Health institutional dynamics in the management of malaria and bilharzia in Zimbabwe in the advent of climate change: A case study of Gwanda district

Abstract Climate change impacts on the transmission and epidemics of vector-borne diseases (VBDs), hence an understanding of the institutional determinants that influence the response of national health systems is important. This study explored how institutional determinants influence health outcomes of malaria and bilharzia using the case study of Gwanda district, Zimbabwe, in the advent of climate change. Qualitative data were collected using in-depth interviews from representatives of public and private institutions; and organisations involved in the prevention and control of malaria and bilharzia. Results from the study showed that the Ministry of Health and Child Care of Zimbabwe and other relevant government ministries and departments involved in environmental and social issues, constituted the primary network in the control and prevention of malaria and bilharzia. Non-governmental organisations (NGOs) formed the secondary network that mainly mobilized resources or complimented the primary networks in the delivery of services. It was noted that there was an institutional structure primarily responsible for responding to malaria and bilharzia but it was not adequately prepared to address climate change-induced VBDs changes. Based on our findings, a framework for reducing vulnerability and enhancing resilience among populations affected by VBDs in the context of climate change was developed.

Abstract: Climate change impacts on the transmission and epidemics of vectorborne diseases (VBDs), hence an understanding of the institutional determinants that influence the response of national health systems is important. This study explored how institutional determinants influence health outcomes of malaria and bilharzia using the case study of Gwanda district, Zimbabwe, in the advent of climate change. Qualitative data were collected using in-depth interviews from representatives of public and private institutions; and organisations involved in the prevention and control of malaria and bilharzia. Results from the study showed that the Ministry of Health and Child Care of Zimbabwe and other relevant government ministries and departments involved in environmental and social issues, constituted ABOUT THE AUTHORS A Mbereko is a public health scientist. He has been the country coordinator. He has experience in conducting research on social-ecological systems, child protection, public health issues and climate change. He was the Zimbabwe country coordinator on the Malaria and Bilharzia programme (MABISA). M.J Chimbari is Research Professor-Public Health, at University of KwaZulu-Natal. He has led 4 major projects in the past decade; Edulink (2008-2012Botswana Ecohealth (2010-2014; MABISA (2013MABISA ( -2017 and the TIBA programme (2018-date). P Furu is a public health scientist based at the Global Health Section of the Department of Public Health, University of Copenhagen. Peter's research interest are; environmental health, health impact assessment, health impacts of climate change and integrated bilharzia control. S Mukaratirwa is currently full Professor of Parasitology at the School of Life Sciences, University of KwaZulu-Natal. His research interest is in a variety of tropical parasitic diseases of economic and public health importance and has a passion on "Neglected Parasitic Zoonoses" affecting the resource-poor communities.

PUBLIC INTEREST STATEMENT
Scientists have already demonstrated that bilharzia and malaria are on the increase in response to the warming temperatures. Yet, health policies and responses aimed at responding to such vector disease have not changed in most developing countries. Hence, this study aims to explore institutional determinants that determine health outcomes of malaria and bilharzia using the case study Gwanda district in southwestern Zimbabwe. In-depth interviews with key informants and the review of departmental documents were the main data collection methods used. The study found that the Ministry of Health and Child Care develops policy and strategic plans to respond to malaria and bilharzia. Climate change issues have not been integrated in the ministry's response to malaria and bilharzia. The health sector is assisted to respond to bilharzia and at a primary level by other government institutions and at a secondary level by non-government organisations. Based on our findings, a framework for reducing vulnerability and enhancing resilience among populations affected by VBDs in the context of climate change was developed.
the primary network in the control and prevention of malaria and bilharzia. Nongovernmental organisations (NGOs) formed the secondary network that mainly mobilized resources or complimented the primary networks in the delivery of services. It was noted that there was an institutional structure primarily responsible for responding to malaria and bilharzia but it was not adequately prepared to address climate change-induced VBDs changes. Based on our findings, a framework for reducing vulnerability and enhancing resilience among populations affected by VBDs in the context of climate change was developed.

