Final Project Report Zimbabwe PMTCT Grant Report Prepared for: The Bristol- Myers Squibb Foundation 345 Park Avenue New York, New York 10154 Contact: Nazanine Scheuer, Associate Director, Global Corporate Partnerships (203) 221.3781 / nscheuer@savechildren.org 54 Wilton Road, Westport, CT06880 1.800. SAVETHECHILDREN www.savethechildren.org Save the Children is the world s leading independent organization for children, working in more than 120 countries. Our mission is to inspire breakthroughs in the way the world treats children, and to achieve immediate and lasting change in their lives. For more information, visit www.savethechildren.org. For our privacy policy, visit http://www.savethechildren.org/about/policies/privacy.html.
1. GENERAL INFORMATION Save the Children U S Contact Details: Eric Swedberg Save the Children United States Email: eswedber@savechildren.org Save the Children Zimbabwe Contact Details: Helene Andersson Novela Save the Children 221 Fife Avenue Harare Fax 263 4 708 200 Phone 263 4 251 739/ Email: helenen@savethechildrenzw.org 2. PROJECT SUMMARY Project Title: Organization: Project Manager: Location of Project: PMTCT Grant Chiredzi Save the Children Alice Mazarura (alicem@savethechildrenzw.org) Chiredzi District (Masvingo Province), Zimbabwe Duration: 12 months (1 st November 2011 to 31 st October 2012) 2012) Sector of Intervention: Health i
TABLE OF CONTENTS PAGE Acronyms iii Project Context 1 Summary of Key Accomplishments 2 Monitoring and Evaluation 14 Key Lessons Learned & Challenges 14 ANNEXES Annex I: Summary of Trainings 17 Annex II: PMTCT Support Groups Created 18 Annex III: Project Supplies 19 Annex IV: PMTCT Challenges for some of Health Centers in the Districts Highlighted in the last PMTCT Quarterly Review Meeting Annex V: Project Log Frame 22 Annex VI: BMSF PMTCT End of Project Evaluation Report 2012 (under separate cover) 20 ii
List of acronyms AIDS ANC ART BMS CBD CBO DBS DEHO DHE DMO DNO EGPAF EHT FACT FGD FP HIV IYCF KII M&E MoH&CW NEDICO NGO OI Acquired Immuno Deficiency Syndrome Antenatal Care Anti Retroviral Treatment Bristol Myers Squibb Community Based Distributors Community Based Organization Dry Blood Sample District Environmental Health Officer District Health Executive District Medical Officer District Nursing Officer Elizabeth Glaser Pediatric Foundation Environmental Health Technician Family Aids Caring Trust Focus Group Discussion Family Planning Human Immuno-Virus Infant and Young Child Feeding Key Informant Interviews Monitoring and Evaluation Ministry of Health and Child Welfare New Dimension Consultancy Non-Governmental Organization Opportunistic Infections iii
PCN PNC PMTCT PSI RHC RGN sdnvp SC SCZ VAAC VHW VCT WAAC WHO Primary Care Nurse Post Natal Care Prevention of Mother to Child Transmission Population Services International Rural Health Centers Registered General Nurse Single Dose Nevarapine Save the Children Save the Children Zimbabwe Village Aids Action Committee Village Health Workers Voluntary Counseling and Testing Ward Aids Action Committee World Health Organization iv
PROJECT CONTEXT In December of 2011, Save the Children (SC) entered into a partnership with Bristol Myers Squibb Foundation (BMSF) upon receipt of a grant made possible through its Secure the Future program. This partnership includes collaboration with in-country (NEDICO) and regional advisors within the Secure the Future network. Chiredzi district is one of the 62 districts in the country, and is primarily rural. The total population for the district is 258,224 with 57,429 women of child bearing age (15-49 years) and the expected birth rate is 3.6%. The district has four hospitals, 25 rural health centres (RHC) and 7 health centers which are peri-urban. Health staff consist of Primary Care Nurses (PCN), Registered General Nurses (RGNs) (some with midwifery and the majority without midwifery), District Nursing Officer (DNO), District Medical Officer (DMO) and three other doctors, an Environmental Health Technician (EHT), and a District Environmental Health Officer (DEHO). The district has a District Health Executive (DHE) which plans, coordinates, implements and administratively leads in all health activities in the district. The district offers all health activities including provision of Prevention of Mother to Child Transmission (PMTCT) in its four pronged strategy. The district also has a few Non Governmental Organizations (NGO) and Community Based Organization (CBO) partners addressing HIV/AIDS activities; only one, EGPAF, focuses on building health service capacity for PMTCT, with primarily facility focused activities. PMTCT activities in the district