A total of 193 people took part in the study through 11 FGDs, 17 IDIIs, and 3 community meetings conducted in rural, peri-urban, and urban settings. Their ages ranged from 18-65 years (see Table 1 for participant distribution).
Table 1: Study participants in Kwekwe District Health Centres (18)
CATEGORY
|
RURAL PARTICIPANTS
|
PERI-URBAN
|
URBAN
|
TOTAL NO.
OF PARTICIPANTS
|
AGE RANGES
|
EDUCATIONAL LEVEL
|
MARITAL STATUS
|
FGDS
|
Pregnant women
|
14
|
8
|
12
|
34
|
17-38
|
22 Secondary school.
10 Primary school.
2 none
|
26 married;
8, not married
|
WOCBA
|
20
|
-
|
15
|
35
|
19- 37
|
27 Secondary school.
5 Primary school.
2 none
|
23 married;
6 widowed;
1 single;
5 divorced
|
Elderly women
|
17
|
-
|
7
|
24
|
53-65
|
11 Secondary school.
9 Primary school.
4 none
|
15 married;
3 single;
6 widowed
|
Spouses
|
-
|
-
|
8
|
8
|
23-65
|
8 Secondary school
|
8 married
|
KEY INFORMANTS
|
Health staff
|
5
|
4
|
1
|
10
|
28- 51
|
10 Secondary school
|
8 married;
2 single
|
Transporters
|
-
|
1
|
-
|
1
|
42
|
Secondary school
|
1 married
|
Pregnant women
|
3
|
-
|
-
|
3
|
23-29
|
Secondary school
|
3 married
|
WOCBA
|
-
|
1
|
1
|
2
|
25-36
|
Secondary school
|
1 married;
1 divorced
|
Spouses
|
-
|
-
|
1
|
1
|
43
|
Secondary school
|
1 married
|
PARTICIPATORY LEARNING APPROACHES (PLA)
|
Community members
|
74
|
-
|
-
|
74
|
27-64
|
57 Secondary school.
12 Primary school.
5 none
|
51 married;
19 widowed;
4 single
|
The sub-themes were organised through the lens of the SEM and sorted with their barriers and enablers towards the RoadMApp MHMW (see Table 2).
Table 2: Socio-Ecological Model of the barriers and enablers towards the RoadMApp MHMW
CATEGORY
|
SUB-THEME
|
BARRIERS
|
ENABLERS
|
Individual-level factors
|
Income/livelihoods;
Distribution of income
|
Low/stable incomes;
Women’s lack of autonomy over finances;
No access to mobile phones;
Financial illiteracy
|
Low coverage of health insurance
|
Community/ Institutional level factors
|
Reducing OOPs;
Community savings;
Banking services;
|
No formal follow-ups on maternal savings;
Culture/religion;
Poor network coverage;
Banking practices
(high transaction charges; limited savings options)
|
Maternal layette list is given at FANC sessions;
Existing ROSCAs in communities;
Existing mobile money services
|
National factors
|
Poor performing economy
|
The high cost of living;
Power outages
|
Availability of funding for maternal healthcare (Results-Based Financing, Government funding)
|
Individual-level factors
Incomes/livelihoods. Mining is the most common source of livelihood in Kwekwe District. It is practiced in established mines as well as in artisanal gold panning shafts. Mostly, it employs men. Women are often engaged in gold panning around riverbeds and the provision of services like food vending for the miners. This was described as an unstable source of income—this potentially compromised women’s autonomy in mobilizing money for maternal savings. Furthermore, the women were at risk of being robbed by rival miners and marauding machete-wielding gangs known as “mashurugwi.” It was challenging to establish the real family incomes from this study due to the unreliability of sources of revenue. Table 3 summarises estimates of income generated from livelihoods to raise maternal savings. The data on Table 3 was obtained in IDIIs as some of the details could not be collected using FGDs. The interview guide with questions on financial strategies is available (18). At the time the data was collected the rate between the USD and the Zimbabwe dollar was USD 1: Z$10.
Table 3: Estimated income per livelihood to raise maternal savings.
