Journal of Social Development in Africa (1990), 52,45-59 
A Discussion Point: 
A Strategy for Primary Health Care for the Elderly in 
Zimbabwe 
SHIRAZRAMJI* 
1. Introduction 
This discussion paper will focus on social networks, pensions schemes, health and 
the nutritional status of the elderly. 
The few studies that have been conducted in Southern African tend to be 
concerned mainly with the urban elderly living in institutions. Information about 
social networks, pension schemes, and the health and nutritional status of the 
elderly living in the rural community is still to be collected and compiled. In 
addition, there is a growing need to obtain information about grandchildren, 
including those orphaned by AIDS, who are in the care of the elderly (see case 
study). Such studies are important to assess the current social position and health 
status of the elderly, and to form the basis for the development of future policy and 
planning for the elderly. 
"Instead of perceiving an increasingly elderly population as a growing 
burden upon the nation, we should regard it as a cultural blessing and seek 
to enhance its position in our society in a variety of ways. One point which 
needs to be borne in mind is that traditionally elderly parents have relied, 
to a large extent, if not wholly, on the virtues of the extended family with 
a large number of children, grandchildren and other relatives to support 
them in old age. However, because of the general trend in whichthe average 
family size is decreasing and life expectancy is increasing the responsibility 
of looking after elderly parents and grandparents is tending to fall more and 
more on the shoulders of fewer children and grandchildren. Thus, policy 
should be principally aimed at ensuring some measure of security for those 
who in their old age will tend to rely more on the benefits of community 
welfare than on their offspring." 
RobertGMugabe, 15th December,atage62(School of Social Work,1986). 
"We don't get older, we get riper." Pablo Picasso, at age 90. 
+ Epidemioiogia, 9 Fife Avenue, Htnue.ZJmb.bwe
46 Sh'wazRamji 
"Health affects everybody - the unborn and the dying. Change policies on 
health and you automatically change attitudes towards ageing." 
Maggie Kuhn, at age 76, Founder of the Gray Panthers (quoted in New 
Internationalist,1982). 
"In African countries, as in many other developing nations, the family and the 
extended family network is the provder of basic welfare - the safety net 
when illness, misfortune and death strikes. This is one big asset, according 
to AIDS counsellors atthe AIDS Service Organisation (TASO) in Uganda." 
(Panos Institute, 1989) 
There is a need for more baseline information on the elderly living in rural and 
urban areas, and more participation by this group in making suggestions for a 
national pension scheme and a programme of nutrition intervention as part of 
Primary Health Care for the elderly. Data on household size and composition 
would give information on the number of grandchildren, including those orphaned 
by AIDS, dependendent on the elderly. The first case study at the end of this paper 
illustrates the potential impact of the care of AIDS orphans by the elderly (Hilclock 
Ogola, in Panos InsUtute.1989). 
2. Who are the elderly in Zimbabwe? 
To answer this question, several issues have to be considered. People born in 1900 
are 90 years old today and are quite obviously elderly. The adverse socioeconomic 
conditions of Zimbabwe's colonial era have meant that many Zimbabweans who 
are less than 60 years old may already look physically old. According to the 1982 
Population Census, the total population of Zimbabwe was 7 500 000 people, 
including 3 700 000 males and 3 800 000 females, a gender ratio of 96 men to 100 
women. About 25 % of this total population live in the urban areas, which are 
defined as cities and towns of 2 500 people or more (CSO,1984;1985;1986). 
Zimbabweans aged 60 years and above make up four percent of the total 
population; and are defined as the elderly of Zimbabwe. 
Demographic information about the elderly is limited and only available from 
the 1982 Population Census. However, the Central Statistical Office (CSO) has 
projected the number of elderly people in Zimbabwe for the period 1987 to 2007, 
as follows: 
Table 
Year Total Elderly Population Aged 60 + Years 
Population Male Female Total 
1987 8 639 823 164 328 188 646 352 974 
1997 11153 853 215 333 253 910 469 243 
2007 13 918121 315 290 377110 692400
Discussion: Primary Health Care for the Elderly 
Africans 
M
6794 
1192 
6469 
25 828 
25 244 
22775 
11279 
15 238 
19 877 
17289 
27 689 
179 674 
City 
Province 
Harare 
Chitungwiza 
Bulawayo 
Manicaland 
Midlands 
Masvingo 
Mat North 
Mat South 
Mash East 
Mash Cent. 
