Technical Area: Governance and Systems
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In 2008, at the height of the economic crisis in Zimbabwe, the public health system faced collapse. Dwindling Government of Zimbabwe (GoZ) investment in the health sector had led to substantial loss of personnel, neglected infrastructure, and a lack of basic commodities. As the economy stabilized after dollarization in 2009, a tentative recovery of the health system restored functionality of health service delivery. In 2012, most primary care nurse posts are filled and donor support is assisting the Ministry of Health and Child Welfare (MOHCW) to deliver basic and essential services at primary, district, provincial and national levels. While slowly increasing government wages and a donor funded retention scheme have helped retain health workers, concerns about the sustainability of the current pay rates point to the uncertainty of the continued revitalization of services. Patient user fees help facilities meet operating costs that are generally inadequately catered for through the 2012 budget, yet there are indications that the fees may deter users, including pregnant women, from seeking care.
Ongoing political uncertainty, limited economic growth, and a bloated civil service wage bill limit the capacity of the Zimbabwean government to adequately fund the health sector. While the national budget allocation for health increased from US $256 million in 2011 to US $345 million in 2012, this represents a decrease in the percentage of the total budget from 9.3 percent in 2011 to 8.6 percent in 2012. Advocacy efforts within the GoZ to increase health spending are nascent. Donor funding, including the Global Fund, USG, DFID, the EU, and others sustains critical curative and preventative services including HIV-related interventions. The recent cancellation of Global Fund Round 11 has prompted increasing dialogue between donors, the GoZ, and other stakeholders about the need for the GoZ to increase investment in health, particularly for critical programs such as the national ART program.
Observers within and outside government are increasingly looking to the National AIDS Trust Fund (NATF) to fill gaps in the national HIV/AIDS response. Initiated in 1999, the levy, a 3% tax on income is raising increasing sums of money as the formal job sector expands. From $5.7 million collected in 2010 to $20.5 million collected in 2011, the levy trust fund represents the expanding capacity of the GoZ to finance the National HIV/AIDS response. Commitments have already been made for the National AIDS Council (NAC)- managed funds to support increased numbers of people on treatment from 2011 to 2015. In the past, NAC funds have also been used to support male circumcision commodities and laboratory equipment.
The MOHCW’s capacity for program implementation is limited due to a shortage of resources; however, Zimbabwe health programs are generally well-coordinated and robustly led by the MOHCW from a technical and coordination perspective. Evidence-based decision making provides a solid foundation for MOHCW policy making and coordination of inputs. It is within this complex context of macroeconomic challenge that the USG is working to support an appropriate balance of service delivery and systems strengthening activities.
Global Health Initiative
The basic premise used in formulating the GHI strategy was to identify how to best reduce preventable deaths and lessen the burden of disease within Zimbabwe. Development of the strategy considered the major causes of death and approaches of assistance that could save the maximum number of lives. Additionally, the strategy was produced with the objective of including interventions that had the potential for greatest public health impact within the general population.
Under GHI, one of the ways the USG will improve health is by strengthening the integration of selected health services. USG efforts in these areas will complement the work of other development partners to improve the availability of and access to a comprehensive package of quality health care. With PEPFAR support, the integration of HIV/AIDS and TB services at the health facility level will be expanded and strengthened (through training, technical assistance and formative supervision) to better respond to the needs of patients who are both HIV-positive and have TB. In addition, PEPFAR is helping to scale-up the availability of more efficacious regimen (MER) of antiretroviral drugs for PMTCT across the country. Under GHI, PEPFAR is supporting the expansion of the number of sites that offer MER, integrating ART into PMTCT programs.
The strategy promotes the integration of PMTCT and MNCH services and builds on the work that the Zimbabwe ART and MCH Task Forces have begun. Using a variety of funding sources, the integration of family planning within HIV/AIDS services will also build on past work and, under the new strategy, will be strengthened and expanded. The USG will continue to work closely with NGOs, government technical counterparts, and other donors to ensure that synergies among programs are captured and resources optimized.
USG efforts in integration are designed to increase the availability of and access to comprehensive health services by creating opportunities for vertical health services to co-locate and integrate with related services and with longstanding USG-assisted efforts (such as PMTCT services) to better serve clients. The USG will also have new opportunities for shared investments in improving service-delivery and improving efficiencies that span across disease-specific activities.
