By Bigboy Madzivanzira
“Oh we tried to reach you but failed. Your patient has gone to the mountain for prayers. She will be there for five days” said a woman in Chitungwiza after I had travelled all the way from Harare.
“Today I am in pain. Come tomorrow” said a man in Glendale after I had travelled all the way on a booked schedule.
These are not excuses. These are not stories I read in a book. These are the words I heard this week, as a therapist doing home-based therapy.
This is the real face of Community-Based Rehabilitation (CBR) in Zimbabwe.
CBR sounds simple on paper: take therapy to the people, in their homes, in their communities. No hospital queues. No transport costs for the patient. Dignity, inclusion, and care where people live.
In practice, it is one of the hardest forms of healthcare to deliver.
1. The Journey That Ends At A Closed Door
I left Harare early, paid kombi fare, changed routes, walked to the house in Chitungwiza – only to find the patient was not there. She had gone to the mountain for prayers for five days.
The family said they tried to reach me, but they only tried _after_ I had already travelled.
That trip cost me money, a full morning, and a slot that another patient in Chitungwiza was waiting for. That other patient lost therapy that day, not because I did not care, but because I was sent to an empty house.
This is why we now have a rule: Confirm the day before, or No YES = No visit. It sounds strict, but it is the only way to protect other patients.
2. “Come Tomorrow” Means Double Transport
In Glendale, the man said he was in pain today, so I must come tomorrow.
I understand pain. Pain is real. But what he was asking was for me to make a second, special trip to Glendale tomorrow – double kombi fare, double time – for one client, while other clients in other areas wait for their turn.
Home therapy cannot work like a private taxi service. If I go to Glendale today, I see him today. If he cancels today, he waits for his next Area Day. Otherwise, the whole timetable collapses.
We have learned to ask: Is this new, severe pain that needs hospital? If yes, go to hospital now. If it is the usual pain, let us do a short assessment today – therapy often _helps_ pain. But we cannot keep moving the appointment because the day is not convenient.
3. Everyone Wants To Be First
When you do home visits, every client believes their need is the most urgent. A stroke survivor in one area, an amputee in another, a child needing a wheelchair assessment – all want you today, and all want you first.
Without a clear timetable, you spend more time negotiating than treating. That is why we introduced Area Days: each community has its own day, and we travel furthest-first and work our way home. It is fair, but it requires clients to understand that fairness is not favouritism.
4. Public Transport Is Our Biggest Enemy
Most community therapists do not have a vehicle. We use kombis and buses.
Congestion, route changes, and rain can turn a 30-minute journey into 2 hours. A day planned for 4 clients can easily become 2 clients. Transport costs also eat into already small budgets – and when a client is not ready, or has gone to the mountain, that transport money is lost.
CBR cannot succeed if therapists are expected to absorb transport costs from their own pockets.
That is why we now ask private clients to confirm with transport upfront, and why a wasted trip – where the client confirmed but was not ready – must be paid for by the client on the next visit. It is not punishment. It is sustainability.
5. The Patient Is Not Ready
We arrive, and the patient is still bathing. Or cooking. Or asleep. Or has visitors. We wait 15 minutes, 30 minutes, and then we must leave for the next client who _is_ ready.
Many families do not understand that therapy is a medical appointment, just like a hospital appointment. If you miss a hospital appointment, you lose your slot. The same must apply at home.
Our rule is now simple: We wait a maximum of 15 minutes. After that, we leave and mark it as a missed visit. Once one or two clients lose their slot, all others start being ready.
6. Visitors, Pastors, and Family Functions
In our culture, a home is never just a home. It is a church, a meeting place, a family court.
We often arrive to find a pastor praying, visitors gathered, or a family function in progress. Therapy needs privacy, quiet, and concentration. It cannot happen in a crowd.
We handle this with respect, not rudeness: we ask families to give us 45 minutes of private time, or we reschedule. But rescheduling costs time and transport for everyone.
7. Safeguarding in Private Homes
A clinic has nurses, receptionists, and open doors. A home does not.
A male therapist must never be alone with a female client. A female therapist must never be alone with a male client. Children must always have a guardian present.
This is not distrust – it is protection for both the client and the therapist. But finding a chaperone in every home, every time, is a daily challenge.
8. Funding and Sustainability
CBR is often funded by short-term projects. When the project ends, the therapy ends – even though the stroke survivor still needs therapy, and the child still needs a wheelchair review.
Families cannot always pay. Donors cannot always fund. Therapists cannot always volunteer. We need a sustainable model: a mix of donor support, government support, community contribution, and fair client contributions for transport and basic services.
9. Caregiver Burnout
Behind every patient is a caregiver – usually a mother, wife, or grandmother – who is tired, unpaid, and overwhelmed. If we do not train and support the caregiver, therapy stops the moment we leave the home.
CBR is not just about the patient. It is about the whole family.
So, What Is The Way Forward?
Despite these challenges, CBR works. I have seen stroke survivors walk again, children sit properly in a well-fitted wheelchair for the first time, and amputees regain independence.
To make it work better, we need:
1. Clear policies- timetables, confirmation, waiting rules, and transport rules that clients sign and understand
2. Community education- that home therapy is real healthcare, not a casual visit
3. Transport support – for therapists, not just for patients
4. Safeguarding standards chaperones, registers, and signed visits for every home
5. Long-term funding – not project-to-project survival
Community-Based Rehabilitation is not charity. It is healthcare. And if we want it to survive in Zimbabwe, we must treat it with the same seriousness as hospital care.
If you are a policymaker, donor, partner, or community leader, I invite you to walk a day with us. Come to Chitungwiza. Come to Glendale. Come and see the real work, the real challenges, and the real impact.
About the Author: Bigboy Madzivanzira is a multi-faceted Medical Rehabilitation Practitioner registered with the Medical Rehabilitation Practitioners Council of Zimbabwe, a Health Promotion Practitioner registered with the Allied Health Professions Council of Zimbabwe, a Family Therapist, a Special Needs Educator, a Wheelchair and Supportive Seating Specialist accredited by International Society of Wheelchair Professionals and a Freelance Journalist accredited by the Zimbabwe Media Commission. Bigboy writes about disability inclusion, Health Promotion, Public Health and social justice. He is the Founder and Director of Health Promotion Clinic Trust and CAN Africa Network Zimbabwe Representative. He can be contacted on 0773 367 913 or email him on healthpromotionclinic@gmail.com