Mash West 
Total 
Gender ratio 
F
3 659 
1057 
3 997 
27401 
24841 
25 887 
12582 
16319 
20175 
14164 
18200 
168282 
107:100 
a. Africans and people of mixed racial parentage (see case study) 
It is believed that the majority of the elderly in Zimbabwe live with their multigeneration 
extended famUies in the rural areas. There are onlyabout 70 institutions 
and homes for elderly in Zimbabwe, with a residential population of less than 2 000 
elderly. The official age for retirement in Zimbabwe is 60 years old for women and 
65 for men. This retirement age applies mainly to civil servants, professionals, 
domestic workers, and factory and transport workers. The age of retirement for 
workers in privately owned mines and plantations is often lower and arbitrary, 
depending on me availability of younger workers to fill vacancies. There is, of 
course, no clear retirement age for peasant fanners, most of whom are women. 
Racially, the Zimbabwean population, including the elderly, consists of three main 
groups (The people of mixed racial parentage, the coloureds, usually being 
grouped with one of the other existing groups) (see Table 2). 
Table 2 
Elderly population aged 60 years and above in Zimbabwe by racial groups 
Source: Central Statistical Office (CSO) Census 1982, compiled by Shiraz Ramji, 
1987 
Thisgroupfoims93^%ofu^approximatdy370000elderiyinZunbabwe. The 
majority of elderly African women are peasant fanners, and Ihe majority of the 
elderly African men are retired workers. This is reflected in the gender difference 
pattern in rural/urban migration. About 8 % of elderly men and 5 % of elderly 
women live in urban areas. The higher number of elderly men in urban areas may 
be due to the fact that retired migrant workers often settle in the urban areas. A 
47
F 
6120
0 
3311 
632 
746 
255 
86 
62 
343 
183 
716 
Coloureds Asians Europeans 
M
114
0 
205 
28 
67 
15
4 
25
7 
27 
43 
535 
105:100 
7998 12454 
64:100 
F 
141 
0 
M 
1909
0 
2917 
580 
729 
93 
24 
17 
F 
157
0 
239 
18 
42
4
3 
2
2
430 
257 
113 
201 
307 
201 
784 
M
111 
0 
84 
20 
24 
3
0
4
1
2 
15 
16
3 
11 
18 
511 
11 
264 297 
89:100
48 Shiraz Ramji 
significant number of these men were born in Mozambique, Malawi, Zambia or 
South Africa. They came to Zimbabwe to work on the railways, plantations and 
mines (Muchena,1978). Adamo et a\ (1984:58) say: 
"An important aspect of relations between Mozambique and Zimbabwe 
during the colonial period was the supply by Mozambique of migrant labour 
to Zimbabwe. The cumulative effect of decades of recruitment was that by 
1974 there were an estimated 79 978 Mozambican men and 8 048 women 
working on the farms, mines and industries in Zimbabwe." 
A large number of the elderly are known to be integrated into the extended 
family structure and continue working as peasant farmers in the rural areas. Some 
of the elderly women serve as traditional midwives on an occasional basis. Very 
few of these elderly receive a pension, money from social welfare schemes, or are 
beneficiaries of medical aid schemes. 
Today's African elderly grew old under British colonialism. The majority lived 
and worked under harsh conditions of forced labour on plantations, farms, mines, 
the railways and factories with very little remuneration. The women lived separated 
from their husbands who were often away working in other parts of the country for 
extended periods. Consequently children grew up without going to school or 
receiving adequate parental care and attention. 
b. Asian immigrants 
This group of the elderly population (less than 1 %) came to Zimbabwe from Asia, 
mainly India, via Mozambique and South Africa (Mandivenga,1983). They are 
either housewives or retired businessmen. About 74 % of the elderly men and 79 
% of the elderly women live in urban areas. They are known to be integrated into 
their extended family and religious structure. Some of them (Hindus and Muslims) 
get support from their own religious social welfare system. None of the elderly 
Asians live in institutions or homes for the elderly. 
c. European immigrants (see case study) 
European immigrants came to Zimbabwe from England, Scotland, Ireland, 
Netherlands, Portugal and Italy, as part of Cecil Rhodes and the British government's 
colonial programme to invite European settlers to grow cash crops, mainly tobacco 
and cotton, for export (Arrighi,1967; Mandaza,1986). The European elderly 
consist of 6% of the total population of the elderly in Zimbabwe. They are retired 
commercial farmers, businessmen, civil servants, teachers, nurses, doctors, 
housewives and politicians. About 75% of the elderly women and 44 % of the 
elderly men live in urban areas. The significantly higher number of European 
elderly women living in the urban areas may be explained by the fact that they
Discussion: Primary Health Care for the Elderly 49 
moved from the rural commercial fanning areas after the deaths of their husbands, 
possibly to join their children and grandchildren. 
