical activity, tobacco use), to those found in social and community networks, living and working conditions to the wider socio-economic and cultural determinants like religious beliefs, food markets (see Figure 2). He outlined the various steps and areas of focus in delivering on public health goals (promoting health, primary, secondary and tertiary prevention)

Figure 1: Rainbow diagram on the determinants of

health

Source: Dahlgren and Whitehead, 2007

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On the context of public health and the public health framework in Zimbabwe, Mr Kadungure noted that the 2013 Constitution guarantees the right to health care in section 76 providing that (1) every citizen and permanent resident has the right to access basic health care including reproductive health services, (2) every person living with a chronic condition has the right to access basic services for the illness, (3) no person may be refused emergency medical treatment in any health-care institution, (4) the State must take responsible legislative and other measures, within limits of resources available to it, to achieve the progressive realization of the rights set out in this section. It also includes rights to safe clear potable water (Sec 77), sufficient food (Sec 77), state funded basic education (Sec 75) and an environment that is not harmful to health (Sec 73). The Public Health Act [Chapter 15:09] of 1924 is the principal law regulating public health, administered by the MoHCC and complemented by other laws (see Figure 2). The Minister of Health is empowered in the Act to promulgate regulations to implement the law. Figure 2: The Public Health Act and laws that complements it.

He summarised the public health system in Zimbabwe, shown in Figure 3, noting the importance of coordination given its complexity. He outlined the context of public health in Zimbabwe using evidence on challenges in the social environments for health (eg lower enforcement of smoking control regulations), communicable and non-communicable diseases, water and sanitation, housing, social conditions, food, transport systems and food markets, and working conditions. This calls for affirmative, proactive, partnership approaches to promotion of public health rather than reactive, restraining approaches that focus only on nuisances and risks and individual curative care. Community level processes like clean up campaigns and health committees, partnerships with private sector and use of appropriate technologies can support public health in Zimbabwe.

The Public Health Act and its Complimentary laws

Source: PHAB, MOHCW (2011)

The Public Health Act [Cap 15:09]

PUBLIC HEALTH

MoEnvironment Environment Management Act Water Act

MoLabour, Public Services and Social Welfare Factories and Works Act Pneumoconiosis Act

MoAgriculture Animal Health Act

Mo Local Government Prov Councils Admin Act Rural District Councils Act Councils Act Traditional Leaders Act Regional Town and Country Planning Act Housing Standards Control Act Civil Protection Act

MoHCW Anatomical Donations & Post-mortem Examinations Act ; Dangerous Drugs Act Food and food Standards Act Medicines and Allied Substances Control Act Termination of Pregnancy Act Zim Nat Fam Planning Co Act Health Services Act Mental Health Act Medical Services Act Nat AIDS Council of Zim Act Radiation Act

Affirmative and collaborative approaches to public health are required. Top left: A private sector provided SWM cage for management of cans (c) T Chikwature, 2012, Rest of photos: Appropriate technologies in health (c) TARSC 2015 except bottom right which is (c) World Vision 2015

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Box 2: Context of Public Health (EW, 2014) Progress 2011-2014

High education enrolment, literacy and gender parity in education; high levels of adult and health literacy Improved child survival and nutrition, and recently in maternal mortality; fall in HIV prevalence Improved coverage of immunisation, maternal health, HIV and SRH services Reduced inequalities for services closer to universal levels. VHW programme supporting health promotion and service uptake. Improved medicine and personnel availability at primary care and district level Improving use of funds for specific services Challenges

Widening inequalities in wealth within areas, increased urban poverty, gender and social inequality Insecure incomes, urban food poverty, increased reliance on commercial food markets and rising food prices. Cost barriers to enrolment in education, early childhood development, and in completing secondary

schooling. Shortfalls in functional improved water and sanitation -> preventable disease. Shortfalls on MDG targets for IMR, MMR, child malnutrition, especially for poorer households. Rising NCDs, late or unmanaged NCDs. Wealth and education disparities in the uptake of services Domestic health financing too low to meet costs of the core services, high dependency on external funding for

key areas of health delivery Source: Loewenson R (2015)

Figure 3: Public Health institutional framework

Source: PHAB, 2011

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3. Participatory exercise: Public health challenges and opportunities in Bulawayo

B Kaim, TARSC, facilitated this participatory session. Participants were split into two groups and were asked to identify;

the challenges and opportunities for improving the public health of our communities in Bulawayo and

the opportunities for improving wider knowledge and enforcement of public health laws and regulations

The flip charts with the responses from the groups were stuck on the walls and participants discussed the presentations. The key themes are shown in Box 3 below

Box 3: Key issues from the discussion on challenges and opportunities

Challenges dealing with lack of awareness on the provisions of the Act: Under this theme, delegates felt that there is lack of awareness on provisions of the Act within communities, and policy makers like councillors. In addition, other stakeholders who are supposed to be working in collaboration with the City of Bulawayo like residents associations, civil society organisations and other state departments have limited knowledge on the provisions of the Act. As a result of the limited knowledge, some policies may appear to be not supporting each other, for instance how the policies on dog laws relate to the department of veterinary work on vaccinations against rabies in dogs. Lack of adequate knowledge of the Act was also highlighted as one of the reasons why communication amongst the different actors who implement the Act may be weak. Participants also felt that the courts and Police appear to give less priority to the offences created by those who violate the regulations and this required mind set change.

Challenges relating to inadequate financial resources to implement the law. Inadequate resources (within council, central government) has resulted in poor service delivery in areas of public health, such as roads (for transport systems) and waste collection and management leading to illegal dumping, poor street lighting. This endangers Bulawayo resident lives. They also noted sewer blockages and leakages in some areas, drug abuse by young people and dilapidated recreational centres. The lack of adequate financing requires rethinking on partnerships and modern methods of delivering these services in a cost effective manner.

On opportunities for improving wider knowledge and implementation of the Act, delegates noted that there are existing organisations (new and old) that bring various stakeholders together, for instance the Zimbabwe Public Health Association which is being formed. Some coordination exists at the different levels and these mechanisms need strengthening horizontally and vertically, for instance bridging gaps between community level processes and those in council. Another opportunity relates to emerging public- private partnerships in health. The local authority can partner with private sector like Delta Zimbabwe, Waste paper collectors and others in the management of solid waste, linking with community groups who collect waste for recycling. City solid waste management models may be remodelled to take cognisance of an increasingly supportive role of communities through waste segregation. There is a constitution that promotes the right to health and determinants of health. There are supportive laws administered my other ministries, for instance, environmental laws on pollution, those on meat hygiene and a supportive community exists (that is organised in form or the other in some instances) that needs to be activated.

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4. Functions, rights, duties and powers in the Public Health Act 4.1 Duties, functions, powers of government, private sector and communities Mr A Chigumbu, a public health law consultant presented on the roles, duties and functions of Central Government, private sector and communities as set out in the PHAct. He pointed out that the Act is assigned to the Ministry of Health and Child Care for its administration. Public Health Act defines the functions of the Ministry of Health and Child Care as;

to prevent and guard against the introduction of disease from outside, to promote the public health, and the prevention, limitation or suppression of infectious

and contagious diseases within Zimbabwe; to advise and assist local authorities in regard to matters affecting public health; to promote or carry out research and investigations in connection with the prevention or

treatment of human diseases; to prepare and publish reports and statistics or other information relative to the public

health; and generally to administer the provisions of this Act.

At national level the Permanent Secretary is the Chief Health Officer who has a team of officers at all levels who implement and administer the Act. The Ministry has established a Port Health Service to ensure that the country prevents and guards against the introduction of diseases from outside. Within the country various departments and units were established and various structures set up to deal with specific issues concerning the promotion of public health and the prevention, limitation or suppression of infectious and contagious diseases. The Ministry advises Local authorities and provides some of the critical services on behalf of smaller local authorities like Rural District Councils. The Act also provides for the appointment and composition of the Public Health Advisory Board whose function is to advise the Minister on all matters relating to Public Health in Zimbabwe. At the district level the Act provides for the establishment of District Health Management Committees (DHMCs) to manage and coordinate the provision of health services in rural district areas. Unfortunately, it seems that since the amendment to bring the provision on DHMCs on board was promulgated in 2002 RDCs are yet to set up such committees. The appointment of various officers by the Ministry and by local authorities to administer the the Act is provided for. The Act cites the Chief Health Officer (Permanent Secretary), medical officers (Provincial Medical Directors and local authority health directors), as well as health inspectors (environmental health officers). It also provides for the duties of local authorities and of those appointed officers regarding public health, and provides for how the Minister deals with local authorities that default in exercising their powers, or in performing their duties, and how any costs incurred by the Ministry are to be recovered from the defaulting local authority. The district level is the main implementing and enforcing level for the Public Health Act. Through the District Health Management Committee and other related committees, the district ensures the proper management and coordination of the provision of district health services. Every profession in the district health services has an important role in ensuring the effective protection of public health. Rural District Councils which are also defined as “local authorities” in the Act are also key players who, together with the District Health Services, the District Administrator and police officers, perform specific functions under the Act. Various district officers are empowered to enforce relevant provisions of the Act with full authority to prosecute. Others play a supportive role in enforcement, in prevention, treatment and control of infectious diseases, in ensuring food and water safety, and in ensuring good sanitation. The District Medical Officer (DMO) and his/her team enforce the various sections of the Act pertaining to infectious diseases, eg immunisation of children, and reporting and management of disease outbreaks and cases of infectious diseases, contact tracing, certification of food handlers and food inspections. They have powers to close down schools, crèches, churches and other institutions where an infectious disease occurs. They also have power to order local authorities and heads of mines and other industrial concerns to provide potable water and to maintain a healthy and sanitary environment.