TYPE OF WORK/LIVELIHOOD
|
ESTIMATED INCOME
|
Male artisanal mining
|
USD 50 per week
|
Formal mining
|
Z$1,000/ $100 USD per month
|
Non-financial domestic work
|
USD 20 per month/Tokens of appreciation
|
Small scale trading
|
Z$400/USD 40 per month
|
Market gardening
|
Z$400/USD 40 per month
|
Cattle rearing
|
Z$2,500/USD 250 per beast
|
Steel Makers company
|
Z$300/USD 30 per month
|
Female artisanal mining
|
Z$2 per day/ Z$30 per point
|
Paid domestic work
|
Z$20 per day or $Z100-150 per month
|
Brick-making
|
Z$300-600/USD 30-60 per 1000 bricks
|
Prostitution/transactional relationships
|
As little as Z$20/USD 2 per encounter
|
The lack of stable incomes/ low incomes from livelihoods was stated as a significant barrier to maternal savings. This is shown in the following excerpt from a conversation about salaries at an urban clinic;
“My husband is a contract worker for one of the big mines in Kwekwe. He earns around Z$1, 000 (USD 100) per month. He currently has a 3-month contract. There is no guarantee that the contract will be renewed after its expiry. This makes planning for any eventualities difficult because there is no guarantee of job security.” (25-35 year-old pregnant woman).
It was common to find that most of the mines and steel factories reportedly did not provide health insurance to their workers and beneficiaries. Also, there was no health insurance in the informal sector. This could be a significant enabler when implementing the MHMW as a large number of the population is excluded from health insurance.
Distribution of income. The distribution of income may affect the mobilisation of maternal savings. Communities attributed the absence of household budgets to financial illiteracy. From the data, it was gathered that men take a large portion of the family income while they distribute little or nothing to women. Most women claimed they had never seen their husband’s payslip and could only access what their husband gave them in either cash/groceries. Women viewed men’s spending habits to be reckless, for example, spending money on alcohol, gambling, extramarital affairs, and forth. One-woman rural woman spoke about this matter in the following quote:
“My husband never gives me money. I make sure that I do piece jobs when he is at work. All the pregnancies I have carried, I have fended for myself as he has never been a responsible husband.” (WoCBA age, 29-35 years).
Accordingly, women had a lack of autonomy in mobilising maternal savings, which made it difficult to plan for pregnancy as they did not make much money in their forms of livelihoods.
Willingness to pay for the MHMW. The participants were questioned how much they would be willing to on the proposed MHMW to determine their willingness to invest as savings into the MHMW to receive maternal health services. The proposed amounts ranged from Z$10-20 (USD 1-2) per month. These amounts were offered by the participants considering their socio-economic reality and the macroeconomic issues in the country.
Community/Institutional level factors
Maternal layette. The introduction of the RBF facility has seen the scrapping of user fees for maternal and child health services. Despite the free services at public health institutions, women still must meet specific requirements to augment shortages at the health facilities. These requirements were separate from the preparations of the usual maternity layette or maternity preparation bag in anticipation of the new-born baby. The baby preparation bag items were costing approximately an equivalent of USD 100 at the time of the study. Additionally, most health institutions expected the women to bring other things that would typically be supplied by the institutions, which included cord clips, methylated spirit, cotton wool, and 5 litres of petrol or diesel for the hospital generators. Women were also expected to bring extra cash for transport in cases of complicated deliveries like caesarean sections and the need for referrals to the next level of care. Women were advised of the requirements during the Focused Antenatal Care (FANC) visits. Health care providers saw the list as a potential enabler for the RoadMApp MHMW as women were informed of items needed for birth preparedness and complications readiness.
A potential bottleneck noted by most participants (including pregnant women) was the inadequacy of following up on the progress in the preparedness of the women as the health providers tended to focus on health education and the physiology of the woman/baby. Women who booked late obtained the maternal layette list at a late stage of their pregnancy. This may have affected their strategies to save for the pregnancy adequately. Nurses struggled to serve this group when the medical supplies were low.