Under GHI, one focus for systems strengthening is the optimal utilization of laboratory support in providing quality care and reliable diagnostic support for all disease areas. A major PEPFAR emphasis has been on laboratory strengthening because of the central role of the laboratory in supporting all HIV program activities. It is important to institute quality systems in the functioning of laboratories since diagnosis, initiation of treatment and proper management of people on antiretroviral therapy depends upon reliable laboratory results. The quality system refers to the organizational structure, procedures, processes and resources needed to implement quality across other health areas. PEPFAR-funded efforts can also help to bring CD4 testing closer to women as part of ANC services.
The GHI strategy incorporates a more deliberate approach to integrated USG and host-country planning and measurement across PEPFAR, PMI and other USG health assistance areas in order to realize improved health outcomes for Zimbabweans. Drawing upon already existing health activities and programs being implemented by USG agencies, there is a group of health intervention platforms that are generating valuable lessons-learned that can inform future efforts to improve health care in Zimbabwe. Past experience will help evaluate the potential of new approaches to accelerate positive change in health service delivery.
In addition, the GHI strategy strives to strengthen district-level recording and reporting for HIV, and other health conditions and services provided. Improvements in the district level health information system can, in turn, strengthen the national health information system. PEPFAR funding is helping to provide training and technical support to make the information system more relevant and useful to health workers. USG and host-country monitoring and evaluation activities are designed to use common national health indicators that are part of the Zimbabwean health information systems. Data quality is a key element of health information support for service delivery and is one of the emphasis areas for monitoring efforts for improvements in integrated HIV/AIDS, malaria, MNCH, FP/RH and TB service-delivery.
Leadership and Governance and Capacity Building
PEPFAR/Zimbabwe plays an integral role in strengthening the ability of the government, private sector, and civil society to design, manage, and monitor HIV programs at the national, regional and local levels. In supporting the development of the National HIV and AIDS Strategic Plan (ZNASP II), PEPFAR/Zimbabwe assisted the GoZ in assuming greater responsibility for decision making and priority setting related to its HIV/AIDS response for 2011-2015.
Through its support of an infection control program, PEPFAR/Zimbabwe aims to strengthen the capacity of the MOHCW to implement infection control and prevention activities in health care facilities nationwide to reduce TB and HIV infection among health care workers and patients. The project aims to develop the capacity of healthcare workers at various levels to deliver sustainable training and support for the ministry’s infection control program beyond the project period. A key component of the program is health worker training. The project will also collaborate with other partners implementing TB/HIV activities to prevent exposure to blood and airborne diseases for both patients and staff in health care facilities.
In another capacity building activity, the USG’s support of health care worker training in OI/ART services is critical to improve Zimbabwe’s ability to follow up patients on ART, reinforce the use of DOTS as a TB management strategy for co-infected patients, and ensure appropriate pharmacy management, basic lab services, recording and reporting of activities. To enhance and strengthen the basic training, USG has provided technical assistance and financial support to the national mentorship program as well as site supervision to underperforming and newly established OI/ART sites. USG supports a physician position at the ZACH secretariat to provide direct mentoring and leadership to institutions that lack resident doctors.
The USG, through support to the PMTCT program, will also continue to support the resuscitation of village/community health workers, strengthening the community aspects of health care. In keeping with MOHCW’s commitment to improve the quality of life of mothers and infants infected and affected by HIV, PEPFAR/Zimbabwe will support a continuum of care that integrates HIV care and support into the overall health system. It is envisioned that community health workers will strengthen the follow up/referral systems for mother-baby pairs and their families and will help link them with psychosocial and other supportive services available within their communities. The USG will support efforts to develop training materials, tools and aids for community health workers to use in delivering PMTCT and Paediatric HIV services. Non-PEPFAR funds will also be used to develop a model(s) for community TB/HIV care. Various models will be piloted in 8 districts to determine feasibility and the potential for scale-up.
The USG is also involved in strengthening the management and governance of the GoZ, civil society and NGOs through its financial support and participation in the Country Coordinating Mechanism (CCM). The CCM is a country-level partnership of stakeholders that is central to the Global Fund's commitment to local ownership and participatory decision making. Composed of representatives from both the public and private sectors, including government bodies, multilateral or bilateral agencies, nongovernmental organizations, academic institutions, the private sector and people living with HIV/AIDS, the CCM is responsible for developing and submitting grant proposals based on country needs, nominating the grantee or principal recipient(s), and providing oversight of grant implementation. PEPFAR representatives in the CCM assist with and facilitate greater government and civil society responsibility for decision making, resource allocation and prioritization and management of conflicting interests within the MOHCW.