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Environmental health officers are specifically appointed “health inspectors” under the Act to perform various duties like, inspection of premises, inspection of articles of food and other items of public health importance, and dealing with public health nuisances occurring in their areas of jurisdiction. In such cases they are empowered to take appropriate action (including prosecution, closure or destruction) to protect public health. Other duties of the district level include the provision of Port Health Services at ports of entry in line with the 2005 International Health Regulations, the supervision of the burial of bodies of people who die from diseases declared to be “formidable epidemic diseases”, medical examination and certification of food handlers and enforcing the regulations on breast milk substitutes (infant formula). Generally the district level is charged with the responsibility of preventing, limiting or suppressing the occurrence of infectious diseases in its area of jurisdiction. While the public health officials in the private sector play an important role in their organisations, they do not have a direct enforcement role. This is left to state and local authority officers. Their role includes:

1. Providing direct advice to their principals/management on a. public health issues and on maintaining a healthy workforce and community, and

on. b. The public health obligations of their organisation.

2. Inviting state and local authority officials to the company’s establishment regularly for on the spot advice and to ensure that their company public health programme is keeping with national laws.

3. Alerting companies on public health violations occurring in their area of jurisdiction and helping to rectify identified problems.

4. Educating company staff and the community on disease prevention, sanitation, hygiene and public health.

5. Being a member of and representing their company in the public health team involved in the promotion of public health in the local authority area, district, province and nationally.

On roles of communities, Mr Chigumbu outlined the rights of communities, notably the right to live and work in a sanitary, disease-free environment, that is where land is not polluted (S83 & 85), where the air is not polluted (S83 & S85) and the right to be protected against infectious diseases, elimination of breeding sites for mosquitoes and other vectors of disease (S82 & S85), access to safe drinking water and basic sanitation (S64), non-exposure to people with infectious diseases (Part III), a right to professional education on disease prevention (S48) as well as to be protected against the sale of unwholesome food (S69). The other rights are: the right to privacy (Section 53), arrange own medical examination during hospital detention (S 54), protection against claims of cures for STIs (S 56), to be served with a notice to remove a nuisance (S 86), to have contracts not affected by a court order to remove a nuisance (S 99), to institute legal proceedings and to obtain damages for losses or injury sustained through negligence of officials (S 100), and to deal with authorized officials (S103). Communities are key players in ensuring public health in Zimbabwe. Various community groups and civic organisations participate in public health matters through the Advisory Board of Public Health and through various committees that the Act provides for. Community health clubs which have been piloted in some districts support hygiene and health behaviour change and are now becoming a country-wide phenomenon. The private sector and communities also help to finance the health sector through donations, through user fees, and in kind. Sections 4 and 4A of the Act establish two important bodies, the Advisory Board of Public Health and the District Health Management Committees. Section 15 and Section 44 provide for the appointment of health committees and epidemic committees respectively. All these bodies afford private institutions and communities a say in public health. The Food and Nutrition Council also includes participation of different bodies involved in public health.

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Box 3: About the Advisory Board of Public Health

The PHAB is established by the Minister of Health to advise him on matters to do with public health. Members are appointed for a period of 3 years. It has power to conduct inquiries into any public health matter referred to it by the Minister and make recommendations. It is composed of health professionals and non-health professionals from the public and private sectors, including from Trade Unions, Red Cross and women’s organisations.

Health Committees are established by Local Authorities. They help in dealing with the prevention of infectious diseases and disease outbreaks. The Minister regulates membership, powers and method of financing the committees

Epidemic committees are constituted by the Minister in cases of epidemics. They coordinate epidemic control efforts and institute preventive measures. They may be constituted to serve two or more local authorities. The Minister can make advances to the committees to deal with outbreaks and are supported by the National Taskforce on Epidemic-prone diseases

The Food and Nutrition Council Set up by Cabinet in 1998 aims to promote a multi-sectoral response to food and nutrition insecurity problems so that every Zimbabwean is free from hunger and malnutrition. It seeks to promote a cohesive national response to the prevailing household food insecurity and malnutrition through coordinated multi-sectoral action.

In the discussions, participants noted that there are two centres of power; central and local government. In some instances friction between these two impacts on public health delivery. They gave the example of the fast track housing project after “Operation Murambatsvina” in Bulawayo which resulted in many houses being built without proper sanitary facilities (about 1200 households without sanitation). The central government then handed over the projects to the city authorities and the city now has to deal with this problem. Participants felt such policy issues needed engagement and dialogue at higher levels before implementation to prevent public health problems in future. They also raised problems with peri-urban settlements which are growing rapidly. The city of Bulawayo is trying to provide services to these communities since any disease outbreak affects all in the city despite some reservations from rural local authorities under which these settlement fall under administratively.

4.2 Duties, functions, powers of local government and City of Bulawayo public health regulations Mr P Ncube, City of Bulawayo, outlined the duties, functions and powers of the local government in public health. He noted that the PHAct seeks to ensure preservation of public health through elimination of conditions likely to be injurious to health. The key sections in the Act relate to its administration, notification of infectious diseases, venereal diseases, international Sanitary Regulations, water and food supplies, infant nutrition, slaughter houses, sanitation and housing. The decentralisation system of local government entails that local government is at the forefront in the implementation of most of the provisions in these sections. Thus, local authorities implement delegated functions. For instance, section 14 of the Act requires every local authority to take all lawful and necessary precautions for the prevention of the occurrence, or for dealing with the outbreak or prevalence of any infectious or communicable or contagious diseases, and to exercise the powers and perform the duties conferred or imposed on it by the Act or by any other enactment. Local authorities derive their mandate to enact bylaws from the Urban Councils Act Ch 29.15. Section 227 of the Urban Councils Act states that:

“A council may make by-laws in terms of this Part in relation to any matter specified in the Third Schedule or anything which is incidental to or connected with a matter so specified or for any matter for which in terms of this Act provision may be made in by-laws.”

He noted that the roles and functions of the City of Bulawayo are realised through the various bylaws the council has enacted. The Bulawayo (Public Health) bylaws deal with control of nuisances, provision of sanitary facilities on premises, provision of water supplies on premises, maintenance of premises, food safety and hygiene, keeping of animals and disease control and prevention. Specific bylaws that are used by the City of Bulawayo include;

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• Bulawayo (Registration of Premises) by laws- provide for the Issuance of registration certificate and minimum requirements for registrable premises. Among the issues that are checked is whether the premises meet the public health standards required. No enterprise will be registered if it fails to meet the standards. Premises are required to have a valid registration certificate at all times. The regulations also provide for legal implications of non-compliance.

• Bulawayo (Abattoir) by laws stipulate that all meat displayed for sale within the city should be from a registered abattoir. Meat from unregistered sources is not permitted. Inspection of butcheries is done routinely and all confiscated meat is destroyed. The city council also licences abattoirs and prohibits sale of meat from unregistered slaughter houses.

• Bulawayo (Noise) by laws. Noise has negative effects on health. The bylaws stipulate what constitutes noise and mitigatory measures against noise.