Introduction
According to the International Panel on Climate Change (IPCC) report (2007), Africa is experiencing rising temperatures because of climate change and this is causing changes in the range and transmission potential of vector diseases such as malaria and bilharzia. Already there is evidence that Zimbabwe's malaria and bilharzia epidemics will increase due to climate change variables like increased temperature and erratic rains (Bosello et al., 2006;Chikodzi, 2013;Gwitira et al., 2015). Malaria and bilharzia have been identified as key vector-borne diseases in Zimbabwe due to high levels of morbidity and mortality (Chimbari et al., 2004;Chimbari, 2012;Midzi et al., 2014). In the past, research on malaria and bilharzia mainly focused on biomedical aspects, but in the past decade social sciences have increasingly been valued because of the need for early warning systems and institutional preparedness to climate-related shocks (Butt et al., 2022;Hawkes & Ruel, 2006;Isaifan & Kooli, 2022;Kloos, 1995;Zhou et al., 2016). With the health equity policy drive, propagated by the World Health Organisation (WHO), social determinants of health have received scholarly and political dominance as they inform the functioning of the health system of any country (; Isaifan & Kooli, 2022;Penman-Aguilar et al., 2016). Although social sciences have studied socio-economic determinants of health, studies on institutional determinants have been limited. Research on the health institutional determinants and dynamics is important more so in the advent of climate change.
Globally, the relative importance of healthy public policies as a means to attain an improvement in the overall level of population health has been increasingly emphasized (Brown & Moon, 2012). The responses to health challenges have been assigned to global regional, national, provincial, district and community levels. In Zimbabwe, the response to health challenges is based on the institutional structure that is set out in the Public Health Act of 1924, which was last revised in 2001. The public health Act creates the framework for responding to vector-borne diseases (VBDs) such as malaria and bilharzia. Unfortunately, the Ministry of Health and Child Care (MHCC) Act does not take into consideration the impacts of climate change on public health. Besides evidence showing that changes in climate induce changes to the spatial and temporal distribution of malaria and bilharzia. In line with the United Nations Framework Convention on Climate Change (UNFCCC), the Zimbabwean government established the Climate Change Management Department (CCMD) under the Ministry of Environment, Water and Climate in 2013. The CCMD has identified and predicted increases in VBD in response to changes in climate. Through CCMD has acknowledged impacts of climate change on the MHCC, it is the mandate of the ministry to respond to health issues. Thus, the institutional framework to respond to malaria and bilharzia change in consideration of the climate change impacts on health outcomes.
Studies on institutional determinants of health argue that a health system is functional when there is a balance between services demand and supply (Nandi et al., 2013). Ecological and medical systems are, to a large extent, dependent on the political economic system (King, 2006). Factors that influence the institutional determinants of health include; government policy and regulations (Curtis & Riva, 2010;Isaifan & Kooli, 2022), performance of the economy, market systems (Butt et al., 2022;Kooli, 2021) and the forces operating in the global political and economic systems (Curtis & Riva, 2010;King, 2006). India has developed a National Health Package (NHP) which envisions a system where every citizen should have full access to free healthcare from either a public healthcare provider or a private provider working under a government contract (Nandi et al., 2013). The policy is meant to allow the Indian system to strike good balance between supply and demand of the healthy system. Another study in Ghana found that in order for hospitals to provide effective treatment of malaria, the facility should be able to receive information from the government on new methods of treatment and any such information should be relayed to health workers (Amporfu & Nonvignon, 2015). Amporfu and Nonvignon (2015) argue that although government regulation is necessary, decentralised health systems performed better than centralised ones in sub-Saharan Africa. This study interrogated the structure of the health system delivery for diseases sensitive to the impacts of climate change in Zimbabwe.
Strengthening of institutional structures will improve responses to malaria and bilharzia and reduce vulnerability of affected communities to the added effects of climate change. However, literature on institutional determinants of health (on malaria and bilharzia) is scanty, with much of the literature focusing on socio-demographics and economics (Crémieux et al., 1999;Friel & Marmot, 2011;Subramanian et al., 2002). Institutional determinants of health are not only limited to health ministry but also include all stakeholders who shape health outcomes, whether directly or indirectly. Health outcomes are important products of government policies and elitist political constructs (Cox & McCubbins, 1997). Public health services are produced through the collective actions of numerous governmental agencies and private organizations that vary widely in their resources, missions, and operations (Biehl, 2011;Nandi et al., 2013). The Ghanaian and Indian cases demonstrate that when government departments are well coordinated, as the primary network, the best health outcomes are achieved (Curtis & Riva, 2010;King, 2006;Nandi et al., 2013). This paper hypothesizes that the current centralized health delivery framework will not be effective in the event of climate change induced increases in malaria and bilharzia in Zimbabwe. This paper uses the case study of Gwanda district in the context of the national health delivery system to understand the health institutional framework that respond to the malaria and bilharzia epidemics and infare on its capacity in the advent of climate-change-induced epidemics.

The study area
The study was conducted in Gwanda, Zimbabwe (Figure 1). A cross-sectional approach was adopted focusing on Ntalale and Selonga wards in Gwanda District. Data were also collected at provincial and national levels. Gwanda district is one of the six districts in Matabeleland south. According to the Central Statistics Office (CSO, 2022), the district covers approximately 14,015 km2 and has an estimated population of 124,548 people, a population density of 14 people/km 2 and 26,773 households with an average 4.9 members per household. The larger human population of the district resides in the rural areas (Manyani, 2011). The district lies in the natural regions IV and V, which are characterised by low and erratic rainfall (less than 700 mm annually) and hot temperatures. Due to the natural environmental characteristics, natural resources-based livelihoods are limited to drought-resistant cropping, livestock husbandry and mining. The rural populations in the Ntalale and Selonga wards have diversified their livelihoods strategies by engaging in non-traditional agricultural activities (e.g. emigration for employment, trading, irrigation farming), mainly in response to climate change and the macroeconomic crisis in Zimbabwe (Cox & McCubbins, 1997).
Zimbabwe is divided into four levels of political administrative units, namely, national, provinces, districts and wards. The country has a centralised decision-making government with the state having autonomy (Skalnes, 2016). The political structure is parallel to the government structures at every administrative unit level. Gwanda rural is constituted of 24 wards, which are headed by elected councillors who are paralleled by the traditional leadership structures. A ward is an administrative area under a district that consists of an average of 10 villages and each village consists of an average of 100 households and is serviced by one clinic tasked with primary health care (Macherera et al., 2017).
Ntalale and Selonga wards have one clinic each and the clinic personnel, the councilor and the village health teams constitute the ward health team, which reports to a district health team (DHT) managed by a district health executive (DHE) (Macherera et al., 2017). The DHT in turn reports to a provincial health team (PHT) that is managed by a provincial health executive (PHE), based at the provincial capital of Matabeleland which is Gwanda. The PHE reports to national level, which is based in Harare.