Through the network of New Life Centers, PEPFAR/Zimbabwe supports the strengthening of private sector health services to efficiently provide quality care to HIV positive individuals. The centers will expand their reach, aiming to strengthen workplace (i.e. commercial farms, mines, etc) health programs through the provision of such support as direct psycho-social counseling and information on positive living to HIV positive employees. The teams will also build the capacity of workplace peer educators to provide ongoing support, establish support groups for PLHIV and sensitize employers and employees on the importance of post-test support services for their HIV positive colleagues. The program will also include counseling on gender-based violence. The USG plans to leverage funding from addition donors to maintain service delivery throughout the country.
The USG is supporting the University of Zimbabwe (UZ)/Department of Community Medicine (DCM) in re-establishing the national health leadership program that trains District Health Executives (DHEs) and Provincial Health Executives (PHEs) on human resources management, cost-effective use of resources, data analysis for decision making, basic epidemiology, and the coordination of civil society and NGO partners in HIV prevention, care and treatment. In 2011, PEPFAR/Zimbabwe supported the UZ/DCM in assessing management and leadership needs in Zimbabwe. The results indicated that the high attrition of experienced health personnel has led to a lack of knowledge, skills and experience among individuals occupying leadership positions and that the experienced staff who do remain in-country do not have the means to provide support, supervision, or mentorship to other staff. Overall, gaps in leadership have led to poor data and information systems to inform planning and monitoring of service delivery, poor human resources management and a lack of capacity to promote, coordinate and facilitate collaboration in public-private partnerships and community involvement in health service planning and delivery.
PEPFAR/Zimbabwe supports the provision of timely and focused strategic information (SI) in order to inform policy, support evidence based programming and ensure efficient resource utilization. The country team has participated in program monitoring and evaluation (M&E), the Health Management Information Systems (HMIS), and national Surveillance and Surveys.
PEPFAR/Zimbabwe Technical Officers have advanced the Zimbabwe national HIV SI capacity through technical assistance in the development of two national strategic plans, the Zimbabwe National HIV and AIDS Strategic plan (ZINASP) and the Monitoring and Evaluation Plan for ZINASP. The PEPFAR SI team provided technical support to the National Monitoring and Evaluation Group (NMEAG) in drafting the Zimbabwe Universal Access Report which was presented at the UN High Level Meeting on AIDS in 2011. Last year, the SI team also provided technical support to the MOHCW AIDS and TB Unit to harmonize key PEPFAR indicators into the Essential Data Set Guide for AIDS programs in Zimbabwe. Further efforts are being made to introduce an electronic individual patient tracking system for the PMTCT, ART and TB programs. Recognizing the need for a country driven research agenda, the PEPFAR team participated in an NAC led initiative to finalize and launch the Zimbabwe HIV and AIDS Research agenda (2010-2011). In 2011, PEPFAR/Zimbabwe continued to support NAC in the implementation of small grants for research by providing technical support for review of research proposals and the implementation of small studies.
PEPFAR/Zimbabwe also provides extensive support to the national HMIS to strengthen the MOHCW’s capacity to provide an integrated routine data collection system to provide information and guide policy formulation and programming. During 2011, the USG supported the successful roll-out the DHIS software and updates to eight provincial and sixty-two district offices. The USG also provided capacity building activities including training and ongoing support and supervision for key personnel.
The PEPFAR team supports the strengthening of Integrated Disease Surveillance and Response (IDSR) through the facilitation of software development, loading of data collection forms and distribution of cell phones procured by GFTAM Round 8. Additionally, the USG supported the training of health personnel from 1200 facilities and provided internet connectivity for a weekly disease surveillance system. The PEPFAR team will continue to support the strengthening of the system in FY12, ensuring all districts are fully furnished with the software and able to report data. Challenges include low human resource capacity at the national level which has delayed implementation of collaborative activities in the Global Fund work plan. A long-term goal of the project is to ensure that interoperable systems are established and that parallel systems are integrated into one functional unit.
The USG provided technical and financial support to the Zimbabwe Demographic and Health Survey (ZDHS) 2010/2011. Additionally, PEPFAR/Zimbabwe provided support to the National Microbiology Reference Laboratory (NMRL) for HIV testing. Preliminary results from the DHS were released in June 2011 and data on HIV prevalence are expected in March 2012. An Extended data analysis is also planned for FY12.