The majority of elderly Europeans receive a pension from-the government, a 
relic of the racial policies of British Colonialism. A few are property owners and 
may have savings in the bank. Some of them live in established old people's and 
nursing homes. 
3. Primary Health Care 
Primary Health Care, with its commitment to providing health for all by fostering 
self-reliance and social action of an intersectoral nature, has to cater specifically 
for the needs of the underserved and underprivileged in order to help bring about 
equity in the field of health (WHO.1983). The pronounced aim of the 1978 
Declaration of Alma Ata is Health for All by the Year 2000, through Primary 
Health Care defined as follows (Section VI, Alma Ata, 1978): 
"Primary Health Care is essential health care based on practical, scientifically 
sound and socially acceptable methods, and technology made universally 
accessible to individuals and families in the community, through their full 
participation and at a cost that the community and the country can afford to 
maintain at every stageof their developmentin the spiritof self-reliance and 
self-determination. 
It forms an integral part both of the country's health system, of which it is 
the central function and main focus, and of the overall social and economic 
development of the community. 
It is the first level of contact of individuals, the family and the community 
with the national health system, bringing health care as close as possible to 
where the people live and work, and constitutes the first element of a 
continuing health care process." 
Primary Health Care has five underlying universal principles, and a number of 
components which vary and change in and between countries and over time. These 
principles are: equitable distribution, community participation, a preventive/ 
promotive approach, appropriate technology, and a multisectoral approach. 
Since Zimbabwe's Independence in 1980, the Ministry of Health has adopted 
the policy of Primary Health Care for All and has expanded health services to the 
majority of the rural population. Zimbabwe's Primary Health Care Programmes 
for the elderly are integrated into the general health care services for the whole 
population. This p>ar)errjroposes ten components of a Primary Health Care system 
for the elderly: namely social networks; pension, social security and welfare 
schemes; housing; nutrition; water, sanitation; rehabilitation and disabilities; 
control and treatment of diseases; health education; and a demography and health
SO SkirazRamji 
information system. Details of these components are described in the following 
sections. 
3.1 Social networks 
Social networks of relatives, neighbours and friends may help to control and 
prevent problems related to mental health, such as loneliness, worries, tension and 
loss of interest in life. Participation of the elderly in social, cultural, political and 
religious activities may improve their quality of life; including talking, reading, 
cooking, walking, attending literacy classes, and playing games and sports. 
32 Pension, social security and welfare schemes 
"The International Labour Organisation (ILO) predicts that only 25% of 
retired men and 6% of retired women will be receiving a pension by the year 
2000. The rest will have to work as long as they are able and then turn to their 
children and other relatives for help." 
(New Internationaust,1982). 
In Zimbabwe, at present, there is no national social security scheme for the 
elderly. However, the 1989 National Social Security Authority Act provides for the 
establishment of social security schemes for employees. There is no provision for 
self-employed elderly peasant women and men living in the rural areas. Some form 
of pension or a social security scheme for all the elderly in Zimbabwe would 
contribute towards the cost of fulfilling the basic needs like food, clothing and 
shelter. Pensions are often calculated at a percentage of the previous working 
wage. The ELO recommends that state pensions should be between 65% and 80% 
of the working wage (New Internationalist,1982). However, this may not be a 
useful formula for peasant fanners. 
33 Housing 
Provision of permanent housing and shelter can be an important component of a 
Primary Health Care strategy. Elderly women and men in the rural areas are known 
to build their own hut as part of their investment for the future. Some elderly people 
in urban areas may have a flat or a house as part of their property. However, a 
significant number of elderly who have worked on commercial farms, mines and 
industries do not have proper shelter. Should investment in housing be a part of 
a national pension scheme? (The National Railways of Zimbabwe is reported to be 
experimenting with this idea.) 
3.4 Nutrition 
The elderly have an appetite for a good diet to satisfy their physiological needs and 
to keep up their quality of life. The pleasure of havingagood meal with otherpeople
Discussion: Primary Health Care for the Elderly 51 
is an important part of consolidating social networks for the elderly. The type of 
food eaten by the elderly is closely connected to tradition and culture, and the 
socioeconomic status of the elderly. 
According to the few case studies which include a dietary history of Zimbabwean
e 
elderly (Ramji and Thoner,1990a), breakfast tends to consists of tea with milk 
maize porridge (sadza), and other types of cereals. Some elderly eat fruit as well' 
Lunch consists of cereals together with either vegetables, meat, fish or eggs 
Occasionally fruit is eaten as dessert. Dinner is the same as lunch, with some 
variations in quantity and quality. Some of the elderly have tea and biscuits in th 
mornings and possibly in the afternoons (see case studies). This pattern was also 
observed in some of the institutions and homes for the elderly. This meal patten, 
may not apply to the majority of elderly in Zimbabwe. 