• Bulawayo (Dog Licensing and Control) by laws. Rabies continues to be a threat to the city’s public health given the city’s proximity to the hinterland. Rabies is a severe disease that affects both animals and humans. It is not curable once symptoms manifest. The bylaws aim to ensure confinement and licensing of dogs. Licensing is done only for vaccinated dogs. Exercises to control stray dogs are conducted from time to time

• Bulawayo (Refuse Removal) by laws control waste management in the city • The Bulawayo model (street Hawkers and vendors) bylaws deal with the licensing of

vendors and hawkers, designation of vending sites and minimum requirements for vendors and street hawkers

The city also uses statutory instruments that are derived from the Food Standards Act. Officials such as medical officers of health are appointed by MoHCC in consultation with the local authority. The Act also provides for appointment of one or more competent health inspectors to carry out the functions of the Act. These inspectors, or environmental health practitioners, are responsible for food and water quality monitoring, investigation of infectious diseases, monitoring of environmental health hazards, enforcement of council bylaws and inspections of business premises and other public buildings. The dismissal of medical officers and health inspectors requires the Minister’s approval except in cases of retirement on account of age, ill health, but a local authority may suspend an official pending sanction by the Minister. It is the duty of the local authority to take lawful precautions to prevent disease outbreaks, when dealing with infectious diseases and to exercise powers imposed or conferred by the Act as in section 14 of the Act. Local authorities may form health committees with the number of members, powers of the committee to co-opt people with special knowledge and skill set by the Minister in regulations.

In the discussions participants noted that sometimes after attending to burst pipes, water from the taps comes out muddy. This was attributed to the need to save water. BCC advised residents to use the water for other purposes than drinking until it ran clear, while assuring that the water will have been chlorinated and safe. To promote safe sanitation, the council was also requiring new houses to have sanitary facilities (plumbing) before connecting the house to water. This ensures that a house that is inhabited has a working toilet.

4.3 Rights, duties and roles and functions of other sectors of government Mr Chigumbu explained that the PHAct is complemented by other laws that are administered by other state departments as shown in Figure 2. He pointed out that the duty to assign administration of laws rests in the Executive arm of government. For instance, the Hazardous Substances Act and the Air Pollution Act used to be administered by the MoHCC but the Executive transferred these acts to the Environmental Management Authority. He outlined the provisions in the Acts that complement the Public Health particularly provisions in Provincial Councils and Administration Act Cap 29:11 , Rural District Councils Act Cap 29:13, Urban Councils Act Cap 29;15, Traditional Leaders Act Cap 29:17, Regional Town and Country Planning Act Cap 29:12, Housing Standards Control Act Cap 29:08, Civil Protection Act Cap 10:06, Shop Licences Act Cap 14:17, Liquor Act Cap 14:12, Traditional Beer Act Cap 14:24, Factories and Works Act Cap 14:08, Animal Health Act Cap 19:01, Education Act Cap 25:04, Environmental Management Act Cap 20:27 and the Water Act Cap 20:24. For instance, the

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Liquor Act promotes public health by controlling the sale and consumption of alcohol and the need for registration of premises that sell alcohol. The PHAct establishes a direct relationship between MoHCC and the Ministry of Local Government based on the principle of decentralisation discussed earlier. The Act allows for the extension of executive powers of the Minister of Health to the Ministry of Local Government to implement and enforce its provisions. The PHAct also bestows powers and responsibilities to the Ministry of Local Government, for instance; Section 14 states thus: “Every local authority shall take all lawful and necessary precautions for the prevention of the occurrence, or for dealing with the outbreak or prevalence, of any infectious or communicable or contagious diseases, and shall exercise the powers and perform the duties conferred or imposed on it by this Act or by any other enactment” The PHAct establishes a relationship between MoHCC and other sectors. For instance, the Act establishes a relationship between the MoHCC and the water sector with regards to water works and water quality standards; with the department of Veterinary Services and the environment sector. Lastly, Mr Chigumbu explained how conflicts with other acts are dealt with on matters relating to public health. Section 110 of the PHACt states that the Act supersedes other laws that are inconsistent or in conflict with it in relation to public health matters. It states:

‘save as is specially provided in this Act, this Act shall be deemed to be in addition to and not in substitution for any provisions of any other law which are not in conflict or inconsistent with this Act. If any other law is in conflict or inconsistent with this Act, this Act shall prevail’.

While the Environmental Management Act has a similar provision, Mr Chigumbu explained that the EMA Act supersedes on issues to do with the environment and the PHACt on public health although in some cases a thin line exists that separates these two spheres. Participants noted in the discussions that coordination across the various stakeholders appeared currently to be weak. The formation of associations like the Zimbabwe Public Health Association was noted as encouraging.

5. Provisions relating to water, sanitation, housing and infectious disease control

5.1 Ensuring healthy urban environments in Bulawayo and in Zimbabwe Mr Ncube presented on how the City of Bulawayo is organised to implement regulations relating to water, sanitation, waste management and the challenges faced in promoting healthy urban environments. The City of Bulawayo health department has two branches; the environmental health and personal health departments. The environmental health branch focuses on prevention aspects, whereas, the personal health branch promotes the curative aspects. The overall roles of the City health department are disease prevention, control and surveillance, pest control, cleansing services, food safety and hygiene, meat inspection, housing and sanitation and water quality monitoring. Mr Ncube explained how each of these roles is met, for instance;

Food safety and hygiene through routine inspection of food premises, food sampling and swabbing of premises, scrutiny and approval of building plans for food outlets, licensing and registration of food premises and conducting training for food handlers.

Water quality monitoring through routine/ weekly water sampling. The city has 100 water sampling points and analysis is done at the council laboratory with quality control being done by an independent/outside laboratory for instance the Government Analyst Laboratory on a quarterly basis. The results are generally satisfactory. In addition, the local authority carries out sampling of bottled water.

Pest control through stream bank clearing, spraying of open water bodies to control mosquito breeding, rodent baiting and control of flies and other vermin.

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Cemeteries and crematorium services through provision of graves, cremation services and identification of new cemeteries. The current city cemetery is full and the local authority is in the process of opening a new site. It is encouraging residents to consider cremation options given the shortage of burial spaces.

Solid waste management: The cleansing section is responsible for solid waste management. Indiscriminate disposal of refuse leads to proliferation of pests and vermin and occurrence of diseases. The local authority currently runs a weekly refuse removal programme in most of the suburbs. Community participation has ensured the weekly refuse removal is rolled out to high density suburbs which previously were on a fortnightly collection schedule. All collected refuse is deposited at the landfill site. Street sweeping is done on a daily basis; in the central business district (CBD), it is done by council workers while residential environs are done by community groups.

Dog licensing and control- see earlier section on bylaws.

Disease surveillance: Curative services are provided at council clinics. The city also has an isolation hospital. The city health department is mandated with the investigation of all notifiable diseases. An Emergency Preparedness Response (EPRT) team is in place to deal with outbreaks. Other key functions are contact tracing, disinfection of contaminated sites, health and hygiene education in schools and communities. The department also studies disease trends and establish possible controls.

Housing: The local authority scrutinise building plans for compliance with public health requirements. It conducts domiciliary visits and investigates complaints on overcrowding and servicing of statutory notices for non-compliance.

Noise nuisances: It involves inspection of premises and advise perpetrators to take remedial action, liaison with ZRP in enforcing the bylaw, prosecution of offenders and enforcing minimum requirements to curb noise nuisances.

Meat inspection: See earlier section on bylaws On challenges in the enforcement of the public health laws, Mr Ncube noted that fines for those who violate the laws are non-deterrent (BCC can issue fines up to level 3; that is $20 only). There is a general disregard of public health law by many stakeholders including communities. Perhaps this may relate to the apparent non-appreciation of the importance of public health issues by the courts. Political interference, where those with political power exert pressure on those who enforce the regulations to be “exempted’ from complying with the law, is also a major challenge. So too is corruption, where enforcers are bribed not to punish offenders. Mr Ncube highlighted that the major challenges relate to the slump in the economy and the stereo-typing of indigenisation. He said that many informal traders view indigenisation as a valid reason for violating proper procedures and laws. Outdated legislation and limited resources such as land for cemeteries also present challenges. In addition, lack of social responsibility by communities and private sector results in the city having to deal with major public health problems that can be controlled at source, for instance waste management practices.

In the discussions, it was noted that the BCC values food safety and hygiene and does visits to premises to check compliance. Mobile food carts were noted to need attention as some of them are violating their terms of operation. They should be towed at the end of each day, have proper sanitary facilities and observe specific standards of hygiene. The local authority carries out swab inspections to check food hygiene. Vending sites (eg for vegetables) lack adequate sanitary facilities for the increased level of informal trading. The local authority is responsible for cleaning the toilets but participants felt that council could arrange with the vendors to organise themselves and do their own cleaning if the council waives part of their rate. The council has suggestion boxes for people to report corruption and other suggestions to improve services. However, informers do not want to testify in court on corruption cases. Bulawayo has recently had a few cases of rabies. With rabies vaccines not available due to cost, the city is focusing on prevention i,e having dogs vaccinated and destroying stray dogs, with 300 stray dogs destroyed in 2015. Recycling was seen as key to improve waste management. Although BCC has one of the best landfills (design and management) in Zimbabwe, valuable waste is still being thrown away in landfills. BCC has introduced innovative approaches in solid

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waste management through use of community based street sweepers and refuse collection services. The community cadres are paid by the council at the end of each month.

