Operational Plan Report



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Zimbabwe
Operational Plan Report
FY 2012


Operating Unit Overview

OU Executive Summary

Country Context


While Zimbabwe has experienced a marked decline in HIV prevalence, the country continues to be affected by a high burden of HIV, which accounts for approximately 60,000 adult and 12,000 child deaths each year. The latest estimates, define adult prevalence at 13.3% (compared to 20.1% in 2005 and 25.3% in 1997). While prevalence among youth has also dropped significantly, it is worth noting the fact that prevalence among girls was twice that of boys in the same age group. The country continues to exhibit a generalized epidemic with populations of presumed higher risk including commercial sex workers, military, mobile populations including truck drivers, migrants, and displaced farm workers. HIV/AIDS is the leading cause of maternal death and the maternal mortality rate in Zimbabwe nearly doubled between 1994 and 2007. Zimbabwe also has a very high TB/HIV co-infection rate (at 80%) and one of the highest rates of TB mortality in the world.
Both the National AIDS Council (NAC) and the Ministry of Health and Child Welfare (MOHCW) lead the national HIV/AIDS response. In 2011, a Zimbabwe National Strategic Plan (ZNASP II) 2011-2015 was drafted and costed. While the level of institutional leadership within the MOHCW is high in terms of technical direction and policy setting, the capacity for implementation is limited. Limited national resources for programming undermines the MOHCW’s capacity to deploy and adequately train sufficient experienced health professionals, provide adequate commodities, and provide a high level of monitoring and supervision to ensure high quality service delivery. As such, donor resources have been essential to national prevention, care, treatment, and health systems strengthening efforts. A majority of HIV/AIDS-related activities are donor funded. Nevertheless, Zimbabwe has not received the magnitude of funding that countries of similar HIV burden have been able to access. Thus, Zimbabwe is facing some potential critical shortages of key inputs to achieve national goals, particularly in the areas of treatment and male circumcision.
The USG is a key partner, investing more than other bilateral donors in the HIV/AIDS response. The Global Fund to Fight HIV/AIDS, TB, and Malaria (Global Fund), however, remains the largest source of support to the national response with an annual investment through Round 8 of approximately US$80 million annually. DFID and the EU also provide substantial health funding in Zimbabwe; however, their investments are broader than HIV and include a new focus on maternal and child health, an area that is receiving renewed attention after alarming increases were noted in child and maternal mortality. A multi-donor funding mechanism that has supported HIV/AIDS activities, the Expanded Support Program (ESP) is now transitioning to a new mechanism called the Health Transition Fund (HTF), which will have a stronger focus on maternal and child health. This has led to some uncertainty about support for certain HIV/AIDS related activities, such as procurement of ARV medicines. DFID is likely to procure some quantities of ARVs, with a particular focus on pediatric treatment, through a new separate mechanism that has yet to be defined. Similarly, DFID will be supporting some HIV prevention activities through an integrated Sexual and Reproductive Health program that is also being finalized.
The USG has a broad program of support to the national HIV/AIDS response. This includes a comprehensive set of interventions in prevention, care, and treatment as well as health systems strengthening. The USG is currently the leading donor in the area of male circumcision, condom programming, laboratory strengthening, and commodity/supply chain management support. In other areas, the USG provides substantial funding, but other partners complement efforts in the areas of: counseling and testing, PMTCT, ART, OVC, and HIV/TB integration. In the area of human resources for health, the USG makes a number of investments in training, informatics, and secondment of key technical staff to support MOHCW but other donors, namely the Global Fund, DFID, and the EU support a broad health worker retention scheme that provides salary top-ups to most professional health workers in the public health system. This health worker retention scheme is expected to phase out by the end of 2013. Multiple donors purchase commodities including rapid test kits, ARV drugs, EID commodities, and laboratory reagents .
Donor efforts are coordinated through a number of mechanisms. The USG recently shared its overall program of health support including PEPFAR investments at a health development partner’s forum monthly meeting. The CCM, is another mechanism of coordination; however, the focus is strongly on Global Fund and coordination across different partners is not a focus of these meetings. Finally, the key mechanism of coordination is through GoZ-led technical working groups (TWGs). At this level that specific technical strategies are drafted and shared, ongoing and planned activities are presented, and opportunities for collaboration, and joining planning are identified. It is through these groups that MOHCW guides and coordinates all donor investments in the HIV/AIDS response.
PEPFAR Focus

In planning for the 2012 program of support, a number of key priorities were defined by the PEPFAR team. Development of the initial Scenario 1 COP budget was led by these priorities, which also informed later budget decisions related to programming to the expanded budget of scenario 2:



  • Investment in national efforts to scale up treatment; In spite of enormous challenges over the last several years, the MOHCW has developed a robust antiretroviral treatment program since its inception in 2004. As of December 2011, an estimated 410,000 people were on treatment in Zimbabwe, with over 8,000 people being initiated monthly. Nevertheless some commodity shortages as well as program weaknesses have threatened to slow progress. As a priority, the USG committed to directing support towards treatment scale-up.