were implemented and focus on all 4 prongs. The rural health facilities offer PMTCT services such as counselling, testing for HIV, and ARV prophylaxis to pregnant mothers, Antenatal Care (ANC) services, deliveries and Postnatal Care (PNC) services as well as paediatric follow up for PMTCT and collection of Dry Blood Spots (DBS) and CD4 cell count. For any complications and other services requiring the Doctors opinion they refer to the district. At the four district hospitals, OI and ART services are offered. This project was implemented in 9 RHCs namely Chilonga, Chibwedziva, Damarakanaka, Chingele, Old Boli, Chambuta, Chomupani, Makambe and Muhlanguleni Rural Health Centers. These RHCs are closer to Chiredzi District Hospital and therefore made it possible to lower logistical costs and increase benefit to beneficiaries. The overall goal of this project was to contribute to elimination of pediatric HIV and improved survival of HIV+ mothers and exposed infants by: 1) Increased use of PMTCT and related services 2) Reduced loss to follow up for HIV+ mothers and exposed infants and improve rates of early infant diagnosis at community level 3) Strengthened monitoring and reporting mechanisms at district, RHC and community level 4) Increased SCZ, District and community's stakeholders capacity in rolling comprehensive PMTCT interventions. 1
KEY RESULTS (OUTCOMES AND ACTIVITIES) The four project outcomes and related activities supporting the achievement of these outcomes are described in this section of the report. Outcome 1: Increased use of PMTCT and related services The project sought to create demand for comprehensive PMTCT services offered through the Cheridzi RHC facilities through improving counseling and support services at RHC and community level and strengthening access to ARV prophylaxis and ART for the HIV+ mother and HIV exposed and HIV + infants. The final evaluation (see Annex 6) reports that 573 mother at end of project booked for first ANC as compared to 538 of pregnant at baseline. One hundred percent of these pregnant women were counseled and tested for HIV infection and received their results as compared to the baseline of 97% (3% increase). At project endline, 110% (72% baseline) of HIV positive women received SD NVP + AZT during the antenatal period. In addition at end of project 10% (baseline 3%) of women were assessed for ART eligibility using CD4 counts. The women assessed using CD4 count percentage still remains low because the RHCs do not have the PIMA machines as they are only located at district level and referral centres. Table 1: PMTCT Cascade for Four Quarters of 2012 Q1 Q2 Q3 Q4 L&D unknown status 3 3 1 4 L&D tested 3 2 1 3 Positive in labour and delivery 2 2 0 1 HIV positive in ANC 48 33 40 34 Dispensed sdnvp only 0 4 0 0 Dispensed AZT ANC 64 41 19 44 Initiated on ART IN ANC 0 0 0 0 Establish ART initiation project in 9 RHC and support availability of ART drugs at RHC level Two sets of trainings were conducted in preparation for nurses to initiate ART at RHCs as was recommended by MoH&CW at national level. The first training was on IMAI/IMPAC PMTCT which was held in June 2012. A total of sixteen (16) nurses were trained. Participants were from the district hospital (OI outreach team) and health care workers from the nine RHCs. Training objectives were to: 2
Train health service providers on evidence based practices in managing pregnancy, labour, delivery and the postpartum woman and new born in the context of HIV infection and preventing mother to child transmission of HIV; and Train health care service providers on practical dry blood spot (DBS) sample collection, drying, packaging and shipping. The training was very successful with support from the SCZ projects Director and Professor Daya from BMSF South Africa Office. The training was based on the Revised National Guidelines for ARV therapy in Zimbabwe, the Emergence Obstetric and New Born Care (EmONC) Guidelines the IMPAC (Integrated Management of Pregnancy and Childbirth) and the WHO guidelines on HIV and infant feeding. Participants received training on providing antiretroviral (ARV) prophylaxis and HIV care for the HIV infected pregnant women and HIV exposed infants. Providing HIV and maternal care services at clinic level helps to reduce the waiting time for the women and her partner and facilitate effective use of the limited human resources. A second training on IMAI (Integrated Management of Adult Illness) was held in August, 2012 and focused on the clinical part of the chronic HIV care with ARV therapy and prevention. The training was attended by 15 (8 males, 7 females) participants from the nine pilot