The dental and health status of the elderly may contribute to difference 
between their past (ie when they were younger) and present diet. For exarnpj 
elderly people often have difficulty chewing meat or problems with digesti0 ' 
Although energy requirements for the elderly decrease with age, the demand f " 
nutrients does not. According to the WHO and FAO publication Energy ^ J * 
Protein Requirements (1978), the energy requirement is thought to decrease k 
5% for each decade between the ages of 40 and 59 years, by 10% from 60 to ^ 
years, and for age 70 and above another reduction of 10% is suggested. \, 
lacking in energy and/or nutrients will affect the nutritional status of the e l ^ " 
This nutritional status could be assessed by different anthropor 
measurements and/or blood parameters, and there is a need for such a 
including measuring height and weight for the calculation of an anthroporn€ 
parameter for nutritional status, Body Mass Index (BMI). Garrow 
classified BMI values into the following weight categories: ****$ 
BMI Value Weight Category 
<20 underweight 
20-24 normal weight 
25-29 moderate overweight 
30+ severe overweight 
Some calculations of Body Mass Index have been done among el^ 
displaced Mozambicans living in Zimbabwe and Mozambique (Ramji T^V 
Thoner,1990b). The number of elderly Mozambican women with a Body 
Index of less than 20 was 69 out of 131 (53%). According to Garrow this 
be classified as underweight The corresponding figure for elderly 
men was 49 out of 109 (45%). The distribution of BMI 
menand women livingin displaced people's centres in Mozam 
is shown in Table 3. This data was collected among displaced people and c^ 
be taken as representative of the elderly living in the community. Sipiilarr^J
52 Shirazftamji 
were observed in a survey done among elderly refugees living in Sudan 
(Godfrey,1986). 
Table 3 
Nutritional status - BMI Values of Displaced Mozambican Elderly Men 
and Women Living in Mozambique (Zambezia Province) and Zimbabwe, 
June 1987. 
Mozambique Zimbabwe 
Body Mass Index Male Female Male Female 
(BMI) n = 43 n = 58 n = 56 n = 73 
<15 1 5 0 0 
15-19 21 41 27 23 
20-24 20 12 27 39 
25-29 10 2 11 
30+ 0 0 0 0 
BMI < 20 51% 80% 48% 33% 
Note: Body Mass Index (BMI) = (weight kg)/(height m ** 2) 
35 Water 
Adequate supplies of safe water is one of the components of the National 
Programme ofPrimary Health Care for All by the year 2 000. The 1988/89 Annual 
Reportof the National Action Committee of the Rural Water Supply and Sanitation 
Sector notes that the project is aiming at 100% coverage of safe drinking water 
supplies and 50% coverage of adequate sanitation facilities in the rural (communal) 
areas by the year 2 000. Regarding rehabiliation, the same report writes that: 
"of the total existing water points, close to 30% may be either completely or 
partially non-functional, due to a variety of reasons, for example belowground 
technical problems, drought, siltation/blocking and handpump 
breakdowns...Thenumberof water points needingrehabilitation [includes] 
2 400 deep wells serving 360 000 people, and 2 500 boreholes serving 
625 000 people." 
The 1988 AnnualReportof theDepartmentof Environmental Health Services, 
Ministry of Health, reports that 5 352 protected shallow wells were constructed in 
the rural areas between 1986 and 1988. The elderly, as part of the general 
population, will benefit from this free rural water programme. However, there is 
a suggestion that rural people should pay for this water service. In such an instance, 
it is to be hoped that the elderly will continue to benefit from the water programme 
without having to pay for the service. 
Saugestad (1990) has made the following observations in her study: 
"Old people use less water than young families.. .An old lady we met the day 
after the survey was finished was asked why she had not been to the well 
the twodays before. She toldus that she had collected onebucketofl81itres
Discussion: Primary Health Care for the Elderly 53 
the day before the survey, and this lasts her for three days. This means she 
uses 6 litres a day for cooking and a rather modest amount for washing." 
3.6 Salutation 
The National Programme on sanitation promotes the construction and use of 
latrines at household level. There are various types of latrines used in Zimbabwe. 
These include flush-toilets, ventilated pit-latrines and other types of pit-latrines. 