Sampling
Gwanda district was purposively sampled because it is a semi-arid area that have water bodies resulting from man-made water resources development. This study was in the context of a bigger research programme called Malaria and Bilharzia in southern Africa (MABISA), which was implemented in the three wards (Buvuma, Ntalale and Selonga wards). The MABISA project focused on bilharzia and malaria which are epidemic in dry-hot areas with localised water bodies that create a perfect habitat for vectors (Chimbari, 2012). This study was done in Ntalale and Selonga out of the Source: Authors three wards because they had high incidences of malaria and bilharzia in the district. Furthermore, Ntalale and Selonga received low rainfall which has necessitated setting up of irrigation schemes. Irrigation schemes have been documented as exacerbating VBDs (Chimbari, 2012).
The researchers purposively identified key organisations that deal with health and climate change from the national, provincial, district and ward levels. The researchers purposively targeted heads of departments or appointed representatives. It was contended that the interviewees from the different departments were technical experts in their professions. At the national level, interview respondents were representatives of an organisation at the headquarters level, which was either a primary or secondary stakeholder, related to VBDs, health and climate change. Primary stakeholders included government ministries whose mandate and operations relate to climate change or VBDs. Three in-depth interviews were conducted from each of the primary stakeholders recruited in the study. Primary institutions interviewed in this study include MoHCC, Ministry of Primary and Secondary Education (MoPSE) and Ministry of Water and Natural Resources. Secondary stakeholders were institutions that cooperated with government in adapting to climate change and VBDs such as NGOs. The secondary stakeholders interviewed for this study were the World Health Organisation (WHO) regional Office and the Institute of Water and Sanitation Development (IWSD). Two interviews were done with the secondary institutions. At the national level, the similar interview guides (slight modifications were made to suit particular stakeholder) were used to collect data. Interview covered the following issues: • The role of organisations, involvement in climate change and health issues (with special focus on malaria and bilharzia).
• Perceptions on the MoHCC policy in addressing bilharzia and malaria in Zimbabwe.
• Perceptions on the adequacy of existing malaria and bilharzia policy and strategies in the event of increased epidemic in response to changes in climate change.
• Perceptions on the integration of climate change issues in health policy.
• Understanding of the health governance structure as a key determinant in health outcomes.
A total of 14 in-depth interviews were conducted with representatives from the four ministries recruited at the national level. The interviews were conducted between, March 2017 to July 2017. In addition to the variables collected at the national level mentioned above, the study further probed on: • Financial and drug budgeting procedures and central government's responses.
• NGO and other stakeholder involvement at the ground level in bilharzia and malaria control and treatment.
• Perceptions on the integration of climate change effects on VBDs.
At the provincial and district levels, the interview guides were customised to be sector-specific, for example the interview done with the MoPSE representative, was biased towards education and the School Health Programmes (SHP). The sample size was determined by the level of data saturation. From a constructivist paradigm, the sample size is adequate and the conclusions are credible since data were close checked and thick descriptions of interview narrations were used in the analysis (Creswell & Poth, 2016).
Relevant documents were reviewed, these included: policy documents, strategic plans and reports from the organisations interviewed were done. An online search for these documents was done and four documents relevant to the study were extracted. The titles were provided by key informants and the soft copies were extracted online. These were two World Health Organisation Documents, IWSD policy document and CCMD report to IPCC. Other documents reviewed in this study were obtained directly from the ministries as hard copies. The researchers' prior knowledge and recommendations from the key informants interviewed informed the documents for review. The documents were reviewed and data relevant to climate change and VBDs was extracted. Information on the institutional policy, mandates, goals and programmes that dealt with malaria, bilharzia and climate change was considered relevant to this study. Furthermore, information on governance policy and structure's linkage to MoHCC policy on VBDs was also extracted. Data from the review of documents were triangulated with interview narratives to increase credibility of the study results.
The qualitative narratives were recorded using a voice-recorder and were verbatim transcribed. Thematic analysis was used to interpret the qualitative data. The narratives were entered into QSR Nvivo version 12, and nodes were used to organise the data for analysis by the researchers. The study followed the five stages prescribed by Dey (1993), namely, description, contexts, intentions, classification and making connections. The documents were loaded into Nvivo software. The documents were run for search word function and word trees were done to show linkages in the discourses. These formed the themes for analysis in nodes.

Ethical Considerations
The research was ethically cleared by Medical Research Council of Zimbabwe (MRCZ) MRCZ/A/1737 and Biomedical Research Ethics Committee (BREC) BE 182/13, University of KwaZulu-Natal. The study involved collection of government data which is protected by state secrecy and nondisclosure laws. Permission to carry out the study was obtained from the ministries before data collection. The researcher protected the respondents from harm or victimization by maintaining high levels of confidentiality and anonymity. Participation in the research was voluntary, meaning that the respondents were to withdraw at any given moment in the event that they feel that they are no longer interested.

Results
In order to answer the research question on the potential implications of increased malaria and bilharzia on the health delivery system in Zimbabwe, the results consider policy interpretations of bilharzia and malaria, then critic of the structure of the system, provincial systems and then district level determinants. In Zimbabwe, the health determinants are unique since they are influenced by deficiencies in key components like shortage of financial resources, weak governance system and institutional power dynamics (conflicting interests). These form the determinants of the performance of the health system in relationship to VBDs in Zimbabwe.