  • Another area of emphasis is male circumcision. In 2011, 30,608 boys and men were circumcised; however, a shortage of planned leveraged funds limited our achievements towards the planned targets for FY11.

  • Another key area is PMTCT. These activities are described in detail in the 2012 PMTCT Acceleration Plan.

While the areas above led discussions about budget, the following priorities are related to how the PEPFAR team is managing partnerships, both internally and externally to strengthen our commitment to PEPFAR and GHI goals.


PEPFAR/Zimbabwe is coordinating with the MOHCW on program planning, implementation, monitoring and evaluation in keeping with the principles of the GHI.

Global Fund collaboration is another area of increasing involvement for PEPFAR. Global Fund updates are now regularly part of the weekly team meetings and dialogue has been strengthened with the CCM as well as with the Geneva-based Fund Portfolio Manager.
Global Health Initiative

The Zimbabwe Global Health Strategy has been submitted and reflects two key priority areas for GHI in Zimbabwe which are the integrated health service delivery with a particular emphasis on women and children and building the capacity of health systems for sustainable programming. These focus areas are oriented towards reducing morbidity and mortality related to HIV, TB, malaria, reproductive health and maternal, newborn, and child health conditions.


The USG also intends to build on efforts to strengthen health systems, particularly in the areas of health commodity logistic systems, laboratory systems, human resources for health and district level health information systems. The GHI focus areas will lead PEPFAR efforts to achieve results that will have broader systems strengthening effects which will enhance national systems to deliver a full package of health care that meets the broad needs of the Zimbabwean population. A fundamental aspect of GHI will be the learning agenda, which will strive to generate the metrics to demonstrate best practices to achieve program effectiveness.

Country Ownership Assessment


The Government of Zimbabwe (GoZ) has always led the national HIV/AIDS. The GoZ through NAC or the MOHCW sets policy, coordinates partner investments through technical working groups, and reviews progress of the national programs, which partners support. A limited spectrum of donor-supported activities occurs in the private sector. In general MOHCW identifies gap areas and advises partners to invest accordingly. USG investments reflect the historical record of these directed investments, generally in national programs, the national ART or PMTCT programs for example. In some cases, where there has been a program supported in the private sector, VCT and post-test support services for example, these programs have emerged from MOHCW request, to fill a gap that is unmet in the public sector. These same programs also partner with MOHCW to utilize “private” services to enhance MOHCW facility-based services. For example, counselors for the private post-test centers deliver on-site counseling services to MOHCW clients. The focus of PEPFAR in Zimbabwe has historically been GOZ facilities and enhancing their capacity to offer high-quality, accessible services. The national ART program serves as a case in point. PEPFAR does not support specific patients at specific sites but rather works to strengthen the program as it cascades from the national level to lower levels through a variety of mechanisms.
The evolution of PEPFAR support is a direct result of MOHCW direction to support their national program rather to set up pilot programs benefiting a single district or province. MOHCW has strongly advocated in this vein to ensure harmonization of all investments and progress on a national scale of key programs. This reflects the high degree of leadership and authority the MOHCW exercises with the national health system. The MOHCW –led technical groups are the primary mechanisms through which donor investments are coordinated. MOHCW leadership of these groups has been key to setting the pace of change and ongoing review of technical areas. Progress and gaps in various technical areas are presented in these forums and set the stage for joint planning between partners and GoZ. MOHCW technical staff participate in these meetings as do implementing partners, both local and international.
As part of the COP development process the USG prioritizes issues raised in TWGs. A few months after the COP budgets were shared, MOHCW held their annual MODO meeting, which requires all partners (donor and technical) to present their programs of support to the MOHCW and to each other to identify which activities are appropriately covered and other that may need additional inputs or may be duplicative. This essential role of the MOHCW has struggled through the economic hardships of the last years. As a result, the USG and other donors through the HTF are now going to supporting this process which is expected to both enhance coordination of technical inputs but also the leadership role of the MOHCW. The USG made good efforts to ensure good representation and a through presentation of the USG portfolio at the last review meeting. When the basic COP budgeting and activity documents were shared with MOHCW, their key concerns were discussed. These were queries about the possibility of MOHCW becoming a prime partner for awards. The procurement process was briefly explained and then we discussed some of the constraints that we have that disallow direct USG awards being made to MOHCW. The limited access MOHCW has to GoZ or donor funding remains a point of frustration for MOHCW leadership. Nevertheless we did discuss possibilities for discussing MOHCW involvement in partner selection and monitoring.
In terms of the outlined dimension of country ownership, we have highlighted some considerations below:

Political ownership/stewardship – The MOHCW has a bold vision for its health sector which is articulated in numerous strategies. MOHCW maintains authority over programming which requires intending implementers to properly coordinate activities through MOHCW administrative structures at national , provincial, and district level;

Institutional Ownership – The level of ownership is diminished because the MOHCW has limited access to funding. Nevertheless, most programs are implemented in the public sector as MOHCW retains oversight of program activities. While UNDP was made PR since the Additional Safeguard Policy was applied to Zimbabwe, MOHCW is still a SR. USG funds and those of other donors are rather channeled through local and international partners. Over time, PEPFAR/Zimbabwe has increased funding through local partners.

Capabilities – In spite of the enormous emigration of skilled personnel, a high level of technical and managerial leadership has been retained in Zimbabwe. At the national level, policy makers actively utilize evidence to make policy decisions. Nevertheless, there is a gap in the capacity of technical staff to effectively perform managerial and supervisory responsibilities. This finding has prompted PEPFAR funding for leadership training of MOHCW national, provincial and district levels. Similarly at lower levels, inexperienced nurses are often responsible for the bulk of service delivery. Thus, PEPFAR continues to emphasize in-service training in an effort to increase quality of care.


Accountability –There is notable capacity to measure achievements of results over time. These are reported regularly to donors. The feedback loop to clients, however, is largely missing. Some anecdotal studies have suggested that there are some serious challenges faced by clients at heath centers, from poor service to high user fees. These have not been measured in a systematic way. New efforts to examine quality of care, particularly in the area of ART, should include some efforts to measure patient satisfaction or to feedback results to beneficiaries. Health committees are no longer functioning well in many rural areas.


Central initiatives
The Zimbabwe PEPFAR team has embraced the opportunity to draw from central initiatives to bolster the PEPFAR program of support. These complementary activities include PMTCT, Gender Challenge Fund, the Global Fund Collaboration Initiative and MEPI.
In 2012, PMTCT continues to be a major focus for the national HIV/AIDS program. As such, the PMTCT Acceleration Plan was drafted and approved through a collaborative and iterative process involving the MOHCW. While the PMTCT Plan articulates the full spectrum of PMTCT interventions, the additive resources will be directed towards key activities to fill gaps in the national program.
The Gender Challenge Fund is another central initiative that the Zimbabwe team is involved in. To date, progress has been slow but the project appears to now have developed a solid foundation for forward movement during the 2012 fiscal year. The focus of the project is on enhancing local capacity to utilize and generate data to inform gender-related programming. Training, policy development, and information dissemination forums are other elements of the planned interventions in 2012.

The Medical Education Partnership Initiative also appears to be off to a very strong start in Zimbabwe. The award, supports the University of Zimbabwe and progress has been made on revision of elements of the overall curriculum, renovation of facilities, and collaborative teaching efforts through the MEPI partnerships with external medical schools.


Population and HIV Statistics

Population and HIV Statistics




Additional Sources

Value

Year

Source

Value

Year

Source

Adults 15+ living with HIV

1,000,000

2009

UNAIDS Report on the global AIDS Epidemic 2010











Adults 15-49 HIV Prevalence Rate

14

2009

UNAIDS Report on the global AIDS Epidemic 2010











Children 0-14 living with HIV

150,000

2009

UNAIDS Report on the global AIDS Epidemic 2010











Deaths due to HIV/AIDS

83,000

2009

UNAIDS Report on the global AIDS Epidemic 2010











Estimated new HIV infections among adults

48,000

2009

UNAIDS Report on the global AIDS Epidemic 2010











Estimated new HIV infections among adults and children

62,000

2009

UNAIDS Report on the global AIDS Epidemic 2010











Estimated number of pregnant women in the last 12 months

379,000

2009

State of the World's Children 2011, UNICEF.