clinics and the district hospital. Key issues discussed were on the importance on conducting a complete assessment of the client and making sure that the needs for the client have been met. Adherence and resistance were discussed and much emphasis was given to adequate counselling to fully prepare the patient who is going to be on ART. Non adherence was discussed as it leads to resistance and eventually treatment failure. Health care workers were reminded of the importance of conducting follow up checks using the support systems available in the health network for example engaging VHWs to reduce the number of defaulters. Specific emphasis was on following up of exposed babies. Other issues discussed were patient HIV care, ART card, the treatment regimens available in Zimbabwe, side effects of ART drugs with special consideration of children, TB, HIV and checking the efficacy of ART and PEP. Support and supervision was provided to the nine RHCs in Matibi 2. Support was offered by MoH&CW district officials (DNO, SICC and other support services staff). The main goal of the support and supervision visits was to ensure that feedback was given to other staff at the RHCs and ensure proper implementation of the project. Support and supervision confirmed that feedback was given as other colleagues who did not attend the workshop had knowledge on IMAI/IMPAC and literature was shared to the rest of the clinic staff. Save the Children assisted with transportation of specimen collected for Cd4 cell count tests from the clinics to the district hospital and some samples were taken to Chikombedzi where the CD4 machine is located. Drug store rooms in the RHCs required improved security through fitting of door screens and burglar bars on the windows to allow for safe storage of ART drugs. The process of 3
accreditation was delayed due to the initial poor workmanship that was done at the clinics to improve security of the clinic drug store rooms. These deficiencies were resolved in December, 2012 when the project was ending. Thus the nurses were unable to initiate ART during the project although the clinics have now been accredited. Establish PMTCT support groups and peer support for adherence PMTCT support groups were established in all nine clinics during June and July 2012. The formation process involved group and individual counselling sessions. Group information and Pre-ART sessions were also conducted to strengthen the support groups. The sessions were offered in a standardised manner to all the clinics in partnership with FACT who facilitated the whole process with SCZ providing logistical support and allowances. Ward focal persons and health facility staff played a crucial role during the formation process by referring HIV positive mothers to the support groups however it was noted that issues of disclosure of HIV status hindered HIV positive mothers from joining the support groups. The major objective of the group information session was to impart accurate information on HIV and AIDS and counsel on positive living to individual clients and PMTCT support group s members. The session content included topics on basic facts about HIV/AIDS, PMTCT, family planning, stress management, positive living, disclosure, decision making, stigma and discrimination. This was accomplished in four sessions. Four other sessions were done during the Pre-ART phase when clients received information on the importance of support group meetings, treatment adherence and supply appointments (information on ARVs how the ARVS work in relation to the CD4, how to take the ARVs, side effects of ARVs, importance of drug adherence, importance of treatment partner, ARVs and herbs) and revision of the basic facts of HIV and AIDS. During these group information and the Pre-ART sessions both group and individual counselling was conducted. In the group sessions the information was discussed as a group and during the individual sessions what had been discussed at group level was personalised to individual level which has helped to yield good results on stress management, improvement on adherence and positive living. The purpose of the PMTCT support groups is to give each other correct information pertaining to HIV/AIDS, share experiences and encourage access and adherence to treatment despite persistent challenges created by cultural stigma and discrimination. A total of 16 PMTCT support groups were established to date across the 9 clinics. 8 clinics have 2 support groups per clinic and one has 3 groups. Ideally the support group meetings were supposed to be done once a week however there are being held at the clinics twice a month with 4 sessions being done per day due to distances covered by the mothers to the venue and other family commitments. Following the formation process the support groups are facilitated by the PMTCT Peer educators who take care of the day to day running of the support groups. The trained peer educators and village health workers meet with the support group members and conducting sessions as per above mentioned topics. The main challenge observed is that the support group members do not feel comfortable to disclose their status to the ordinary community members for fear of stigmatisation and discrimination. On the another hand it was 4