Interpretation of Bilharzia and Malaria
Academics interviewed in share the opinion that bilharzia and malaria remain neglected and important health concerns in the country (Respondents 3 and 4). Despite the mass drug administration which resulted in the decline in bilharzia and malaria, in order to eliminate VBDs, more research is required, but the funding is limited (Respondent 3). Interviewees from WHO (Respondent 2) and MoHCC (Respondent 1) indicated that malaria and bilharzia are declining but remain health challenges to the country's health delivery system. A review of the National Health Strategy (NHS) for Zimbabwe 2016-2020 shows that malaria and bilharzia are diseases of priority as they are both in the top ten. The NHS states that the MoHCC aims to reduce malaria incidence from 39/1000 in 2014 to 5/1000 in 2020 and malaria deaths to near zero by 2020. The NHS indicates that the MoHCC aims to reduce morbidity due to bilharzia and soil-transmitted helminths and other tropical diseases by 50% by year 2020. According to the NHS, bilharzia is ranked number eight among the diseases reported at out-patients departments nationally. Respondent 3 commented on the NHS targets, he said, " … these can be achievable but climate change impacts on VBDs and a dilapidated health system are the major challenges to success." The Structure and policy response to VBDs This study found that the structure is highly centralised with the central government being the locus of power of all resources and power, and this is enshrined in the constitution. The review of the constitution indicates that the MoHCC is mandated in dealing with all aspects of health for all citizens including coming up with national strategic plans (The Public Health Act, 1924 last amended 2001). Respondent 1 stated that, "Further to human health, the ministry is tasked with coordination of health interventions and administering government health facilities like hospitals and clinics throughout the country." Mission and private health facilities were reported to be assisting in health services provision but mainly focusing on treatment and health education while government hospitals manage, control and monitor diseases (Respondents 1,6,7,8). A review of the NHS indicated that the ministry has a section covering the health centres that caters for primary, secondary and tertiary health care and a research section (which is the mandate of the National Institute of Health Research). According to respondent 1, "The MoHCC responds to VBDs like malaria and bilharzia through this structure, which the minister sanctions." Policies, strategic plans, targets and resources are decided at national level then cascaded to the lower levels for implementation. The current administrative structure has the ministry's executive at the national level, to the Provincial Health Executive then the District Health executive and the ward clinic management team. The study found that the power was flowing from the central ministerial headquarters in Harare to the clinic level decreasing at each level. Respondent 12 at Ntalale clinic said, "We get instructions from the district and we just implement. [the researcher probed if they can change anything to suit the local situation] Who are we to change things even if its not context specific we follow protocol." When malaria or bilharzia control programmes come to the clinic facilities, they can only implement them but have no power to modify it to the local situations. On the other hand, the study found that information and acquittals are relayed to the national level through the structures. The interviewees at the national and provincial level concur that health reports, information and data; retiring of imprest for previous financial year and budget requests for the next financial year are passed through the structure from the ward to the national level for approval and resources allocation consideration are done at he national levels.
Power to decide and allocate resources are centralised at the national level with the MoHCC executive. The review of policy and legal documents showed that cabinet sanctions financial resources disbursed to the MoHCC at the MoHCC executive level. The findings of this study show that budgetary consultations are held from the district level, the provincial executives compile a budget that is forwarded to the National executive that then submit to the Ministry of Finance. Respondents 1, 6, 8, 10 and 13 concur that funds allocated to the MoHCC fall significantly short of the required. For example, according to Respondent 1, "The 2016 disbursement of US$330.79 million, which accounted for 8.3% of the total [national] budget, the percentage falls short of the UNDP recommendations." The WHO recommends that 15% of the budget should be devoted towards the ministry of health in line with the Abuja Declaration target (WHO, 2020). It was found that the funds allocated to the MoHCC falls significantly short of the required amount for the institution to run effectively. An interviewee (Respondent 9) from MoHCC at the district level said, "Since the economic crisis in the country, lower levels [in the MoHCC] do not receive a budget level close to what they propose [in the budget consultations]." An interviewee (respondent 10) at the district level within the MoHCC indicated that, "The district received funds for the first half of the year midway the second half of the year." Respondents 1, 6 and 7 indicated that strategic plans for specific disease management and programmes are developed at the national level and cascaded through the structure to the clinic level. A key strategic document to the operations of the MoHCC is the National Health Strategy (NHS). Respondent 1 indicated that, "The NHS is developed at the national level and it covers a period of five years." Interviewees (Respondents 1, 6 and 7) from the MoHCC at the national and provincial levels reported that the MoHCC policies were aligned to the Millennium Development Goals (MDG). Respondents 6 and 7 indicated that the realigning of the policies to the new Sustainable Development Goals (SDG) was still underway at the national level.
A review of the MoHCC Act shows that any other party who is implementing health intervention should adhere to the MoHCC's NHS and operational guidelines. Respondent 1 indicated that, "The NHS for Zimbabwe guides the line items and diseases prioritised for funding." At an operational level, the utilisation structure of donor funds and requirements of the institutions that form the MoHCC structure guides the allocation of funds to the lower structures i.e. provincial and district levels. Although NGOSs carrying out health interventions were supposed to adhere to the NHS, but it was reported by a senior officer from the MoHCC (Respondent 1), that, "The donors have control over the resources invested in intervention programmes." For example, the President's Malaria Initiative (PMI) document outlines the malaria interventions they are supporting in the country and these include insecticide-treated nets, indoor residual spraying, treating of malaria during pregnancy, case management, monitoring and evaluation, operations research, behaviour change communication and capacity building. An interviewee from the MoHCC (Respondent 6) revealed that, "The PMI funds can only be used on malaria despite other diseases being public health problems, even more than malaria."