5.2 Provisions relating to infectious diseases control and port health Mr Chigumbu highlighted that the Act notes specific diseases classified as “Notifiable Infectious Diseases” that include cholera, typhoid, TB, polio, rabies, leprosy, anthrax, chicken-pox and plague. If any person suffers from one of these diseases, the local authority has to be informed (notified). It is the duty of every person who becomes aware of the occurrence of the disease to notify. This includes heads of schools, orphanages and other institutions, hotel managers, medical practitioners, and so on. Local authorities in turn report the cases of notifiable infectious diseases occurring in their areas of jurisdiction to the Permanent Secretary of Health. The Act provides for measures to be adopted by local authorities to prevent the spread of infectious diseases from an infected person to other people. It provides the manner in which the local authority deals with infected premises, and provides isolation hospitals, mortuaries, disinfection stations and ambulances. The Act allows local authorities to issue removal orders. Exposure of infected persons or things to members of the public is prohibited in the Act, including conveyance of infected people in public transport. Removal and burial of bodies of persons who have died of infectious disease is a regulated by the Act. On Formidable Epidemic Diseases (FEDs), Mr Chigumbu noted that the Act mandates the Minister, when necessary, to declare a disease to be a formidable epidemic disease. Currently plague, cholera and epidemic influenza are classified as formidable epidemic diseases. Measures for controlling FEDs include quarantining and closure of schools, churches, and other places of public gathering. All local authorities are required to report FEDs urgently to the Permanent Secretary of Health who in turn reports to World Health Organisation (WHO). The Act provides for the control of sexually transmitted infections (STIs). The provisions include duties of medical practitioners to educate patients on prevention and treatment. The Act provides for the rights of people with STIs. Mr Chigumbu highlighted the role of International Health Regulations (IHR) in public health. He summarised the port health regulations and what they cover and their role in safeguarding Zimbabwe from diseases from outside Zimbabwe. The regulations provide for the designation of ports of entry, functions of port health officers and powers of entry and inspection. They provide for health measures and procedures on international transportation of goods, import and export of food articles and special provisions relating to cholera, yellow fever, typhus and relapsing fever (for instance the requirements of yellow fever vaccination certificates when someone has travelled to a country with yellow fever) Mr Chigumbu noted some of the key regulations relating to infections disease control including the Public Health (Carrier of Infectious diseases) regulations SI507 of 1943;Public Health (Declaration of formidable epidemic diseases) SI1051 of 1976;Public Health (Declaration of Infectious diseases: Infectious Hepatitis) SI958 of 1973;Public Health (Declaration of Infectious diseases: Malaria) SI 6 of 1959; Public Health (Declaration of Infectious diseases: Marburg and Lassa Fever) SI 1051 of 1976;Public Health (Declaration of Infectious diseases: Smallpox) SI461 of 1948; Public Health (Bilharzia) Control and Prevention Regulations SI 587 of 1971; Public Health (Control of Cholera) Restriction of Public Gatherings Regulations SI371 of 1974. These regulations are enforced by the various public health officers discussed earlier.

6. Provisions on food safety, nutrition, and smoking control

6.1 Provisions relating to food safety Food is defined as any substance or product, whether processed, partially processed or unprocessed, intended to be, or reasonably expected to be ingested by humans (SADC regional guidelines for the regulation of food safety). It includes drink, chewing gum and any substance, including water, intentionally incorporated into the food during its manufacture, preparation or treatment. It does not include medicines covered by the Drugs and Allied Substances Control Act

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[Chapter 15:03]. The primary legislation relating to food is the Food and Food Standards Act Chapter 15:04 and the Public Health Act and their regulations. Food safety includes inspection and enforcement services, laboratory analysis, scientific information gathering and analysis, product tracing, crisis management systems, safety of imported and exported foods, novel foods and technologies. The role of the state in this is to:

establish policies and standards governing the safety and nutritional quality of all food sold in Zimbabwe;

carry out foodborne disease surveillance for early detection and warning; enhance public health surveillance to provide immediate information on outbreaks of

foodborne illnesses; administer and enforce all national laws related to food inspection; Inspect and regulate registered establishments which are generally those that move

products across provincial or national boundaries. Mr Chigumbu outlined the provisions of regulations under the PHAct on food.

Public Health (Abattoir, Animal and Bird Slaughter and Meat Hygiene) Regulations SI 50 of 1995. The regulations provides of the registration of slaughter houses, construction and facilities at slaughter houses, the slaughtering of animals and poultry, the handling, dressing and inspection of the meat, packing, marking, storage and transport of carcasses among other areas.

Public Health (Breast Milk Substitutes and Infant Nutrition regulations) SI 163 of 1998;

Public Health (Condemnation of Foodstuffs) SI 235 of 1948

Public Health (Contamination of Food) SI 474 of 1973

Public Health (Effluent) Regulations) SI 638 of 1972

Public Health (Port Health) Regulations SI 200 of 1995

Public Health (Medical Examination) (Food Handlers) Order SI 41 of 1994 He presented on regulations relating to breast milk substitutes and infant nutrition (Statutory Instrument 46 of 1998) covering the establishment of an Infant Nutrition Committee, education and information on infant nutrition, labelling of designated products, advertising, donations, samples, and special offers of designated products, marketing personnel and quality standards. In the discussions, delegates suggested that public health enforcement has suffered due to officials not having a passion for the work. The porous ports of entry were noted as areas of concern. The MoHCC noted that beyond legally requiring medical examinations of food handlers, it is working on a training programme for the food handlers for effective protection of public health. Zimbabwe currently has challenges with people who die in other countries as their death certificates do not show enough information to allow Zimbabwean authorities to assess the risks posed, given the need to combat infectious diseases like ebola, yellow fever and cholera

6.2 Food labelling and smoking control regulations Smoking control regulations Mr Kadungure, TARSC, outlined trends in tobacco smoking in Zimbabwe using recent survey data from Zimbabwe and WHO. He noted that one in ten adults die globally due to smoking. There is no safe level of smoking and the risk rises with duration and frequency. Adolescents and females are more susceptible to smoking. Second-hand smoke harms all who are exposed. In a survey done by Bandasson and Rusakaniko in 2010 covering six secondary schools in Harare and a sample of 650 children, 29% had ever smoked (18.5% female, 37,8% male). Smoking was associated with higher economic status, parents who smoked, peers who smoked and alcohol consumption (16 times more likely). A Global Youth Tobacco Survey (GYTS) done in 2012 showed that 20% of Zimbabwean students are using tobacco products.

“…according to the survey findings, as high as 20% of youths were using tobacco products, 11.2% of whom were current users. “These statistics are alarming, especially considering that only 22% of adults are estimated to be using tobacco products according to the 2011-2012 Zimbabwe Demographic and Health Survey”

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0

20

40

60

80

100

Present Written

at the

top

Written

across

the full

width

Covers

10% of

surface

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Present Written

at the

top

Written

across

the full

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Covers

2% of

surface

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"Danger: Smoking is harmful to Health" Nicotine and tar content

%

“...the results of the GYTS have shown that there is need to enhance capacity as a country to design, implement and evaluate tobacco control and prevention programs. “This will save lives, reduce illness, and help reduce the economic burden associated with tobacco related illness and lost productivity” Dr A Chimusoro, WHO, 2014

The law is a public health measure in smoking. It can help the public and the state to control illicit trade, sales to and by minors, reduce demand and use through prices and taxes; regulate packaging, labelling, advertising, and reduce exposure to smoke. Entitlements can also be set on information, education, cessation services and treatment of dependence. The WHO Framework Convention on Tobacco control (FCTC) approved by member states in 2003 encompasses evidence-based demand and supply side measures to reduce availability, acceptability and use and assist people give up tobacco. The interventions include price and tax measures, health warnings on packages, banning advertising, sales to minors and smoking in public places; controlling illicit trade, and education, training and treatment of dependence. He introduced the Public Health (Control of Tobacco) Regulations SI 264 2002 that controls smoking in public premises, on public transport, requires no smoking signs in public places, prohibits trading of tobacco to or by children and sets messages of certain size and wording on tobacco and product ingredients. He outlined the definitions in the regulations (Box 4)

Box 4: Key definitions in the Public Health (Control of Tobacco) Regulations 2002, SI 264 "advertising" includes any communication by or on behalf of a tobacco company to consumers which has the aim of encouraging them to select one brand of tobacco over another; "cigarette" means any product that consists wholly or in part of cut, shredded or manufactured tobacco or any tobacco derivative and rolled in a single wrap of paper that is capable of being smoked without further fabrication or processing; "consumer" when used in connection with "advertisement" it refers to the person to whom the advertisement is directed as well as to any other person who reasonably can be expected to be reached by the advertisement and, when used in connection with sponsored activities, it refers to those who are permitted to attend the particular event; "designated area" means an area designated in terms of section 3 or 4 as an area in which smoking is not permitted; "food premises" means any premises licensed in terms of the Shop Licences Act Chapter 14:17 where food is prepared or sold for consumption on or off the premises with or without any further preparation; "public premises" means any premises whatsoever, other than private residential remises, to which any person or class of persons has access or is entitled to be; “"point-of-sale advertising" refers to advertising that is located within or attached physically to a retail

outlet for cigarettes;

The regulations requires warning messages to state the following:

Danger: Smoking is harmful to health- Tobacco smoke contains many harmful chemicals such as carbon monoxide cyanide, nicotine and tar, which can cause disease and death. Non-smokers and ex-smokers, on average live longer and are healthier than smokers.