The most common one promoted by the Ministry of Health for construction in the 
rural areas is the Blair ventilated pit-latrine (VIP). The number of new VEP latrines 
constructed in rural areas between 1986 and 1988 was 109 667. It is not yet clear 
whether the elderly are comfortable using VIP latrines, which are dark and have 
no access to natural light 
3.7 Health Education 
Health education or education concerning prevailing health problems and the 
methods of identifying, preventing and controlling them, is one of the components 
of a general Primary Health Care strategy. Health education must be based on a 
knowledge of people, their customs, habits, beliefs and it must be planned 
(Scotney,1976). The question is, who should plan for the elderly? 
"It is assumed.that only health professionals are in a position to assess the 
health needs and priorities of the elderly. This approach blames the sick, 
the poor and the miserable for their illness, their poverty and their misery. 
It ignores the fact that in a number of situations it is not the individuals who 
need to be changed but the social environment they live in." (WHO, 1983). 
In other words, the political, economic, social and environmental factors that have 
a negative or neutralising effect on healthy behaviour may need to be modified. 
In addition, for effective planning of health education activities and services, 
the elderly should participate in formulating policies and strategies, and in 
implementation and monitoring of progress. There is a conventional wisdom in 
every community, and people, including the elderly, are able to think and act 
constructively in identifying and solving their own problems (WHO, 1983). 
Health education on smoking, excessive use of alcohol and medicaments 
should be extended to younger age groups so as to prevent the disease conditions 
of old age, such as coronary heart diseases and malignancies/cancer. 
In Zimbabwe there is a Health Education Unit at both national and provincial 
level. The Unit communicates health messages through the media, schools and 
health institutions. Politicians, teachers, journalists and village health workers are 
involved in giving health education. It is proposed that the elderly should also be 
involved in health education as part of a strategy ofbroad comm unity panic ipation.
54 ShirazRamji 
3.8 Control and treatment of diseases 
Since Independence in 1980, the Ministry of Health has expanded health services 
to the rural areas through a programme to train Village Health Workers and other 
paramedic workers. New health clinics have been built, and district hospitals have 
been expanded to cover an increasing population. Health services are provided 
free to those people, including the elderly, earning less than Z$150 per month 
(Hifeb International/Zimconsult, 1989). 
According to Watcrston (1984) die typical problem list of the elderly at clinics 
and hospitals includes bronchitis (cough), hypertension (high blood pressure), 
congestive cardiac failure (heart failure), arthritis, anaemia, constipation, cataract 
(disease of the eye leading to poor vision), and chronic leg ulcer. 
The elderly, consisting of 4% of Zimbabwe's total population, benefitfromthe 
National Control and Treatment Programme for communicable diseases. For 
example, in 1986outof 5233tuberculosiscasesundertreatment, 19% were elderly 
(Ministry of Health,1986). The control programme also covers diseases like 
leprosy, malaria and bilharzia. In the case of malignancies, the Zimbabwe Cancer 
Registry (Ministry of Health, 1989) recorded 20 cases of elderly women out of the 
total number of 106 women with cancer of the cervix. There were 18 cases of 
elderly men out of a total number of 48 men recorded with cancer of the liver. 
The total number of AIDS cases reported in Zimbabwe in the period 1987 to 
the first quarterof 1990 was2357. The bulk of these cases were in the productive 
age group 20-49, but around 20% were children under 5 years and 2% adults over 
50 years old (Ministry of Health, AIDS Control Programme, 1990). 
Should all elderly get free health services as part of a national social security 
system, and as a way of acknowledging their services to the nation during their preretirement 
life? There are very few elderly who are millionaires. 
3.9 Rehabilitation and disabilities 
According to the Ministry of Labour Report on the National Disability Survey 
(1982) there were a significant number of elderly with disabilities. Some of the 
disabilities mentioned were visual, lower limb, upper limb, hearing and mental 
capacity. 
Since Independence in 1980 the Ministry of Health has created a Department 
of Rehabilitation which has Rehabilitation Assistants, Physiotherapists, 
Occupational Therapists and Speech Therapists working at district and provincial 
level, to provide the necessary tertiary services to both rural and urban communities 
They also do outreach work and promote community-based rehabilitation. These 
services are likely to imporve the quality of life of the elderly through restoring
Discussion: Primary Health Care for the Elderly 55 
their independence and quality of life.. A random sample of reported statistics 
from districts showed that one in three persons receiving rehabilitation services 
were elderly (School of Social Work,1986). 