Stakeholders to the health delivery system
The study results showed that MoHCC collaborates with a number of stakeholders in fighting malaria and bilharzia. Interviewed institutions at the national level that play a role in the control of VBDs are shown in Table 1 and these range from public, private to international institutions. These institutions are divided into primary and secondary stakeholders. In addressing challenges posed by VBDs, the MoHCC networks with government departments, which are the primary stakeholders. Respondent 1 said the ministry convenes inter-ministerial meetings under the Social Services and Poverty Reduction Cluster and health problems are discussed and resolutions passed. Eleven of the 14 respondents indicated that MoHCC works closely with the MoPSE in the implementation of the School Health Programmes. While the respondents from departments within the Ministry of Environment, Water and Climate (MoEWC) such as the Environmental Management Agency (EMA) and Zimbabwe National Water Authority (ZINWA) indicated that their cooperation with MoHCC was limited to assessments of health impacts of new development projects (Respondents 5 and 11). An interviewee from CCMD said the department had not started networking with MoHCC in meaningful ways but plans to do so were reported to be underway.
Besides MoHCC, the interviewed representatives of the different primary institutions indicated that malaria and bilharzia control were considered as peripheral component of their mandated operations. Institutions like the Schools, EMA, ZINWA and the CCMD contribute indirectly to the control of malaria and bilharzia (Table 1). Interviewees from MoEWC argued that while institutions like ZINWA and EMA do not have VBDs intervention programmes, they contribute to the control of malaria and bilharzia through promoting cleaner environments (Respondents 4 and 5). The data shows that issues to do with bilharzia and malaria are dealt with as benefits of programmes with a broader objective. The representative of IWSD who was interviewed remarked that, "The top to bottom approach and the neglect of VBDs and climate change issues at community levels in programs might have exacerbated community vulnerability to the diseases," (Respondent 3).
The results showed that the MoHCC networks with secondary stakeholders who are nongovernmental and at national level, the key non-governmental organisation (NGO) stakeholders to the MoHCC are World Health Organisation (WHO), United States Presidents Emergency Plan for AIDS Relief (PEPFAR), President's Malaria Initiatives (PMI), Global Fund and United Nations Development Fund (UNDP). Other secondary institutions that the MoHCC collaborates with in malaria and bilharzia control are universities and research institutes such as the IWSD. According respondent 1, "WHO and MoHCC collaborate closely on health issues." It was reported that with support from United Nations Development Program (UNDP)-WHO the MoHCC standardised and implemented malaria control programmes in prioritised areas in the country. The NGOs and multi-national organisations were reported by the interviewees from the MoHCC as providing funds for health programmes and drug procurement (Respondents 1, 6, 7, 8 and 14). According to MoHCC interviewees, different organisations fund different health programmes in the country. The attainment by all (Globally) peoples of the highest possible level of health.
• Sets health sector operation standards and monitors their implementation.
• Sets out health policy and evaluates adherence to international pacts.

Disease surveillance
• Develop capacity for implementation of good health practices.
• Raise funds for implementation of control programmes.
• Participate in priority-setting of the national and international health agenda.
• Operations and policies are governed by member states. The problem is that the member states actually vote on certain health issues and their priorities are not always motivated by the country needs.
• Some issues tend to be on the local agenda and much less on the global agenda.
(Continued) • ZINWA works to provide clean water to every citizen of Zimbabwe.
• Increased irrigation schemes are improving nutrition and livelihoods.
• Drought are negatively affecting the supply of portable water to communities and disease outbreaks occur.
• Fiscal challenges at the national level negatively affect resources availability.
According to respondent 1, "VBDs, especially malaria was a national and international priority as such it has received the most support from donors in the district." A review of the 2017 National budget statement showed that the Global Fund had pledged about $4.3 million towards the National Malaria Programme. The MoHCC interviewee (Respondent 6) at the provincial level indicated that programming in bilharzia control lagged behind that of malaria. According to respondent 2 representing the WHO, " … diseases like bilharzia could be important in the country but the program agendas of organisations are globally mandated, [and other diseases left out]". The WHO representative said the policymakers at both national and global scale prioritise diseases to control in the short-run rather than focusing on the long-term disease epidemics (Respondent 2).
It was reported that the MoHCC has not officially factored in the impacts of climate change on VBDs in Zimbabwe (Respondents 1, 6 and 7). According to Respondent 6, the ministry's representative indicated that, "lack of funding limited the ministry in engaging with future VBD epidemics resulting from climate change," (Table 1). It was indicated that the MoHCC responds to climatechange-nduced malaria and bilharzia in line with the National Malaria Strategy and the National Bilharzia Strategy. Furthermore, the National strategies on malaria and bilharzia did not factor in the potential increases in the diseases due to climate change. However, the MoHCC representative interviewed said, "Areas endemic to malaria are changing in spatial distribution, and the ministry is conducting disease surveillances," (Respondent 1). He pointed out that some areas, which were not traditionally malaria hot spots were reporting high incidences of the disease especially in the midlands area (Respondent 1).
The study interrogated the CCMD functions since it is mandated to deal with impacts resulting from climate-induced changes such as spatial changes in malaria and bilharzia. This study found that the CCMD is at the national level and does not have structures at lower levels. The study revealed that besides interviewees from the MoEWC, the representatives of other institutions did not have detailed knowledge on NAPs and thus climate change adaptation is not considered in their policies. In an interview with the EMA at the national level interviewee, "It was confirmed that Zimbabwe did not have a climate change adaptation policy as yet, but it had developed a response strategy which focuses on adaptation to climate change" (Respondent 2). In order to promote climate change adaptation, EMA had embarked onmicro projects like the cooperative gardens and promoting planting of short season varieties to help with nutrition.