Estimated number of pregnant women living with HIV needing ART for PMTCT

46,000

2010

Global HIV/AIDS response: epidemic update and health sector progress towards universal access: progress report 2011











Number of people living with HIV/AIDS

1,200,000

2009

UNAIDS Report on the global AIDS Epidemic 2010











Orphans 0-17 due to HIV/AIDS

1,000,000

2009

UNAIDS Report on the global AIDS Epidemic 2010











The estimated number of adults and children with advanced HIV infection (in need of ART)

560,000

2010

Global HIV/AIDS response: epidemic update and health sector progress towards universal access: progress report 2011











Women 15+ living with HIV

620,000

2009

UNAIDS Report on the global AIDS Epidemic 2010












Partnership Framework (PF)/Strategy - Goals and Objectives

(No data provided.)



Engagement with Global Fund, Multilateral Organizations, and Host Government Agencies
In what way does the USG participate in the CCM?

Voting Member


What has been the frequency of contact between the Global Fund Secretariat (Fund Portfolio Manager or other Geneva-based staff) and any USG team members in the past 12 months? If there has been no contact, indicate the reason.

4-6 times


What has been the frequency of contact between the Local Fund Agent (LFA) and any USG team members in the past 12 months? If there has been no contact, indicate the reason.

4-6 times


Has the USG or is the USG planning to provide support for Round 11 proposal development? Support could include staff time, a financial contribution, or technical assistance through USG-funded project.

Yes
In any or all of the following diseases?

Round 11 HIV, Round 11 TB, Round 11 HSS
Are any existing HIV grants approaching the end of their Phase 1, Phase 2, or RCC agreement in the coming 12 months?

Yes
If Yes, please indicate which round and how the end of this grant may impact USG programming. Also describe any actions the USG, with country counterparts, is taking to enable continuation of any successful programming financed through these grants.

The HIV Round 8 grant is approaching phase 2. The USG has been involved in the phase 2 application process, in particular the quantification of ARVs, which was led by the MOHCW’s PEPFAR–supported Logistics Sub-Unit. This exercise demonstrated that Global Fund’s support would not cover a significant gap for pediatric ARVs and also that proposed reductions in persons to be covered would create large gaps for adults as well. These quantification exercises were essential to informing the GF’s request to Zimbabwe to reprogram the proposed Phase 2 grant to ensure greater coverage of adults. Another donor came in to support peditaric ARVs as did the Government of Zimbabwe through the National AIDS Trust Fund (NATF). These commitments from Global Fund, GoZ, and other donors are essential to maximize PEPFAR investments in supply chain management and human resources. Other inclusions in the phase 2 applications relevant to PEPFAR programs relates to Health Management Information Systems (HMIS). A proposal to include salaries for key staff members in the HMIS under the Global Fund Round 8 phase 2 was made as this would complement efforts to strengthen the HMIS support through a PEPFAR CoAg managed by CDC.
In your country, what are the 2-3 primary challenges facing the Global Fund grant implementation and performance (for example, poor grant performance, procurement system issues, CCM governance/oversight issues, etc)? Are you planning to address those challenges through any activities listed in this COP?

Redacted
Did you receive funds for the Country Collaboration Initiative this year?

Yes
Is there currently any joint planning with the Global Fund?

Yes
If Yes, please describe how the joint planning takes place (formal/informal settings; the forums where it takes place (CCM?); timing of when it takes place (during proposal development, grant negotiation, COP development, etc.); and participants/stakeholders). Also describe if this joint planning works well and its effects (has it resulted in changes in PEPFAR programming, better anticipation of stock-outs and/or TA needs, better communication with PR, etc.)



Redacted
Has the USG stepped in to prevent either treatment or service disruptions in Global Fund financed programs in the last year either during or at the end of a grant? Such assistance can take the form of providing pharmaceuticals, ensuring staff salaries are paid, using USG partners to ensure continuity of treatment, , or any other activity to prevent treatment or service disruption.

Round

Principal Recipient

Assistance Provided

Value of Assistance (If Known)

Programming Impact

Causes of Need







8

Ministry of Health and Child Welfare

HIV Drug Resistance surveillance technical assistance




Involved USG staff time




8

Ministry of Health and Child Welfare

Pediatric ARVs




USG programming impacted by need for reprogramming to cover



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