Tobacco is addictive- Nicotine in tobacco is a drug which acts on the brain and nerves. Most smokers are

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01020304050607080

Schools Health

facilities

Recreational

places

Public

transport

TOTAL

Trading premises

%

written signs present picture signs present

signs visible from the entrance signs legible

dependent on nicotine that is why they feel uncomfortable and get ravings when they go without smoking for a while

Causes cancer (special warning on snuff and chewing tobacco)

For packages containing manufactured cigarettes mgs tar and mgs nicotine.

The regulations specify the size, percentage of container and location of messages for packs, banners, film/video/television and audio advertising. However a TARSC cross sectional survey in November 2010 found poor enforcement of the law (show in the two graphs above and photograph below) especially in public places, schools and shops. The assessment found that some areas of the law were being implemented, for instance; health warning messages were generally present, local tobacco brands were implementing legal requirements on health warnings, health facilities and airports were mostly compliant on “no smoking” signs, service station shops, some tuck shops had health warning messages and age restriction signs at the place where tobacco is sold. Many areas in the regulations were not being implemented: Health warning messages on billboards, print adverts were wrongly placed (bottom) wrong size (too small), health warnings in radio adverts were not complete, (exclude tar/nicotine levels; and not at the end, in English; and misleading). A majority (87%) of imported tobacco packages were not compliant, all packs had competing promotional messages, there was non-compliance with no smoking and signs in schools, recreation, retail, public transport facilities. There were no warning messages or age restriction signs in supermarkets and in places where cigarettes were displayed. Artwell called for improved protection of public health by;

improved awareness of the risks of smoking and of the current regulations, promotion to ensure smoke free environments,

key stakeholders to have to know and enforce the regulations, eg Ministry of Education, media editors, National Social Security Authority inspectorate, Zimbabwe Republic Police, local government, retailer associations,

include SI264 provisions in local authority by laws; stronger local authority enforcement no smoking programmes in schools, upward revision of penalty for breach of the law, prohibit all tobacco advertising and increased tax on cigarettes earmarked for public health, cessation programmes

Top: Graph showing compliance with warning messages on tobacco packages. Middle: Graph showing compliance in relation to “no smoking signs” . Picture at the bottom: A specimen billboard that was not complying with regulations. Source: TARSC 2010

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Food labelling regulations: Mr Kadungure presented on implementation of regulations relating to: (i) Breast Milk Substitutes and Infant Nutrition (SI 46 of 1998) under the Food and Food Standards Act and the (ii) Food Labelling regulations (SI 265 of 2002) under the Public Health Act. The 2004 WHO Global Strategy on Diet states that consumers require accurate, standardized and clear information on the content of food products. Breast milk protects against disease and there are health risks associated with formula feeding and early weaning, including diarrhoea and ear infections. In 1981, the World Health Assembly thus adopted the International Code of Marketing of Breast milk substitutes. He outlined provisions of the regulations and evidence on compliance with them from a 2013 TARSC survey; summarised below.

Table 2: Summary of the findings showing compliance for key areas of the law

Key provisions of the law % labels complying

Colour code*

Food labels

Label should accurately describe the contents 96

Label should not create a false impression of the product 92

Label should not suggest food to be similar to another food 89

Label should have a common/usual name of the food 92

Label should be in in English 98

Label should be clear, indelible, prominent and legible 94

Label should be in contrasting colour to the background 96

Label font is should be at least size 6 font 89

Label should be conspicuous on the package 90

Label should show the name and business address of Manufacturer 97

Label should show the site of production 93

Label should show mass/measure/numerical count 95

The mass should be written with at least size 12 font 75

Label should show the expiry date 80

Label should show the packaging number/ date of packaging 52

Label should show the common name of each ingredient 62

Breastmilk substitutes and infant nutrition

The label should be in English 95

Label should not be easily separated from container 71

Label should show the conditions the food must be stored in 88

Label should show the batch number 85

Label should show the date before product must be consumed 94

Label should show manufacturer's name and address present 99

The label should state the exact ingredients used 100

The label should state “the product is a supplement to and not a replacement of breast milk “

69

Label should show the age at which the product should be used/introduced 90

The label should have the following words

"Breast milk is the best food for your baby" 88

"It protects against diarrhoea and other illness" 64

The words above should be prominent and in bold 63

Words should not be less than 10 point size font 57

Words should be in black against a white background 59

Label should warn that it should not be the sole source of nourishment 69

The label should have the instructions for preparation of the food 97

Label should state ‘continue breastfeeding a child as long as possible’ 79

Label should have a statement on the superiority of breastfeeding 82

Label should state to use only after seeking advice from a health worker 78

Label should warn on health and other hazards of improper preparation 77

Above words should be in bold in not less than size 8 font 45

The word " Important Notice" should be present 84

The above word should be is greater than 10 point size font 45 Key to Colour coding: Green: Compliance is 90% and above, Yellow: Good Compliance is between 80% and

90%, Red: Compliance is below 80%. Source: TARSC, 2013

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In the discussion, participants raised concern with the practice by cigarette manufactures to introduce smaller packs (some with two cigarettes) as this promotes access to tobacco in young people. They raised the need for awareness on the negative public health effects of tobacco use as some parents passively expose their children to tobacco at an early age by sending the children to go and buy them cigarettes from the shops.

6.3 Overview of public health regulations Mr A Chigumbu highlighted that a number of regulations have been promulgated by the Ministers of Health and Child Care over the years under the Public Health Act. The regulations deal with infectious diseases, sale of articles of food, infant nutrition, sanitation and housing and so on. He outlined the key regulations and the areas they cover (some of these had been covered in prior sessions). Some of the key regulations are:

Public Health (Carrier of Infectious diseases regulations) SI507 of 1943; Public Health (Declaration of formidable epidemic diseases) SI1051 of 1976; Public Health (Declaration of Infectious diseases: Infectious Hepatitis) SI958 of 1973; Public Health (Declaration of Infectious diseases: Malaria) SI 6 of 1959; Public Health (Declaration of Infectious diseases: Marburg and Lassa Fever) SI 1051 of

1976 Public Health (Declaration of Infectious diseases: Smallpox) SI461 of 1948; Public Health (Abattoir, Animal and Bird Slaughter and Meat Hygiene) Regulations SI 50

of 1995 Public Health Advisory Board regulations 1966; Public Health (Bilharzia) Control and Prevention Regulations SI 587 of 1971; Public Health (Breast Milk Substitutes and Infant Nutrition) Regulations) SI 163 of 1998; Public Health (Condemnation of Foodstuffs SI 235 of 1948 Public Health (Contamination of Food SI 474 of 1973 Public Health (Control of Cholera) Restriction of Public Gatherings Regulations SI371

1974; Public Health (Effluent) Regulations SI 638 of 1972 Public Health (Medical Examination) (Food Handlers) Order SI 41 of 1994 Public Health (Port Health) Regulations SI 200 of 1995; Public Health (Control of Tobacco) Regulations SI 264 of 1997 (rev 2002). The following are some of those that enforcement officers should be regularly enforcing. Public Health (Abattoir, Animal and Bird Slaughter and Meat Hygiene) Regulations SI 50

of 1995. These regulations control the slaughter of animals and birds for meat for public consumption. Under these regulations, slaughter facilities must be registered by the local authorities and all meat must be inspected by a meat inspector.

Public Health (Breast Milk substitutes and infant nutrition regulations) SI 163 of 1998; these regulations control the sale and advertising of breast milk substitutes or infant formulas.

Public Health (Condemnation of Foodstuffs) SI 235 of 1948. These are important old regulations which enforcers should use in dealing with foods that contravene the Act and food regulations. The regulations simplify the condemnation procedure. While in the Food and Food standards regulations food inspectors have to take 3 official samples of the suspected food for laboratory analysis to confirm their findings, these regulations allow the inspector to condemn the food using the results of his physical inspection.