3,10 Demography and health statistics 
The standard age to define a person as elderly should be 60 years and above for 
both Zimbabwe and other countries in Africa. The Central Statistical Office (CSO) 
could provide a useful service, and further understanding of the elderly group, by 
publishing aprofile of the elderly in Zimbabwe, using figures from the Zimbabwe 
1982 Population Census. At present the morbidity and mortality figures for the 
elderly are combined with the figures of other adults in the routine health 
information system and publications of the Ministry of Health. Should diseases 
and death figures for the elderly aged 60 years and above be compiled and 
published separately? 
References 
Adamo Y, Davies R, Head J (1981) " Mozambican Labour to Rhodesia", in 
Journal of Social Science, No 2, Maputo. 
Alma Ata Declaration (1978) Report of the International Conference on 
Primary Health Care, Alma Ata, USSR, 6 - 12 Sept, UNICEF/WHO, 
Geneva. 
Arrighi G (1967) The Political Economy of Rhodesia, Mouton.The Hague. 
CSO (1984) Zimbabwe 1982 Population Census: A Preliminary Assessment, 
CSO, Harare. 
CSO (1985) Zimbabwe 1982 Population Census: Main Demographic 
Features of the Population of Zimbabwe. An Advance Report Based on 
a Ten Percent Sample, CSO, Harare. 
CSO (1986) Zimbabwe 1982 Population Census: Population Projection of 
Zimbabwe: 1982 to 2032, CSO, Harare. 
GatrowJS (1981) Treat Obesity Seriously, Churchill-Livingstone, London. 
Godfrey N (1986) The Health Needs of the Elderly (Ethiopian) Refugees: A 
Field Study in Eastern Sudan, mimeo, Help the Aged (UK), London. 
Hifab International/Zimconsult (1989) Zimbabwe Country Study and 
Norwegian Aid Review, Oslo/Harare. 
Mandazal (ed) (1986) Zimbabwe: The Political Economy of Transition 1980 
- 86, Codesria Book Series, Dakar. 
Mandivenga E C (1983) Islam in Zimbabwe, Mambo Press, Harare. 
Ministry of Health (1986) Tuberculosis Annual Report, mimeo, Harare. 
Ministry of Health (1989) Zimbabwe Cancer Registry, mimeo, Harare.
56 ShiraiRamji 
Ministry of Labour (1982) Report on the National DisabHity Survey, Harare. 
Muchena O N (1978) The African Aged in Town: A Harare Study, mimco, 
School of Social Work, Harare. 
New Internationalist (1982) "Healthy andWise:TheRiseoftheOverSixties , 
RamjiSandThonerG (1990b) Nutritional Status of Displaced Mozambican 
No 112, June, Oxford (UK). 
Panos Institute (1989) AIDS and children: A family disease, London. 
RamjiSandTnonerG (1990a) Elderly Zimbabweans Talk About Old Age, 
mimeo, Harare. 
Elderly Living in Mozambique and Zimbabwe, mimeo, Harare. 
SaugestadS (1990) Patterns in Water Use: Observations from the Mankaland 
Integrated Rural Water Supply and Sanitation Programme, University 
of Tromsoe, Norway. 
School of Social Work (1986) Zimbabwe Action Plan on the Elderly 
proceedings of a Workshop 15-18 December, School of Social Work, 
Harare. 
ScotneyN (1976) Health Education: A Manual for Medical Assistants and 
Other Rural Health Workers,Rural Health Series 3, African Medical and 
Research Foundation, Nairobi. 
WaterstonE (1982) Medical Problems Associated with Aging: Report on an 
In-Service Training Programme, School of Social Work, Harare. 
WHO (1978) Energy and Protein Requirements, Technical Report Series No 
522, Geneva. 
WHO (1983) New Approaches to Health Education in Primary Health Care, 
Technical Report Series No 690, Geneva. 
Case Studies 
1. "Grandfather cares for 14 orphans" 
(Hiklock Ogola, in Panos Institute, 1989) 
Danson Kilama is IS. When his parents died of AIDS, he and his eight younger brothers 
md sitters found shelter with their grandfather, Emanuel Kilama, at Kasheny Village, 
Bukoba rural district in Tanzania's north-western region of Kagera. The 68 year old 
grandfather also cares for five other grandchildren left orphaned after the death of one of his 
sons. "The children live under difficult situations because I am old, and my income cannot 
keep them," he says. 
Emanuel Kilama'8 deceased sons had supplemented his income from sales of 
coffee from a small plot But since their deaths, and a decrease in coffee yields, his income 
has fallen from 100 000 Tanzaraan shillings per year to less than IS 000 shillings in 1988. 
Darson, who must supplement the family's income with odd jobs, is therefore 
unable to attend classes regularly. And he has difficulty finding work because many 
villagers have negative feelings aboutthediseasethatkilledhisparents. "In the three years 
since my parents died, I have learned that people are not sympathetic with my situation.
