A Critical Paradigm Analysis of Community Health System Strengthening to Reduce Neonatal Mortality in Rural Zimbabwe

Despite near-universal antenatal care and facility-delivery coverage, neonatal mortality in Zimbabwe rose between 2019 and 2023–24, exposing a gap between service contact and newborn survival. A cluster-randomised trial in Mashonaland West Province found that institutionalising three community health system "vital signs" (trained village health workers, functional community governance, and participatory women's and men's learning and action groups) reduced neonatal deaths by 57%. The women's and men's groups protected newborns only once attendance was sustained over multiple meeting cycles, consistent with a cumulative participatory social-change mechanism rather than an effect of assignment alone. Policy should formalise village health workers, grant community governance structures real financial and operational authority, and sustain participatory groups over the years, directing investment toward the most under-governed and underserved communities.