Public Health (Contamination of Food) SI 474 of 1973. The regulations lay down measures to be taken to prevent contamination of food intended for sale by pet food and rough offals.

Public Health (Control of Cholera) Restriction of Public Gatherings Regulations) SI371 1974;

Public Health (Effluent) Regulations) SI 638 of 1972 Public Health (Medical Examination) (Food Handlers) Order SI 41 of 1994 Public Health (Port Health) Regulations SI 200 of 1995; Public Health (Control of Tobacco) Regulations SI 264 of 1997 (rev 2002).

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In the discussions, Mr Chigumbu noted that it was easier to prosecute using the Public Health regulations than regulations under the Food and Food Standards Act as no samples are required when using the former. Access to the regulations was raised by delegates as a gap; soft copies of regulations and mobile applications could enhance access to these key regulations.

7. Implementation of the Act

7.1 Actors, roles, duties and incentives Mr Chigumbu noted the levels of actors involved in the implementation of the Act from supervision and monitoring by the Chief Health Officer to enforcement by health inspectors. On the incentives and capacities relating to enforcement of the PHAct and its regulations, he noted the protection of state and local authorities, protection of officers, powers of entry and provisions relating to the primacy of the PHAct on public health matters. Other incentives provided in the Act include;

refund of one-half of the cost of providing and equipping an isolation hospital,

refund of one-half of the cost of managing and maintaining an isolation hospital and

refund of two-thirds of the cost of preventing, investigating, dealing with or suppressing outbreaks of formidable epidemic diseases, including, where necessary, the provision of temporary isolation hospital accommodation.

Mr Chigumbu outlined the process of preparing a prosecution. Enforcement of public health legislation has been progressively low over the years due to a number of reasons. These include the downplaying of the enforcement role vis-a-vis the public health educator role; inadequate hands on training on enforcement; fear of the unknown; non availability of public health legislation for reference and for training; attitude of prosecution and judicial officers towards public health cases brought to the courts and inadequate public health enforcement officers on the ground. He identified key gaps in capacities to enforce the law as inadequate hands-on training on enforcement, non-availability of public health legislation for reference and for training as well as inadequate public health enforcement officers at community level.

In the discussions, participants noted that implementing the law is supported by wider knowledge of the Act. They suggested programmes like the training course should cover as many districts as possible and should include diverse stakeholders. It was felt that effective enforcement should be based on proactive actions and partnerships rather than concentrating on sanctioning and punitive measures only.

7.2 Role of the Zimbabwe Republic Police Superintendent Moyo, Zimbabwe Republic Police, presented on the role of the ZRP in the implementation of the Act. He first provided the legal framework for the institution of the ZRP, citing the provisions in the 2013 Zimbabwe Constitution. The ZRP enforces all laws in Zimbabwe and in some instances, the ZRP is complemented by officers in state departments who are empowered to enforce laws as the case with the PHACt. He outlined some examples, quoting sections from the Act, where the ZRP can investigate, detect and prevent crimes.

o Section 18 Notification of infectious disease: “1.Whenever any child attending any school, orphanage or other like institution, or any person residing in any hotel, boarding-house or other like institution, is known to be suffering from any infectious disease, whether such infectious disease is specified in this part or not, the principal or person in charge of such school, orphanage or other like institution, or the manager or proprietor or person in charge of such hotel, boarding-house or other like institution shall forthwith send notice thereof to the local authority of the district, and shall furnish to the medical officer of health, on his request, a list of scholars or residents thereat, together with their addresses. 2. Any person who fails to give any notice required by subsection (1) shall be guilty of an offence and liable to a fine not exceeding level four or to imprisonment for a period not exceeding three months or to both such fine and such imprisonment.”

o Section 19 Notification by Medical Practitioners: “ (1) If a patient suffering, to the knowledge of the medical practitioner attending him, from an infectious disease dies

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there from, such medical practitioner shall immediately furnish to the local authority of the district a written certificate containing the appropriate particulars mentioned in subsection (1).2) Any medical practitioner who fails to furnish a certificate of notification as required by this section shall be guilty of an offence and liable to a fine not exceeding level four or to imprisonment for a period not exceeding three months or to both such fine and such imprisonment, and in any prosecution under this section the onus shall be on the medical practitioner charged to show that he was unaware that the patient was suffering from or the deceased had died of an infectious disease.”

o Section 29 Removal orders: “An order made under section twenty-four or twenty-eight may be addressed to any duly authorized officer of a local authority or any Police Officer. Any person who wilfully obstructs the execution of, or fails or refuses to comply with, any such order shall be guilty of an offence and liable to a fine not exceeding level four or to imprisonment for a period not exceeding three months or to both such fine and such imprisonment.”

o Section 69 Sale of unwholesome, diseased or contaminated articles of food prohibited. “(1) No person shall sell, or shall prepare, keep, transmit or expose for sale, any milk, dairy produce, meat or other article of food which is not clean, wholesome, sound and free from any disease or infection or contamination; and no person shall collect, prepare, manufacture, keep, transmit or expose for sale any such article without taking adequate measures to guard against or prevent any infection or contamination thereof2) If any person contravenes subsection (1), he shall be guilty of an offence and liable to a fine not exceeding level six or to imprisonment for a period not exceeding six months or to both such fine and such imprisonment.”

o Police inspect butcheries: Section 90 Examination of premises licence. The ZRP check for certificates of registration, protective clothing, medical health certificates, hanging of meat (in cold room), mixing of meat in the same trays (beef, pork, goat meat), whether meat is inspected or not, and general cleanliness in the butchery.

o Section 78 Licence required for use of premises as slaughter-house: “(1) No person shall use any premises as a slaughter-house within the district of a local authority unless he is personally licensed in respect of those premises.(2) Any person who contravenes subsection (1) shall be guilty of an offence and liable to a fine not exceeding level seven or to imprisonment for a period not exceeding six months or to both such fine and such imprisonment.”

In the discussions, it was noted that while the ZRP is mandated to enforce the Act, it was ideal that it collaborates with officers and inspectors in the MoHCC for technical support to avoid sending mixed and sometimes contradictory signals to the business community. In some cases, it would be good to do the inspections together. In addition, ZRP should also prioritise awareness and information in as much as it should apprehend and prosecute those who violate the Act.

7.3 Proposals for Action to strengthen implementation B Kaim and A Kadungure, TARSC and A Chigumbu, Public Health Consultant facilitated a session on development of proposals for action to strengthen implementation of the Act and its regulations (and bylaws) in Bulawayo. Building on the participatory session during first day of the workshop and discussions during the presentations, Mr Chigumbu facilitated a discussion on the priority issues for action. In buzz groups, participants wrote on cards areas their proposed areas for follow up. The cards were put on the floor in clustered under each theme and reviewed by the group.

Participants work on proposals for follow up in groups (c) TARSC 2016

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Two themes emerged as key areas for follow up, i. widening information awareness on the Act and; ii. strengthening coordination and networking on the implementation of the Act

Based on these two areas, participants were organised into four groups, with two groups working on proposed area one and the other two on proposed area two. Groups were asked to identify the actions/ activities, roles and outcomes on each area. The principles for selecting the activities were that they should not require huge additional resources, were realistic and addressed the key issues discussed during the meeting and that an evaluation could be done by November 2016. After the group work, presentations and discussions were done in plenary. The following issues emerged; On widening awareness: The BCC would lead awareness campaigns with support from all the institutions that participated in the training workshop. It was agreed that BCC would develop information leaflets on the Act outlining the key areas, community roles, private sector roles, local authority roles and key or selected public health programmes being implemented in Bulawayo. The materials should contain the logos of all the organisations for ownership. Organisations will use their current work programmes as well as joint platforms to make people aware of the provisions of the Act and their roles. BCC could also identify one key area, say solid waste management, which is cross cutting and use it as a case for widening awareness on the Act. Besides information dissemination, it was also agreed that it is important to create awareness through dramas on specific public health areas (eg tobacco smoking and the health effects) in schools. In the meeting, the BCC noted that they are currently using community based approaches in waste management and it was felt that this should be used as an entry point for widening awareness. Several strategies were identified for use in widening awareness such as local newspapers with stories of change, link stories of change to the provisions of the Act, regulations and bylaws; negotiating for talk show space with local radio and television stations. Flyers with key messages should be produced and distributed by the various organisations in their networks and through posters in city of Bulawayo clinics, at workplaces and workers union meetings. Schools were identified as strategic areas for disseminating information. Participants noted the need to bring the Ministry of Education to the table. Churches were considered as strategic areas of focus for widening awareness through presentations when they gather for specific events. It was agreed that awareness would be done at two levels: At the primary level targeting communities, councillors, business leaders (through their business forums), religious leaders and informal traders as well as residents associations while at the secondary level the strategies would target, through meetings, those who enforce the law to ensure that public health is prioritised (police, health inspectors). The BCC would take a leading and coordinating role on this. Priority areas for widening awareness were noted as water and sanitation, solid waste management and tobacco control. “The BCC working with us could use an innovative strategy to widen awareness. We could introduce a competition on hygiene in selected suburbs and reward communities that keep their streets clean through reduction of rates for a limited period of time”

Contribution from a participant. On awareness, the following priority outcomes were noted;

i. a sense of belongingness to the PHAct as measured by the level of participation of stakeholders in public health related activities,

ii. increased knowledge on the existence and a few key provisions of the Act by school children, teachers, residents and informal traders and

iii. organizations starting to act in their areas even on smaller issues like supporting community based solid waste management.