Discussion: Primary Health Care for the Elderly 57 
AIDS is looked upon as a shame, and they look at me as a symbol of that shame. It is like 
AIDS is a result of a mistake of my own making," he says. 
But economic hardship and rejection have strnegthened bonds of solidarity among 
the 14 children. "We like each other. Maybe it is because we suffer together. When there 
is no food we all go hungry and at night we all sleep in one room." 
2. Sarah 
(Ramji and Thoner, 1990a) 
Sarah was born at home in Rusape district on the 6th of June 1927. She was the first born 
in the family, and has two sisters and one brother. Her father worked in Harare before 
returning to the village. 
At the age of three years, Sarah became blind in one eye after being bitten by an insect 
while playing with her friends. Despite this handicap, she studied for three years at St 
CassianMission Primary School, Rusape district. She could not continue schooling because 
her parents moved to another village and there was no school nearby. 
In 1949, at the age of 22 years, Sarah married her husband who had been a cook for a 
European family in Kwekwe district. They lived in Nyanga district and she gave birth to ten 
children, but one baby was still born. The other nine children were three boys and six girls. 
Two babies, one boy and one girl, died at eight and nine months respectively, because 
of diarrhoea. Another girl died at the age of eight years because of herbal poisoning 
(medicine given by traditional healer). 
One other daughter, a policewoman and a combatant/freedom fighter during the 
Zimbabwe liberation war, died in Harare at the age of 26 years because of herbal poisoning. 
Presently, one son, the eldest in the family, is working as a cook at the Post and 
Telecommunication (PTC) hostels. The other son is studying at All Souls Mission Secondary 
School. One daughter is a soldier and working in the army. They visit their mother Sarah 
during Christmas holidays and annual leave time. 
Sarah's husband died in Nyanga in 1962. He fell off a lorry. He used to work for the 
Tsetse Fly Control Programme and was on his way to a farm. Since then Sarah lives with 
her youngest daughter Callista (19 years old) and three grandchildren. One grandchild, 12 
months old, belongs to her daughter who got pregnant when she was doing her Grade 7 
primary school. At present this daughter is living with Sarah and doing Form 2 in the nearby 
secondary school. The other grandchild, aged seven years, belongs to the daughter who died 
of herbal poisoning in 1986. The third grandchild belongs to her daughter Anatolia who got 
pregnant in Mozambique. At present Anatolia lives in Nyanga town with her husband who 
is a school teacher, and their two children. 
Regarding her health status, Sarah does not feel well. She gets body pain and has back 
problems. She takes anti-malaria tablets regularly and goes to the government health clinic 
for her illnesses. She feels lonely, especially at night during the rainy season. Sarah is afraid 
of sleeping long hours because she is worried that she may die in her sleep. 
Sarahdoesnot smoke tobacco(cigarettes), but takes local beerduring various celebrations 
including marriages and birth of babies in her village. The elderly in the village «lso 
sometimes drink together to discuss (informally) problems of the village. Sarah is « 
Christian, and a member of the Roman Catholic Church. 
Sarah grows maize, pumpkins, groundnuts and green vegetables. She earns ZS40 per 
year from her agricultural activities. She has fifteen goats valued at ZS300.
8 Shirat ftam/i 
She slaughters a goat when her children visit her during Christmas and other occasions, 
arah has problems of chewing meat, but she enjoys eating meat when it is available, that 
i once a month. Sarah does not like drinking milk, but uses milk for her occasional tea in 
ie morning. That is her breakfast Her lunch is maize porridge (sadza) with green 
egettble*. The supper is what is left over. 
Her daughters and her son provide her with clothes and blankets. 
Her house in Katerere ward, Nyanga district, is a one room hut with a thatched roof and 
jud walls. The roof leaks during the rainy season. She has no private latrine, but has an 
nproviaed bathroom. Her daughter and her three grandchildren sleep in a similar hut 
Since Independence in 1980, the water situation in the village has improved. She used 
walk more than five kilometres to fetch water from a stream. Now the Government, as part 
' Primary Health Care Programmes for the community, has dug a borehole for water which 
less than one kilometre from where Sarah lives. 
Regarding her future plans, she will continue to struggle to get enough food and survive. 
Edna 
(Ramji and Thoner,1990a) 
idna was bom on the 4th of February, 1921, in Manchester, England. Her father was a hair 
Iresser and her mother worked at a fabric warehouse. They were four sisters in the family, 
ut one died at an early age. 