Rotating Saving and Credit Associations (ROSCAs). Saving schemes were typical within the rural and urban areas. These included burial societies and women’s clubs for crowdsourcing money on a rotational basis, commonly known as mukando/ukutshayelana. Participants identified ROSCAs as potential enablers for the RoadMApp MHMW because of their availability throughout the District.
Commonly, ROSCAs were utilised for mobilising groceries, monetary savings, funding the full or partial cost of burials/property, and so forth. Crowdsourced funds were preferred because they reduced financial risks, raised capital for income-generating projects, and increased women’s security over their money. Rural women were the most active participants of ROSCAs, in most cases, the ROSCAs constituted of 2-40 members. Their subscriptions ranged from Z$10-50 (USD1-5). Savings were determined by the type of the group, income levels, constitution, frequency of sharing the savings, and general household issues (such as consent from their husbands).
Most ROSCAs did not lend to non-members and circulated money among members. To hedge against hyperinflation, some ROSCAs traded their local currency to foreign currency savings (as it was considered more stable than the local currency) or ploughed their money into income-generating projects like rearing cattle, goats, poultry, and piggery and market gardening.
However, there were no ROSCAs dedicated to funding maternal costs fully. FGD participants who were members of the ROSCAs said:
“…for pregnancy it is every person for herself,” and;
“…our funds are mainly for assisting in the burial of loved ones, not pregnancy.”
However, pregnant women could join a ROSCA and use its services to mobilise funds for their pregnancy. The elderly women noted a high apathy among young women in communal ROSCAs. Elderly women attributed youthful women’s apathy to dependence on the permission/funds from husbands/partners who were migrant labourers.
Religion and maternal savings. There are ultra-conservative religious sects such as the Apostolic faith, which has a considerable following across Kwekwe District. Apostolic sects encourage members to use spiritual healing instead of medical facilities. Women subscribing to this religious sect deliver in member(s) home(s)/shrines assisted by church midwives.
The sects rely on a different form of ROSCA, in which members contribute towards a fund/gifts to assist the church’s pregnant women. A church member stated that members were supposed to know the due date of pregnant women in their church to help in maternal savings. The church would then organise women to visit the expecting mother with gifts (monetary/non-monetary) before and after giving birth.
Reaction to community savings scheme for pregnancy. The consensus was that a maternal saving is ideal as it prevents OOPs, leads to the adequate transportation of pregnant women, and balances home budgets. The participants highlighted their interest to join the RoadMApp MHMW if it was introduced as a ROSCA that was run using the USSD platform through various mobile service providers to cater for areas with poor connectivity. The Midlands State University (host institution of the study) was recommended as the ideal potential manager of the funds from the ROSCA that would be set-up for the MHMW.
Banking/financial system in Kwekwe District. Most of the study sites were rural with no formal banks. The few people with bank accounts are discouraged by the Zimbabwean policies of the 2% levies charged on every transaction. Account-holders in the rural areas would travel to Kwekwe urban to access their funds. Suffice to mention, travelling to Kwekwe has a lot of challenges as the transporters demanded cash up front. Also, the cash shortages in the country did not guarantee access to scarce cash.
Despite the acceptance of mobile banking in the District, it was criticised for attracting hefty transaction charges. Also, participants from rural areas could not adequately utilise mobile money services due to poor network connectivity and no access to electricity. This adversely affected their day-to-day mobile money transactions and led to a reliance on the use of use cash in the form of local and foreign currency.
National factors
Economic challenges. The financial difficulties that are being experienced by the country are taking a toll on pregnant women. Over the past two years, Kwekwe District has suffered economic instability just like other parts of the country, characterized by hyperinflation, severe unemployment, and food shortages leading to a low quality of life. Having disposable incomes is, therefore, a considerable challenge.
Results-Based Financing. Across all interviews, participants felt strongly that the RoadMApp MHMW would only be successful if there were funding attached to it. Some even suggested that the RBF (which had introduced free maternity services) could be extended to the RoadMApp intervention. In this way, the RoadMApp MHMW would be more sustainable beyond the pilot and at scale-up.