Provincial institutional issues
Respondent 7 from the MoHCC provincial offices reported that, " … although the NHS guided health system operations, the provinces drawing from the NHS were expected to develop their own strategic plans". It was reported by a senior staff member of the MoHCC that the provincial plan amalgamates inputs from the district and ward levels to the NHS guidelines (Respondent 7). At provincial level MoHCC officials concurred that, special programs undertaken by the MoHCC with partners had independent strategic plans such as the Malaria Strategic Plan and the accelerated UNNC Strategy (medical male circumcision) (Respondents 6,7 9 and 11). The provincial strategic plans take into consideration the needs of the province and set out operational strategies and targets. A review of the provincial strategic plan for Matabeleland South targeted halting of malaria transmission by 2017, and having zero local transmission in Matabeleland South. An interviewee with the provincial Malaria coordinator revealed that the strategic documents guided the health centres in the province on day-to-day operations and management of malaria (Respondent 7).
Interviewed representatives from MoHCC concur that in some cases, special programs were brought into the province with a set out implementation strategy (Respondents 6 and 7). Usually special programmes, were reported as being donor funded and they were usually implemented in more than one province. A good example was the control of malaria which was guided by the National Malaria Control Program. The provincial Malaria coordinator said that, "The National Malaria Strategy (NMS) was part of the Integrated Vector Management (IVM) which guided provincial and district health practitioners in their everyday work," (Respondent 7). It was reported that two districts (Gwanda and Beitbridge) in the province were implementing the indoor residual spray program and following up on any new cases to control malaria (Respondent 7. The interviewee said, "such programs were welcome since they contributed towards the provincial goal of zero transmission by 2017," (Respondent 7). Senior health official at the district level interviewed indicated that special programmes had the risk of trivialising other important conditions in the province such as non-communicable diseases that were among some of the top 10 reasons for visiting health centres in the communities (Respondents 7, 8 and 9).
MoHCC officials from Matabeleland South reported that the provincial and district levels of the MoHCC primarily operated with funds that were disbursed by the government of Zimbabwe (Respondents 6 and 8). The head of the provincial health team narrated the procedures followed to get funding from the state. She said, "Health centres submitted financial requirements from the district to the provincial directorate," (Respondent 6). The provincial directorate consolidated the district level financial requirements and forwarded them to the national executive for onward transmission to national treasury. The budget line items approved were then relayed to provinces and district levels for operationalisation. According to Respondent 5, "even though they present their budget since the economic crisis much of the budget has been for curative care and that preventative activities were grossly underfunded. Preventive medical care was said, " … to be important but the budget allocations were difficult to obtain since the funds depends on availability of funds or an outbreak of a disease." (Respondent 6). It was reported by interviewees from MoHCC that the government was experiencing difficulties in meeting the full budgetary requirements (Respondents 1, 6, 7, 8 and 9). According to Respondent 6, "Preventive medical care benefits from disaster response funds as donors assist but they do not reveal their budgets to district health management team." Hence, they cannot plan on these funds since they are highly dependent.