PEPFAR/Zimbabwe continues to take the lead in supporting the MOHCW and National AIDS Council in conducting surveys and in establishing and maintaining surveillance systems. The USG has supported the main source of HIV prevalence data, the antenatal clinic survey (ANC), since 2000. The last survey was conducted in 2009 and a 2012 ANC survey is planned. The 2012 survey will increase the number of sentinel sites from the 19 included in past years to a total of 55. The 2012 survey will involve both ANC sentinel surveillance as well as the analysis of PMTCT based routine data. The goal is to determine the efficacy of transitioning from the use of ANC surveys to routine PMTCT data in order to estimate the population prevalence of HIV.
A follow up study to determine HIV incidence using BED and avidity assays on ANC and ZDHS samples is planned in collaboration with MOHCW, ZVITAMBO project and Manicaland HIV prevention project. The aim of the study is to provide a more accurate estimate of HIV incidence in Zimbabwe. PEPFAR technical officers also participated in the ANC/HIV Estimates technical working group that produced updated Zimbabwe national HIV Estimates (2011) for the Global Health HIV and AIDS Report.
In response to new and emerging issues, PEPFAR/Zimbabwe has provided technical leadership in protocol development and implementation of the HIV Drug Resistance Surveillance System (HIVDR) since 2006. To date, the team has conducted four rounds of Early Warning Indicators Surveys 2007, 2008, 2009 and 2010. The PEPFAR team collaborated with the MOHCW, WHO and other partners in onsite health worker training to collect and analyze an indicator data set from routine data collection tools. The MOHCW plans to implement a requirement that all facilities offering ART services collect and report their EWI data sets to the national level. Facility reports will enable managers to prioritize site level interventions that support good quality service delivery.
PEPFAR/Zimbabwe recently supported the Broadreach team to conduct an efficiency demonstration project for ART services delivery. The main finding was that due to bottlenecks at observation stations and pharmacies, 90 percent of patient time in facilities is time spent waiting for services. Major recommendations include reducing the number of visits to quarterly for stable patients and creating additional service delivery points within existing structures. Plans are also underway to support a 2012 assessment of the PMTCT program in public health facilities, focusing on survival rates of mothers and babies. Another study to evaluate access and acceptability of alternative male circumcision procedures is also planned (contingent on WHO approval of the Prepex device).
PEPFAR investments are working to ensure availability and access to essential services in Zimbabwe. Two basic approaches are being taken to support service delivery: 1) investing in public sector programs and 2) where substantial gaps in implementation capacity exist, complimenting public sector offerings though the provision of high quality services through the private sector.
In an effort to support sustainable country owned programs, PEPFAR/Zimbabwe works closely with the MOHCW to support service delivery in the public sector. In alignment with the country’s GHI strategy, USG program investments enhance the availability and quality of services through national level technical assistance as well as facility-based support.
Along the continuum of response, USG provides inputs to bolster the MOHCW public sector implementation of provider initiated treatment and counseling (PITC), PMTCT and ART/OI management. The strength of these national programs has largely eliminated the demand for complimentary private sector programs. In areas where public sector implementation capacity has been weak or where GoZ counterparts have encouraged complimentary service delivery, PEPFAR has provided support to promote the availability of high quality essential services through NGOs. The preferred mechanism has been to use awards that use an umbrella type structure to strengthen local capacity for service delivery.
The Strengthening Private Sector Health Care Services (SPSS) program supports behavior change communication for sexual prevention as well as demand based programming for counseling and testing, male circumcision, and TB screening. The national SPSS network offers voluntary counseling and testing (static and mobile services), TB screening, and broad post-test support services. The MOHCW considers the SPSS programs part of the national response and has encouraged the delivery of services through non-governmental entities. There is generally good collaboration between local facilities and SPSS NGO partners. Thus, counselors from the private sector provide regular post-test support services, generally a four session package for adherence counseling at MOHCW facilities. Similarly, district and provincial staff of the National AIDS Council (NAC) coordinate community-based behavior change efforts.
The PEPFAR program has taken a dual approach in order to balance system strengthening efforts while ensuring the availability of vital prevention and care services. In building local capacity, the program engages a prime partner that trains local organizations to provide service delivery. Through a franchise-based system the local organizations run and operate sites. Laboratory strengthening provides another example of our dual approach. USG invests significantly in supporting the national Laboratory Directorate in developing its capacity to provide HIV-related services throughout the country. Capacity building activities include support for laboratory quality assurance, equipment, maintenance, human resources, essential commodities, training and transport services. Due to weaknesses in the system and continuing challenges in ensuring the availability of CD4 testing, PEPFAR also supports targeted point of care testing with a focus on pregnant women to facilitate the timely initiation on ART.
