Multimorbidity and health system priorities in Zimbabwe: A participatory ethnographic study

Multimorbidity, increasingly recognised as a global health challenge, has recently emerged on the health agendas of many countries experiencing rapid epidemiological change, including in Africa. Yet with its conceptual origins in the global North, its meaning and possible utility in African contexts remains abstract. This study drew together policymakers, public health practitioners, academics, health informaticians, health professionals, and people living with multimorbidity (PLWMM) in Zimbabwe to understand: What is the transformative potential and possible limitations of elevating multimorbidity as a priority in this setting? To bring these different perspectives into conversation, we used a participatory ethnographic design that involved a health facility survey, participant-observation, in-depth interviews, audio-visual diaries, and participatory workshops. We found that multimorbidity was new to many respondents but generally viewed as a meaningful and useful concept. It captured the increasingly complex health profile of Zimbabwe's ageing population, foregrounded a range of challenges related to the 'vertical' organisation and uneven funding of different conditions, and revealed opportunities for integration across entrenched silos of knowledge and practice. However, with capacity and momentum to address multimorbidity concentrated within the HIV programme, there was concern that multimorbidity could itself become verticalized, undercutting its transformative potential. Participants agreed that responding to multimorbidity requires a decisive shift from vertical, disease-centred programming to restore the comprehensive primary care that undergirded Zimbabwe's once-renowned health system. It also means building a policy-enabling environment that values generalist (as well as specialist) knowledge, ground-level experience, and inclusive stakeholder engagement. We conclude that the 'learning' health system represents a promising conceptual lens for unifying these imperatives, providing a tangible framework for how knowledge, policy, and practice synergise within more self-reliant, person-centred health systems able to respond to complex health challenges like multimorbidity.