Edna finished her secondary education at the age of 15 years, and did odd jobs for the 
lext six years, selling shoes, gloves, etc. In 1942 she attended Deaconess training college 
or two years to be a Methodist Deaconess. For the next eleven years she worked as a 
deaconess in the Methodist Church. 
In 1947, at the age of 26 years, she went for the Methodist Missionary Training Course, 
he had planned to go and work as a missionary in China, but instead she was posted to 
Zimbabwe. Edna arrived in Bulawayo in 1948 at the age of 27 years and started to work with 
he Methodist Church organising church meetings and doing the work of the Deaconess. 
Edna met her husband John, a methodist, in Bulawayo in 1951 and they bought a house 
b settle down after their marriage in 1953. Her husband worked as the estates officer for 
National Railways of Zimbabwe. 
John was bom in Birmingham, England, and was doing his first year medical studies at 
Cambridge when he was called for service in the British Army. He was posted to India where 
le trained to be a radiographer. In 1945 he was posted and then discharged/demobilised in 
South Africa. He tried to continue his medical studies, but dropped out in the second year 
because he became more interested in race relations. He worked for the Federation of 
African Welfare Societies until 1953. He tried to get a job as a radiographer, but was refused 
because all the radiographers at that time were women and no men were allowed to practice 
u radiographers. He then joined the National Railways of Zimbabwe. 
Edna had four children with her husband; three boys and one girl. One of the sons, now 
aged 35 years, is married and working in the South African mines in Transvaal. The 
daughter, now aged 34 years, is married and living in Harare. She makes cakes at home for 
sale, and teaches cake king. Edna's second son, aged 32 years, is in Johannesburg, South 
Africa, together with his family, working with computers for a company making planes. Her 
last son, aged 30 years, and also married, is living in Bulawayo. He works as a chartered 
accountant for the National Food Company.
Discussion: Primary Health Care for the Elderly 59 
During thcperiod when the children were growing up, Edna stayed at home. In 1963,she 
got a job as a headmistress of Sizane Secondary School in Bulawayo. She worked for this 
school for 13 years. After Sizane she went to work as a lecturer in Education Psychology 
at the United College of Education. While she was working at the college to train teachers, 
she did a Master's degree course in Curriculum Studies with the University of Zimbabwe. 
After her retirement, Edna was invited by a friend to teach English and Bible Knowledge 
at St Bernard's Secondary School in Bulawayo. She thought it would only be for one year. 
Instead she was asked to teach for four more years. Edna finally retired in 1986 at the age 
of 65 years. 
Edna is a very active woman with a variety of interests, and she has accepted her li fe as 
a retired person. She has had a driver's licence since 1951, and at present she has her own 
car. She enjoys driving and her mobility. Every alternate week she attends a meeting of 
young married women who call themselves "The Homemakers". The women come from all 
racial backgrounds, and they discuss every thing mat affects making a stable home. Edna 
sometimes leads Bible studies, and she shares her experiences and knowledge with the 
younger women, some of whom have children. 
When we asked Edna if she ever felt lonely or got bored, she replied "No, I am too busy .** 
Besides being active with young married women's group, she is a care giver volunteer for 
the Island Hospice Service for terminally ill people and their families who are going through 
a hard time. 
Ednaleft the Methodist Church in 1965, and joined the Religious Society of Friends (the 
Quakers) because she wanted a silent worship meeting. Her husband remained a methodisi, 
but one of the things they do together is Bible studies. They enjoy their regular short walks 
and they also do some of the cooking together. John and Edna share the cooking work. In 
the morning Edna and John eat their home made 'muesli*, yogurt, fruit and herbal tea. For 
lunch, they have baked potatoes, vegetables, and sometimes boiled eggs or tinned tuna fish. 
For supper, Edna prefers a light meal; vegetables, meat or fish or macaroni cheese. Her 
husband prefers a bigger supper, so Edna makes a big portion. 
Edna has been told by her doctor that she has a low level of calcium and potassium in 
her Wood, so she eats a lot of bananas and drinks milk before going to bed. Edna says that 
the biggest difference between her past and the present diet is that now she eats less meat 
and more fruit. 
Regarding her health status, Edna has slightly high blood pressure. To control her blood 
pressure she has to have pills alternate days, and go for a regular medical check up every six 
months. The doctor has not told her anything about changing her diet to lower her blood 
pressure. 
Both Edna and John meet their children and 11 grandchildren on a regular basis. In 
Bulawayo they meet their son and his family at least twice a week. Last year they made three 
visits to South Africa to meet their children and grandchildren. 
Edna's advice to other elderly is: "Do not give up. Find out what you can do.**.