Human Resources for Health
Human Resources for Health (HRH) continues to be a significant challenge in Zimbabwe due to financial obstacles within the MOHCW to recruit and retain skilled health workers including doctors, midwives and laboratory technicians. Primary Care Nurses (PCNs) currently make up the bulk of frontline providers in health facilities and the USG supports trainings that have been adapted to target these crucial health care workers. PEPFAR/Zimbabwe supported the development of the MOHCW Human Resources for Health policy and strategic plan through support of the review processes and document printing. The USG plans to further support the printing and dissemination of the Policy through the Leadership project.
In recognition of the need to have highly qualified and competent leaders to run national programs, the USG supports several key positions in the MOHCW AIDS and TB unit as well as the Directorate of Pharmacy Services (DPS). Previous attempts to employ and retain such staff on government conditions of service have failed or attracted less qualified individuals. USG support has provided for the retention of qualified staff, bringing stability and ensuring continued expansion and strengthening of supported programs. The USG supports 10 positions within the AIDS and TB unit, including the national program coordinators (and their deputies) for ART and PMTCT programs. The USG also provides support for 14 individuals to run the National Logistics Unit which forecasts, quantifies, procures and distributes medicines and other medical commodities nationwide. Although the human resource support is envisioned to continue, the USG is cognizant of the need to eventually transition these positions to the GoZ. In this regard, all the supported positions in the ART and PMTCT programs are part of the established MOHCW organogram.
The PEPFAR/Zimbabwe program is also supporting the MOHCW in the development of a Human Resources Information System (HRIS). The project will establish connectivity, functional integration and interoperability of databases at the Nurses Council of Zimbabwe, the MOHCW and five professional bodies. The HRIS will improve the efficiency of the HRH data exchange, plan for interoperability with other health information systems, and link HRH data so that it is more readily usable for public health decision makers. USG support covers the design, development and testing of databases and provides training for health managers in data analysis, utilization and reporting.
PEPFAR, with the US National Institutes of Health, is partnered with UZ to improve undergraduate, postgraduate and faculty training in clinical management and research capacity. Partnerships with international universities will provide training to new health care workers and improve the capacity of health institutions to deliver care. Similarly, the USG supports a two-year, full time MPH training using the Field Epidemiology Training (FETP) model. The goal is to train highly competent multi-disciplinary public health professionals who will assume influential posts in the country’s public health structures and thereby comprehensively address priority public health problems in Zimbabwe.
Laboratory Systems Strengthening
The Ministry of Health and Child Welfare (MOHCW) is the largest provider of diagnostic medical laboratory services. The network includes 52 district, 8 provincial, 5 central and 3 national reference laboratories: the National Microbiology Reference laboratory (NMRL), the National Tuberculosis Reference Laboratory (NTBRL) and a National Virology Reference Laboratory. There are also 1,200 health centers that provide primary health care services and limited laboratory testing. PEPFAR/Zimbabwe supports the Zimbabwe Association of Church Hospitals (ZACH), a faith-based organization (FBO) that provides lab services at rural hospitals,.
Zimbabwe has achieved ongoing success in providing laboratory system support to the national HIV and AIDS response. PEPFAR-supported accomplishments include the successful national roll-out of HIV counseling and testing services to 1025 sites (980 public sector sites, 45 private sector sites); revision of the standard HIV testing package; expansion of CD4 capacity and evaluation; the adoption of more cost effective CD4 testing technologies; and international accreditation of the Zimbabwe National Quality Assurance Program (ZINQAP). Currently, PEPFAR supports 28 sites in the public health system and 10 in the private sector offer CD4 testing services and participate in an external proficiency testing (PT) program through ZINQAP.
Despite substantial progress, the laboratory systems in Zimbabwe continue to face many challenges including: a lack of human resources (40% of national capacity) due to low salaries, a lack of funding specifically for laboratories since laboratories are part of a facility and the absence of a laboratory logistics system for distribution of laboratory consumables. Other challenges include: shortages in supplies and subsequent interruptions in testing services due to financial and logistical difficulties, a lack of laboratory equipment standardization, especially in chemistry, and a decrease in funding partners to support laboratory services. Finally, Zimbabwe is in need of a functional laboratory M&E system for laboratory testing as well as commodity and reagent quantification and laboratory surveillance systems.