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Some outcomes were noted as longer term such as realising a cleaner city, healthy people and environment and increased collaboration between the BCC, communities, other state departments, CSOs and business people on public health. These were noted but it was agreed that they were be difficult to achieve within a year. Summary of roles:

o Design of materials for use in awareness campaigns- BCC and TARSC by July 2016. o Printing of materials- BCC (organizations with budgets should support) by August 2016. o Coordinating the process: Each institution, after the workshop will identify and map

constituencies they can reach based on their current programmes. BCC to take the leading coordinating and documentation role by July 2016.

o Implementation of the awareness programmes: Institutions, after consulting their directors, decide on the timing, institutions to invite all the others so that it a collaborative activity. BCC to take a leading role in coordinating and follow up.

The programme would be reviewed in September and November 2016 On strengthening coordination, it was felt that the awareness activities will achieve this objective indirectly. Already, Bulawayo city council has a solid waste improvement platform that provides a forum for stakeholder involvement. It was felt that having another public health platform at this instance was not ideal, but the current platform needs to be revitalised and inclusive. It should include all key state departments, teachers associations, ZRP, EMA, media representatives, private sector representatives and CSOs (Faith Based Organisations, vendor associations and so on). It was noted that the existing forum should be used for disseminating information on the other key areas of public health. The forum can identify people who can present on public health issues the forum discusses as public lectures in relevant spaces. Summary of Action

o Identity stakeholders and invite them to join the current forum- BCC, by July 2016

8. Final sessions

8.1 Proposals for the review of the Act Mr Kadungure, outlined the reasons why it was necessary to review the Act, including in terms of its piecemeal revisions and fragmentation, the need to apply the law to new hazards, to address gaps, including in the rights and principles, provisions for affirmative action, ensuring coherence with other laws and to comply with International obligations. Other reasons were to review the roles and powers needed to implement duties and functions and promote an affirmative, proactive, partnership approach beyond the reactive, ‘nuisance’, restraining approach. In 2010 the Minister of Health and Child Care asked Public Health Advisory Board (PHAB) to review Act. In 2011 the PHAB through a technical working group held various stakeholder forums, circulated a White Paper, held focus groups in 10 districts; obtained 29 written submissions and consulted specific technical expertise nationally and internationally. The final proposals were reviewed by the Technical Working Group, national stakeholders and the Public Health Advisory Board. A principles document was submitted to the Minister of Health and Child Care in late 2011 for the legislative process. The Principles were reviewed internally by MoHCC and were taken to cabinet for the legislative process. The process of drafting the Public Health Bill is in process. The broad issues in the review were that it should not weaken, dilute or reduce the powers in the current Act; that the Act remains the umbrella Act in public health and applies to the state. Definitions were updated and 20 proposals were made within five broad areas of

principles, vision, objects, rights, responsibilities, duties and powers, public health functions, the public health system and implementation and enforcement of the law.

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He detailed the proposals for review which are captured in full in the final stakeholder meeting report and background document from the PHAB that was given to the participants. The proposals provide for a preamble that states a broad vision for public health and objects that clarify the mission of the state and other actors in public health, cross referencing for promotion of beneficial links and effective co-ordination across health laws within Ministry of Health Child Care and with health laws under other Ministers. He noted that the review would strengthen the framing of rights in the Act, and the general duty to prevent harm to health. The review provided for new measures, such as health impact assessments, for powers for the state to restrict individual freedoms in specific circumstances to protect public health in line with human rights and restraints set in the Siracusa Principles, duties on individuals (including corporate individuals) to prevent wilful and intentional harm to health; eg deliberate transmission of HIV, exposure to harmful substances and strengthened the framing of Intersectoral mechanisms and co-ordination on the social determinants of health. New provisions provided for health promotion and non-communicable disease control. Mr Kadungure noted that the Act retained a decentralised approach, in line with capacities, with greater attention to roles and mechanisms to involve communities and stakeholders in decisions and actions on health. There was need to widen / update membership of the Public Health Advisory Board for stakeholder participation and update the provisions for the public health workforce. The proposals also included powers for the Minister to mobilise resources from a range of specified sources and for stronger, graded penalties and incentives for good practice and provision of public information to support implementation. In the discussions, participants noted that TARSC and MoHCC should continue leading the awareness programmes through the training course even when the new Bill is enacted into law so that communities and stakeholders are made aware of the new provisions. Technologies could help in this work, for instance through mobile applications on the Act and what people can do in their areas to strengthen knowledge and application of the law. The biggest gap identified in the current Act relates to financing and it was pleasing to note that this has been addressed in the review process.

8.2 Course evaluation At the end of the training course, participants completed an evaluation form and discussed their views in plenary. A total of 30 participants completed the formal evaluation. The evaluation showed that all (100%) the participants felt that the training was relevant to their work or roles and was useful. Participants rated the quality of trainers and materials highly with all participants rating both as good. Participants understood most of the issues discussed during the training course with an average of 63% understanding all sessions. Sessions were rated as relevant and useful by an average of 87% of the participants. Participants felt that more time would be desirable for discussions. It was commended that the meeting was well conducted and organised. The full results of the evaluation are shown in Appendix 3.

8.3 Closing On behalf of CC, Mr Ncube thanked TARSC for the training programme. Participants were now armed with capacities that are vital in strengthening implementation of the public health laws in Bulawayo. He hoped that the skills gained would be used in implementing the public health action plans. On behalf of the MoHCC, Mr Mangwadu thanked all participants for attending the training noting that the main aim of the programme is to build wider awareness of the current provisions to strengthen their implementation even as the review process is ongoing. In areas like management of solid waste, communities and other stakeholders are important. This awareness is thus important. Despite a challenging economic environment, it is vital that public health issues are safeguarded. The MoHCC may not have adequate resources and welcome initiatives with partner institutions for the promotion of public health. He thanked TARSC personnel, BCC and all the presenters for the successful workshop.

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Mr Kadungure thanked the participants, presenters, MoHCC, BCC, TARSC personnel and MoHCC support staff and OSISA for the financial support. He was happy that delegates were enthusiastic about the follow up process and that BCC would take the leading and coordinating role. The small steps in strengthening implementation of the law provide building blocks for other support processes by other partners and stakeholders. It is TARSC’s desire to have similar trainings in other districts. After these closing remarks, Mr A Kadungure, Mr Chigumbu and Mr Mangwadu presented certificates of completion to the participants.

Participants follow proceedings during the training workshop © TARSC 2016

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Appendix 1: Programme BLOCK COURSE TITLE FACILITATOR

Monday 9 May 2016

Opening, objectives and issues faced in public health in Bulawayo and Zimbabwe

0845-0915hrs

Welcome, Delegate Introductions Delegate expectations, Objectives of the training course, outline of the programme Key note address: Background and overview of the Public Health Act

Mr P Ncube, Environmental Health Dept, City of Bulawayo A Kadungure, TARSC Mr G Mangwadu, Director: Environmental Health Services, MoHCC

0915 to 1030hrs

Public health challenges and opportunities in Bulawayo district, in Zimbabwe: Participatory Exercise

B Kaim, TARSC

1030-1100 hrs Tea Break

Functions, rights, duties and powers in the Public Health Act

1100-1200hrs Roles, duties, functions and powers of central government, private sector and communities Discussion

Mr A Chigumbu, Public health Consultant, UNICEF

1200-1300hrs Roles, duties, functions and powers of Local government. City of Bulawayo Public Health By-laws Discussion

Mr P Ncube, City of Bulawayo

1300-1400hrs Lunch

1400 to 1500hrs

Rights, duties and roles and functions of other sectors of government in public health. Discussion

Mr A Chigumbu, Public health consultant,

Provisions relating to water, sanitation, housing and infectious diseases control

1500 to 1600hrs

Legal provisions and roles relating to water, sanitation, waste management, housing and their enforcement Discussion

Mr P Ncube, City of Bulawayo

1600-1630hrs Tea and departure

Tuesday 27 April 2016

0830-930hrs Provisions, regulations and their implementation in relation to infectious disease control

Mr A Chigumbu, Public Health Consultant, UNICEF

Provisions relating to food safety, nutrition, port health, smoking control

0930 to 1030hrs

Provisions, regulations and roles in relation to food safety and nutrition, port health. Discussion

Mr A Chigumbu, Public Health Consultant;

1030-1100hrs Tea

1130-1215hrs

Food labelling and smoking control regulations A Kadungure, TARSC

1215-1300hrs Overview of the public health regulations, what they cover. Discussion

Mr A Chigumbu, Public Health Consultant

1300-1400hrs Lunch

Implementation of the Act

1400 to 1500hrs

Implementation of the Act: Actors, roles and duties, incentives and capacities.