Institutional determinants at the Gwanda district level
The medical superintendent from MoHCC (Respondent 8) reported that, "Gwanda hospital mainly provides tertiary curative services that included, general surgery, rehabilitation, gynaecology, obstetrics, physiotherapy, paediatrics and support services.". The hospital was said to be serving as a provincial and district hospital (Respondent 8). Administratively, the provincial (known as the Provincial Medical Office) is separate from the district (known as the District Medical Office). The district does not have a hospital. Respondent 9 said, "Gwanda district MoHCC personnel provides support to rural health centres". The district medical staff provided technical support to clinics, environmental health services and human resource services. It was reported that the government district hospital was assisted by two Christian mission hospitals, namely, Manama and Chabeza. These mission hospitals mainly provided primary health care and limited curative care. According to respondent 9, "Gwanda district requested a total of $184 000 for the 2016 financial year". A review of the fund allocation shows that the district was allocated $81 729,20 for curative care. The amount allocated to the District accounted for 20.23% of the total curative care allocation to the province. The allocation schedule did not indicate how much was allocated for preventive services. It was reported that for the first quarter the district had received $6 000 and were awaiting the balance to be disbursed. The two MoHCC interviewees at the district level reported that the district was "financially broke" and under-resourced (Respondents 9 and 10). According to respondent 8, "The Gwanda Provincial health facilities benefitted from moneys paid by patients for services." This fund was referred to as out of pocket (OOP) expenditure in the NHS. A review of the NHS showed that OOP constituted 49% of funds used in running government hospitals in Zimbabwe.
The representative of the MoHCC at the district level concurred that prevalence trends of malaria and bilharzia were declining in the district. A review of the district's annual top ten Out-Patients Departments (OPD) reported conditions show that from 2011 to 2015 malaria was in the top 10. In the case of bilharzia, it was in the top 10 from 2011 to 2014. Thus, bilharzia was no longer in the top 10 of the conditions reported at OPD. According to respondent 8, " … in addressing malaria and bilharzia, the district medical team was assisted by NGOs." It was reported that the district was a beneficiary to the National Malaria Control program with a strategy of malaria elimination in the District and was at the pre-elimination stage (respondent 8). An environmental health worker with the MoHCC said that, "In malaria control the district was undertaking larviciding, physical and chemical control of mosquito population, prophylaxis, and prompt treatment," (Respondent 15). It was reported that when there was a confirmed malaria case the MoHCC personnel carried out investigations, sprayed the households and provided prophylaxis to family members (Respondent 15).
With exception of the EMA officer, very little was known on NAPs at the district level. The EMA representative interviewed acknowledged that by virtue of them being part of MoEWC, the department was mandated to consider climate change issues in their programming. According to respondent 11. "CCMD had skeletal staff at the national and provincial levels and no personnel at the district and community levels." The interviewee was of the perception that climate change policies were being designed at the national level with the hope of cascading them to district and ward levels.
The study found that just like at the national level, health practitioners at the district and community level do not seriously consider impacts of climate change on health in the delivery of their duties. According to respondent 9, "The closest that the ministry [MoHCC] deal with vectorborne diseases and climate change was through the environmental health department responsible for ensuring environmental health and hygiene." Warmer weather conditions were presumed to be associated with increases in malaria, eye problems, bilharzia and hypertension. Floods were associated with diarrhoeal disease and droughts were associated with increasing number of patients with malnutrition (Respondents 7,8,13 and 14). A nurse in charge at a ward clinic said, "The worst affected populations were the children under 5 years of age, pregnant mothers and those with compromised immune systems," (Respondent 13).
Cooperation with government, NGOs, researchers and communities on malaria and bilharzia Four interviewees from MoHCC concurred that they collaborated with government and nongovernmental institutions (Respondents 7,8,10 and 15). They indicated that the collaboration with other ministries/departments/NGOs depended on the nature of the activity. For example, on issues to do with water they collaborated with Zimbabwe National Water Authority (ZINWA). The environmental health department of the MoHCC also worked closely with EMA. However, it was reported that all other ministries were called to assist when there was need, and MoHCC and MoPSE had established a long-term cooperation (Respondents 8 and 12). In Gwanda district, the MoHCC had formed School Health Masters programme (SHM).
It was reported that the MoHCC trained at least one teacher to become a School Health Master (SHM) and these SHMs were trained in disease identification, child counselling and in engaging family in order to find out more about the origin of various illnesses. SHMs reported to the local clinic and to the headmaster at the school on a monthly basis and they were provided with medical kits and information, education and communication (IEC) material (Respondents 12,18 and 19).
MoHCC interviewees indicated that the ministry also works with NGOs in malaria and bilharzia management and control. It was reported by interviewees from the MoHCC that in Gwanda District they worked with World Vision in the area of nutrition and UNICEF was said to have provided Blair toilets (ventilated pit latrines) to the communities (Respondents 8 and 14). Population Services International (PSI) provided mosquito nets and funded the training of Village Health Workers (VHW) (Respondents 10 and 13). Respondent 10 reported indoor residual spray to have been carried out with the assistance from Clinton Health Access Initiative (CHAI) and a UN department.
Donors were said to have supported the mass drug administration (MDA) programme that was done in the district in 2012 (Respondents 7 and 8).
VHW formed the lowest structure of the MoHCC. According to MoHCC interviewee at the ward level, every village had VHWs and a health club (Respondents 13, 14 and 17). The VHWs were trained in community health and malaria rapid testing. According to respondent 17, "Each VHW was given medical and rapid diagnostic testing (RDT) kits," [for malaria]. It was reported that VHWs conducted the village health club meetings once per week (Respondent 16, 17). These meetings were used for health education and creating a forum to discuss health and hygiene issues. The councillors convened community meetings where VHWs and clinic health staff took advantage of to educate and disseminate health information and programs (Respondent 16).

Institutional and community preparedness
With regard to malaria and bilharzia, the MoHCC prepared medical supplies for the peak season every year. A ward level nurse said in preparation for the malaria season they calculated the threshold, i.e. comparing the maximum cases for 5 to 10 years, in order to anticipate for the coming season (Respondent 13). The threshhold would guide the clinic on the drugs stocking level and environmental elimination of breeding grounds. The clinics at the ward level carried out training of the trainers, training local leadership and managing community health workshop. According to respondent 14, "The clinic distributed mosquito nets and provided prophylaxis treatment." A ward level nurse reported that, "No preparations were made for bilharzia because of its low prevalence in the ward and district," (Respondent 13).