PEPFAR/Zimbabwe has supported a national laboratory systems strengthening effort to address major gaps in the quality of services rendered by the public health laboratories. Shortcomings identified include the absence of: a national laboratory policy and strategic plan, national laboratory standards, a laboratory information management system, standardized laboratory monitoring and evaluation systems and an effective laboratory quality assurance program.
A comprehensive assessment of the laboratory services was conducted in 2009 to generate quantitative and qualitative data for developing a national laboratory strategic plan. The USG supported the MOHCW/Laboratory Directorate in the writing and dissemination of the National Laboratory Policy and National Laboratory Strategic Plan. Together the policy and strategic plan shape all laboratory assistance to Zimbabwe. In August 2010, the USG funded the launch, printing, and distribution of the Laboratory Policy and the Strategic Plan (more than 50 stakeholders attended the launch). PEPFAR/Zimbabwe and its partner ZINQAP, along with the Laboratory Council and the Laboratory Directorate developed, printed, and launched the Laboratory Standards in 2011. The team anticipates providing scientists with in-service training on the Laboratory Standards in 2012.
PEPFAR/Zimbabwe is providing laboratory services with External Quality Assurance (EQA) through Proficiency Testing (PT) to improve the quality of services. Currently, 157 laboratories and testing sites participate in the EQA program. PEPFAR/Zimbabwe is establishing a laboratory mentorship program to improve laboratories towards accreditation through the WHO Stepwise program and for South African National Accreditation System (SANAS). Zimbabwe is using the Strengthening Laboratory management Toward Accreditation (SLMTA) model to strengthen laboratory testing for improved service delivery and in preparation for accreditation. Eleven laboratories are currently piloting the SLMTA and the model will be rolled out to ten more sites in 2012. In the first quarter of FY12, in preparation for the roll-out, mentors were trained to assist sites through the SLMTA process. The target is to prepare a total of 30 sites for accreditation over the next few years. The USG is further working to build the capacity of the laboratory council to oversee quality laboratory services. The USG supports the strengthening of the lab directorate and NMRL/NTBRL to oversee the purchase of equipment, lab reagents, equipment contracts and trainings of scientists for the MOHCW reference laboratory services.
In order to improve the availability of data for evidence-based decision making and in strengthening the laboratory capacity for communicable disease surveillance and disease outbreak confirmation, PEPFAR/Zimbabwe also supports the national laboratory services in the development and implementation of a lab M&E system. Standardized M&E tools have been developed and were piloted in October 2010. In September 2011, the USG supported the nationwide launch of the M&E tools and trained laboratory scientists for implementation. A reporting tool for disease surveillance will also be introduced in 2012. PEPFAR/Zimbabwe is also working with Laboratory services in Zimbabwe to establish Laboratory Management Information Systems (LMIS) and has seconded an IT officer to the NMRL to handle all laboratory related IT issues.
Through its support of the National Micro-biology Reference Lab (NMRL), the USG assists Zimbabwe in completing samples testing, processing and dispatch for all provinces. The lab receives an estimated 120 samples a day for processing and a photocopy of the results are sent back to the facilities through courier (EMS or FedEx). Authorized users can access the web-based EID system from any location using the internet. However, results are currently printed and dispatched through a local courier. A lack of capacity and connectivity at sites impedes real time results dispatch. The lab is exploring expansion to include the results of viral load testing. The NTBRL has a similar LIMS in place for TB results. The system went live in January 2010 with Global Fund and USG support and is currently used internally. However, due to a lack of funding, the capability to dispatch results electronically has not been developed. Due to current financial challenges in the MOHCW, there are no plans in place to move the project forward.
In partnership with CHAI, the USG supported a pilot project for Sample Referral and Structured Transport to allow more patients access to care. The Mpilo laboratory in Bulawayo now has LIMS in place to dispatch results to its ten referral sites. The USG has also invested in an HIV/AIDS Patient Monitoring project through ZINQAP which will implement Labware at more laboratories to effectively manage laboratory data in early 2013.
PEPFAR/Zimbabwe has assisted the NTBRL in renovating its building to become a Bio-safety Level 3 facility for TB diagnosis and has assisted the lab purchasing reagents and commodities to process TB samples. The goal is to generate clinically significant results to be used to initiate therapy. The planned MDR TB survey has been postponed and PEPFAR funding has been reprogrammed to strengthen MDR TB surveillance.