Mr A Chigumbu, Public Health Consultant

1500-1600hrs Facilitated plenary discussion on proposals for action to strengthen implementation of the Public Health Act and its regulations in Bulawayo.

B Kaim, TARSC and Mr A Chigumbu, Public Health Consultant

Concluding sessions

1600-1630hrs Proposals for the review of the Public Health Act A Kadungure

1630-1640hrs Course Evaluation, Discussion Mr A Kadungure, TARSC

1640-1700hrs Course certificates, closing remarks Mr G Mangwadu, MoHCC M Mr A Chigumbu, UNICEF Mr A Kadungure, TARSC

1700 hrs Tea and departure

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Appendix 2: Participants’ list

FULL NAME AND TITLE M/F NAME OF ORGANISATION,

Agrippa Tsumba, Program Manager M Umuzungwane AIDS Network, 0288-449

ZororoZenda, Vice President M Zimbabwe Chamber of Informal Economy (ZCIEA)

MusawenkosiNyoni, president M ZCIEA

KundaiChedundo, Provincial Engagement Coordinator

F Community Working Group on Health

NonjabuloMhlangu, Program manager F Community Working Group on Health

Foster Matyatya, Social Accountability Advisor M Save the Children, Zimbabwe

Lister Dube, Assistant Social Services Officer F Mangwe Rural District Council

NdlobvuNkosilathi M Zimbabwe Republic Police

Jeremiah Takavarasha, M Zimbabwe Republic Police

Mandlenkosi Moyo M Zimbabwe Republic Police

Alice V.Wabatagore, Program Officer(HIV& AIDS) F National Railways of Zimbabwe

BhaktibenChapaner, President F Zimbabwe Occupational Health Nurses Association

Simon Malunga, Occupational Nurse M Delta Beverages, Bulawayo

Vannessa Sandra Chasi F Kingdom Partnership Relief

Peter Mkandla, Program coordinator (HIV&AIDS) M Umuzingwane AIDS Network

Joseph Nkomazana, Resident M Resident

BandilleMaduma M African Women Initiatives in Developing Economies (AWIDE)

McebisiMadundulu M AWIDE

Huda Moyo F AWIDE

Nhlowipho P Sibanda F Bulawayo City Council

Patrick Ncube M Bulawayo City Council

Precise Tshuma F Zimbabwe Congress of Trade Unions

Margret Gwati F Department of Veterinary Public Health

Barbara kaim F Training and Research Support Centre (TARSC)

HlomphoNalepiKulube F Environmental Management Authority

SandisiweSibanda F Mangwe Rural District Council

SikhanyisiweDube, District health Field Officer F CORDIAD

Pharcah Mlambo, District Health Field Officer M CORDAID

Abednego Chigumbu M Facilitator

Jeffrey G Chimbo, Veterinary Meat Inspector M Veterinary Public Health Dept

SibongileMbanje, Securing Rights Project Officer F Hope for A Child For Child Christ

MongiKhumalo, Project officer M CWGH

Pretty Ndlobvu, Registered General Nurse F Zimbabwe Association of Church Hospitals

Sunga Mzeche, Director F Hope for A Child In Christ

Wilson Mangena, Teacher M Zimbabwe Teachers Association (ZIMTA)

AlsonNtini, Provincial Executive Officer M ZIMTA

SimangileNgwenya, Program Officer M Matabeleland AIDS Council

Mandy Mathias, Program Officer F CWGH

Mildred Banda, Program Officer F Matabeleland Aids Council

Artwell Kadungure, Programme Officer M Training and Research Support Centre (TARSC)

Mr G Mangwadu, Director M Ministry of Health and Child Care, Env Health Dept

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Appendix 3: Evaluation results

1. This skills training course is (N=30)

Relevant to my work or role Not relevant to my work or role

100% 0%

2. Overall, this training was (N=30)

Very useful Useful Party useful Not useful

97% 3% 0% 0%

3. The trainers were (N=30)

Very good Good Poor Very Poor

50% 50% 0% 0%

4. The materials were (N=30)

Very good Good Poor Very Poor

43% 57% 0% 0%

5. The venue for the course was (N=30)

Very appropriate Somewhat appropriate Not appropriate

80% 20% 0%

6. Communications from organizers was (N=30)

Very good Good Poor Very Poor

60% 4% 0% 0%

SESSION NAME Percent distribution of responses on (N=30) UNDERSTANDING OF

SESSIONS (N=30)

RELEVENNCE AND USEFULNESS

(N=30)

CLARITY AND USEFULNESS OF

MATERIALS Under-stood all

Understood

most of it

Did not

understand

Relevant and useful

Partly relevant and useful

Not Relevant and useful

Clear and useful

Partly clear and useful

Not Clear and Useful

1. Welcome, introductions and course objectives

70 30 0 87 13 0 93 7 0

2. Participatory exercise: Public Health Challenges and opportunities in Bulawayo and Zimbabwe

63 37 0 100 0 0 83 17 0

3. Roles, duties, functions and powers of central government, private sector and communities

50 50 0 83 17 0 73 27 0

4. Roles, duties, functions and powers of local government

67 33 0 77 23 0 77 23 0

5. Rights, duties and roles of other sectors of government

63 37 0 87 13 0 77 23 0

6. Ensuring healthy urban environments: legal provisions relating to water, sanitation, waste management, housing and challenges in enforcing the law

63 37 0 83 17 0 77 23 0

7. Provisions, regulations in relation to infections disease control

53 47 0 93 7 0 83 17 0

8. Provisions, regulations, roles in relation to food safety and nutrition, port health and international health regulations

60 40 0 90 10 0 87 13 0

9. Food labelling and smoking control regulations

70 30 0 90 10 0 83 17 0

10. Overview of public health regulations, what they cover

67 33 0 83 17 0 87 13 0

11. Implementation of the Act: Actors, roles and duties, incentives and capacities

63 37 0 80 20 0 77 23 0

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12. Facilitated plenary discussion on developing proposals for strengthening implementation of public health law and regulations in Bulawayo

73 27 0 87 13 0 87 13 0

13. Proposals for the review of the Public Health Act

57 43 0 90 10 0 80 20 0

14. Closing and Next steps 63 40 0 87 13 0 73 27 0

10. How are you going to use the training

Share with colleagues at workplace, neighbors other organisations (formally and informally) x 6

Mainstreaming public health issues in our work and programmes x 5

In our policy advocacy work, debates on public health x 3

Raising awareness on the Public Health Act particularly the youth x 4

In debates that will come during the review of the Public Health Act in my work area.

I will give feedback to VIDCOs and WARDCOs in my area

11. What changes should be made to improve course content delivery, administrative issues

The course is very useful in our work and roles x 4

Such courses should cascade to the community level, they are very useful x 3

I am now aware of my public health rights and I should claim them

No changes, the course was very informative and eye opening x 4

Course was well planned and different players made it more dynamic x 2

You should involve more participants and organizations x 3

Facilitators should have more discussions rather than lecturing x 2

Use more electronic media, maybe include videos of some of the issues covered.

Distribute materials at the beginning of the course

Course required more time (three and half days) and consider a bigger venue x 2

Use local languages in delivery.

Consider covering transport costs of participants

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List of Acronyms BCC Bulawayo City Council CBD Central Business District CSOs Civil Society Organisations DHMC District Health Management Committee DMO District Medical Officer EHT Environmental Health Technicians EMA Environmental Management Agency EPRT Emergency Preparedness Response Team FED Formidable Epidemic Disease GYTS Global Youth Tobacco Survey IHR International Health Regulations LA Local Authority MoHCC Ministry of Health and Child Care NID Notifiable Infectious Disease PHAB Public Health Advisory Board PHAct Public Health Act Ch 15:09 PMD Provincial Medical Director RDC Rural District Council SADC Southern Africa Development Community STIs Sexually Transmitted Infections SWM Solid Waste Management TARSC Training and Research Support Centre TB Tuberculosis WHO World Health Organisation ZRP Zimbabwe Republic Police