Discussion
The study has found that the response to malaria and bilharzia at a local level is embedded in a complex web of structural institutions with the locus at the national executive and an array of NGOs. The two key institutional determinates to health services delivery, namely, governance structure and power over financial resources are at the top. This paralysis critical planning and resources allocation at the district and ward levels. Thus, health outcomes are dependent on the political will and the ministry's capability to provide efficient services to the lower structures. Literature has demonstrated the weaknesses of intertwining the local institutions to centralised authorities for health policies and programmes (Mosley et al., 1990). There are examples in Africa were local leadership, elites, supporting agencies and lack of political support negatively influenced health projects/outcomes at the national level with negative effects downstream.
It has been a decade after the Zimbabwean government rectified the climate change treaties but the MoHCC Act and NHS, which form the framework for response to health issues does not factor in the effects of climate change to health. The study showed individualised pockets of important knowledge on the impacts of climate change to VBDs but these are not institutionalised. While CCMD and MoHCC executive at the national level has access to research and epidemiological data that demonstrate vector and spatial impacts of climate change. Slow reaction to change has been documented to be typical of centralised systems, that are blamed for sacrificing efficiency through centralising decisionmaking (Chopra et al., 2009;Lahariya et al., 2020). The centralised systems of the MoHCC could be blamed for the slow integration of climate change impacts on health outcomes of VBDs. There is potential for health and environmental policies to mainstream the interaction of climate change factors and VBDs especially malaria and bilharzia in Zimbabwe (Dodman & Mitlin, 2015). Countries in southern Africa are increasingly integrating health impacts resulting from climate change in their NAPs (Amis et al., 2014).
In the Zimbabwean context, the MoHCC and government have responded to the two VBDs with a "business as usual" approach. The study demonstrates that MoHCC has dominantly responded to VBDs using treatment controlled from above. Other countries are making good progress through supporting and empowering the primary health systems (Lahariya et al., 2020;Lahariya, 2019). However, in cases were funding was availed by NGOs environmental control of vectors of the two diseases where done. The business as usual approach in resources constrained context will not be able to deal with future epidemics. There is increasing evidence in science that climate change is influencing the biology of vectors and spatial coverage (Chikodzi, 2013;Gwitira et al., 2015). The UNFCCC has supported countries like Zimbabwe to develop NAPs. The Zimbabwean government has mandated MoEWC to deal with climate change adaptation through the CCMD. Evidence from the study suggests that there is very limited engagement with the MoHCC. However, there is potential for cooperation between the CCMD and MoHCC on VBDs which are negatively influenced by climate change.
The study participants argued that financial resources determine the District health team's response to malaria and bilharzia. National health is an expression of the country's economic development stage (Bhasin & Nag, 2011). Thus, the politics and economy of a country shapes the structure and functions of institutions that determine health services provision. Zimbabwe is undergoing political and economic crises which have forced it to cut the health budget (Bond, 2007). A study by Rusvingo (2014) showed that in the Zimbabwean health system, the financial inadequacies and unpredictability has resulted in poor planning, low staff salaries, shortage of medicines and poor infrastructure and equipment (Rusvingo, 2014). Our study shows that the MoHCC focus is biased towards curative care because of budgetary constraints. Furthermore, the curative budget is heavily augmented by the OOP. Yet much of the vectorborne diseases control efforts require environmental interventions (Chimbari, 2012). In Gwanda district, besides seldom environmental vector control measures, the MoHCC's main strategy is to treat reported cases. This situation may compromise access to health by the poor since they cannot afford the health fees, creating inequalities in access to health services.
There was evidence from this study that showed that NGOs assisted government with programmes to control malaria and bilharzia. Literature has demonstrated that NGOs and private capital assist in areas of the health systems in cases were governments fail to meet service demand (Biehl, 2011). This study showed that malaria control received more funding in comparison to bilharzia. NGO's and private sector were key players in health system networks because they had an advantage over government in mobilisation of resources (Gilson et al., 1994). The NGOs would control the resources and dictate on the uses and which diseases to prioritise. However, NGOs' role in developing health systems has limitations. In this study it was indicated that operations of NGOs were dependent on policy makers at the global and local level, thus they tended to fund their areas of interest which might not be priority for the Gwanda District. The NGOs monopolise power over key health resources yet they might have a poor understanding of the country's health prioritise. Yet government has knowledge of the priority health issues but lacks the resources for programming. This dialectical relationship will continue influencing health delivery in Zimbabwe in the future. There is need for careful coordination of stakeholders and guard against power and hegemonic contestations at the expense of health, more important in the future with climate change.
Based on our findings a framework for reducing vulnerability and enhancing resilience among populations affected by VBDs in the context of climate change was developed (Figure 2). The framework argues that the MoHCC should form the coordination centre. According to the framework relevant government departments form the primary stakeholders in addressing VBDs in the context of climate change. NGOs, academic institutions and private capital form the secondary network to the coordination team. The vulnerable communities have input into the system in order to come up with community-based adaptation plans. Thus, the communities are part of the process and the outcome. With sound interventions the vulnerable community may be transformed to being a resilient community. Figure 2 Suggested response structure to community vulnerability to VBDs in the context of climate change, developed by the authors.

Conclusion
In conclusion, the MoHCC is the national structure responding to malaria and bilharzia in Zimbabwe. Unfortunately, it does not integrate the impacts of climate change on diseases biology and spatial distribution. Thus, MoHCC needs to capacitate its self by networking with government, NGOs and private capital to deal with climate change induced challenges like disease epidemics. Hence, the performance of the health delivery system in dealing with VBDs such as malaria and bilharzia is determined by the strength of the MoHCC. However, there is potential to utilise the NAPs in prioritising health issues that relate to climate change impacts. In the current political economy, the country's VBDs health outcomes need to be tied to the global system of health funding if desirable health outcomes are to be achieved. Thus, Zimbabwe has a weak institutional framework to respond effectively to malaria, bilharzia and other VBDs in the context of climate change.

Recommendations
The study makes the following recommendations: • Integration of climate impacts on VBDs in both the MoHCC policy framework and CCMD's NAP.
• Improve coordination inline with the model suggested in figure 2 of this paper.
• Further research on the relationship between NGO and MoHCC in the potential influence to VBD programmes.
• The findings of this study can be generalised for the Zimbabwean health delivery system.