In 2012 PEPFAR/Zimbabwe plans to:
1) Support the MOHCW in decentralizing lab services with the district as the basic unit, working strengthen the referral network among laboratories of different levels for efficient use of resources and provision of care. The USG proposes using the Supra laboratory and structured referral and transport network with a new funding opportunity announcement: Improving Access to Laboratory Testing for HIV/AIDS Patient Monitoring in the Republic of Zimbabwe under the President’s Emergency Plan for AIDS Relief (PEPFAR);
2) Strengthen and integrate the SCMS logistic unit(s) to cater for laboratory commodities and ensure support of comprehensive health care service delivery;
3) Support the establishment and maintenance of the Bio-medical Engineering Unit to service and maintain national laboratory equipment;
4) Promote the establishment of a Technical Advisory Board to support the laboratory directorate in decision making and strategic planning;
5) Advocate integrating the financial resources from vertical programs for laboratory tests to form a laboratory budget to address the challenges that laboratory services are facing;
6) Assist the MOHCW in the coordination of laboratory services among partners.
Health Efficiency and Financing
PEPFAR is supporting the MOHCW National ART Program to conduct a study to cost the national HIV and AIDS Treatment and Care Package. The MOHCW introduced the Opportunistic Infections and Antiretroviral Therapy (OI/ART) program in April 2004. As of December 2011, a total of 414,250 of the estimated 576,683 patients needing treatment were receiving HIV treatment (MOHCW, 2011). The broad objective of the PEPFAR-supported study is to assess the cost of providing a comprehensive HIV and AIDS Care and Treatment package for PLHIV in Zimbabwe. PEPFAR/Zimbabwe is also working with the new multi-donor Health Transition Fund to better coordinate donor investments and financing of health programs.
Supply Chain and Logistics
In support of Zimbabwe’s national ARV treatment program, PEPFAR utilizes the Supply Chain Management Systems (SCMS) mechanism and the Partnership for Supply Chain management (PFSCM) as procurement agents for ARVs. PEPFAR/Zimbabwe investments in SCMS, along with the globally declining costs of ARVs, have resulted in considerable program cost savings. Operating globally, SCMS is able to pool procurements across countries and is better positioned to negotiate reduced prices for large orders from manufacturers. PEPFAR funds adult ARV supplies to Zimbabwe through an SCMS buffer stock in a Regional Distribution Center (RDC) in South Africa, further enabling cost efficiency. Historically, SCMS Zimbabwe shipped ARVs utilizing a costly air freight method that shipped orders directly from manufacturers in India. Now ARVs are transported by road from the RDC in South Africa at a significantly reduced cost. The cost savings achieved have enabled the PEPFAR team to support the increased costs of switching to Tenofovir-based treatments.
PEPFAR/Zimbabwe also supports system strengthening efforts at the national ART program. In 2006, the MOHCW, with the support of PEPFAR-funded SCMS, established the Logistics Sub Unit (LSU) to coordinate the procurement and distribution of HIV/AIDS commodities. The LSU is a unit of the MOHCW based at NATPHARM, the central medical store in Harare. Through SCMS, PEPFAR/Zimbabwe will continue to provide technical assistance and trainings to the LSU and funding for the 20 LSU staff positions as well as a Supply Chain Management Advisor based at the MOHCW DPS. The LSU plays an essential role in ensuring commodity security and the quality of national treatment programs through its technical oversight and efficient management of the national health commodity supply chain. The technical duties of the 20 LSU staff are to engage in product selection, conduct forecasting and supply planning, coordinate donor procurements, expedite clearance of goods through customs, conduct physical inventories, facilitate sampling of medicines for quality assurance, distribute commodities, manage a central level computerized logistics management information system (LMIS), and supervise and train staff at ART facilities. SCMS continues to train LSU staff to promote a technically capable, sustainable and efficient LSU. In addition, the LSU, along with the DPS, chairs the Procurement and Logistics Sub-Committee of the ART Partners forum, which serves as a central body for donor and partner collaboration. In supporting the LSU, the PEPFAR works to promote country ownership and ensure commodity security and the quality of ART services.
In recognition of the LSU’s achievements, in April 2010 the MOHCW recommended the LSU be moved from the MOHCW Aids and TB Unit to the MOHCWs DPS, in order to expand the role of the LSU beyond HIV/AIDS. In 2010, the LSU was formally integrated into the DPS, and renamed LSU-DPS, where it currently serves as the health commodity management unit for the MOHCW including Malaria, TB, and PMTCT related commodities. The LSU now manages all levels of the national country supply chain which is essential to ensure that patients receive a continuous supply of best value medicines. As a result of the leadership of the LSU the forecasting, quantification and supply planning for all health commodities is now harmonized at the national level and stock-outs have been reduced. Through the strategic efforts of LSU, PEPFAR/Zimbabwe has strengthened the capacity of the national supply chain to a level where stock-outs at central and facility levels rarely occur. Efforts to reduce stock outs include encouraging partners and other donors to import medicines that have been registered and pre-qualified by the Medicines Control Authority (MCAZ), reducing lead time to central warehouses and promoting the importation of quality medicines. In addition, the LSU has designed and implemented a training curriculum, enabling LSU staff to train over 296 ART facilities on ARV best management practices. Finally, the LSU has established an ARV ordering distribution system and standard operating procedures (i.e. for emergency orders when drug stock levels are below 3 months).
The LSU-DPS also holds quarterly presentations of quantification results. The presentations serve as a forum in which the donor community and the MOZ participate, enabling the LSU-DPS to concurrently highlight supply gaps and mobilize resources to fill gaps for all health commodities. PEPFAR/Zimbabwe funds will also continue to support the development of the LSU’s Logistics Management Information System (LMIS), currently Zimbabwe Information System for HIVAIDS Commodities (ZISHAC). The LMIS will be used to capture data related to: ART patients and MC procedures; ARV, Fluconazole and MC commodity consumption; stock levels, losses and adjustments. Data will inform decision making on quantification, storage and distribution. SCMS will also continue supporting Top-up and Auto-DRV, the LMIS and data capturing tools used to operate the Delivery Team Top Up (DTTU) distribution system for HIV RTK, PMTCT, CD4 POC commodities and EID bundles.
The investment of PEPFAR/Zimbabwe in SCMS and the LSU has been remarkably strategic in that a small amount of funding works to ensure commodity security for the entire health supply chain. SCMS and the LSU work collaboratively to coordinate with other donors and leverage donor inputs to support the national supply chain. Under GHI, USG support is also working to leverage the resources and increase the reach of the multilateral Global Fund, the newly established multi-donor Health Transition Fund and the World Bank (WB)-administered Multi-Donor Trust Fund. The LSU plays an indispensable role in the national supply chain, and given the increasing number of patients and treatment sites, declining support from other international donors, and low national health budgets, the USG will continue to fund the LSU staff and LSU capacity building activities. With PEPFAR funds, the LSU will continue to ensure access to ART for over 469,927 HIV-positive patients in FY12.
The MOHCW national strategic plan is heavily focused on equity with core priority areas addressing the needs of women and girls for health services (including and HIV). The USG team participates in policy development at the national level (such as for the revision of the national reproductive health policy) and helps to identify gaps in the current policy environment to respond to inequities in gender will be part of this process. In addition, Zimbabwe already has many laws in place to protect women including: Termination of Pregnancy Act; Marriage Act; Sexual Offences Act 2003; Domestic Violence Act 2006; National Gender Policy; Policy on HIV testing; and Male Circumcision Policy. The USG team ensures implementing partners are aware of these policies and laws so that appropriate action can be taken if they are violated.
Nevertheless, pre-adolescent and adolescent girls face systematic disadvantages including in health, education, nutrition, labor force participation, and the burden of household tasks. Because of social isolation, deprivation, economic disadvantage, and discriminatory cultural norms, many girls are forced to marry at very young ages and are extraordinarily vulnerable to unintended pregnancy, HIV, sexual violence, and physical exploitation. Lacking a full range of opportunities and devalued because of gender bias, many girls are seen as unworthy of investment or protection by their families, communities and governments.
USG-supported programs address gender issues through such efforts as: the use of positive youth development through peer networks and mentorship programs in and out of schools; OVC activities for the most vulnerable out-of-school adolescent and pre-adolescents (especially married adolescent girls); the promotion of youth-friendly “safe spaces” for health information and service delivery activities; age-appropriate sexual and reproductive health and HIV/AIDS education and interventions; and, interventions to prevent and respond to sexual abuse of minors.
The PEPFAR/Zimbabwe program considers gender in the development of services communications and service delivery and most programs include a gender mainstreaming component. Given that most health care workers in Zimbabwe are women (ex: Primary Care Nurses and village health workers), PEPFAR programs support the retention and training of women.