noted that positive pregnant women and lactating mothers feel free to express themselves when they are among other group members. Men are also joining in as members. It is promising that with continued support the support groups will continue to exist and play an integral role in PMTCT advocacy messages. The payment of allowances to peer educators will affect the continuity of the activity after the end of the project. NAC is already paying allowances to the ward focal persons and it is unclear how the peer educators will be supported. Peer education training The three day training for peer educators was held in July 2012. The participants were HIV positive men and women recruited from the PMTCT support group joined with (WFPs) Ward focal persons within Matibi 2 area. 34 participants (21 F and13 M) were trained on basic facts about HIV and AIDS, positive living disclosure, OI/ ART, Nutrition and HIV adherence, roles and responsibility of peer educator, family planning, communication, report writing and data capturing. Emphasis was given on the four pronged approach for the prevention of PMTCT. The Peer educators were trained and supported to take care of the day to day running of the support groups meeting with support from FACT, MoH&CW and Save the Children. Currently two support group meetings are being held at each clinic per month with the peer educator s facilitating the whole process. Reports received from the peer educators are indicating that the support group meeting are being held however still more need support as there are issues in dealing with HIV and AIDS due to the cultural and religious beliefs let alone stigma and discrimination. The trained peer educators continued to offer support to the support groups once every fortnight, conducting group sessions on PMTCT initiatives. The nurse at the clinics supervises the sessions and continues to provide technical advice where necessary. Establish/strengthen Village Aids Action Committees (VAAC) that coordinate PMTCT care and support at community level As a means of strengthening PMTCT care and support at community level, the nine clinics were supported to create 2 VAACs per clinic. The ward focal persons led the selection of these cadres. Save the Children supported a two day training for the VAACs. The training was supported by NAC with assistance from Regai Dzive Shiri. A total of 20 VAACs were trained from the 6 wards in Matibi 2 area covering Chilonga, Chambuta, Chibwedziva, Mhlanguleni, Chingele, Makambe, and Old Boli. The training was conducted in 6 groups of 42 participants with each group receiving a 2 day training. Each VAAC consisted of a committee comprising of the following cadres: Chairperson and Vice Chairperson Secretary and Vice Secretary Treasurer Committee members Topics covered during the training: 5
Roles and responsibilities of VAAC Basic facts on HIV/AIDS PMTCT Discordant results Condom use Male motivation Community mobilisation and collaboration with other stakeholders in the community Reporting and report writing All the VAAC members accepted their roles and responsibilities in the communities and agreed to always include PMTCT topic on their agenda each time when they are conducting village meetings. It was agreed that the VAACs will also assist in male mobilisation so that males support their pregnant women and accompany them to the clinic for HIV testing and further support. Community leadership strengthened to address barriers to PMTCT uptake, retention and adherence 184 community leaders within Matibi 2 areas were strengthened to address barriers that hinder PMTCT uptake, retention and adherence. Discussions were held with the local leaders in one day meetings. The following barriers were discussed: a) Cultural and religious beliefs b) Distances to the clinics c) Stigma and discrimination issues d) Knowledge gaps on PMTCT e) Lack of privacy at the clinics f) Issues of families not staying together g) Non availability of drugs at the local clinics h) Non adherence As a result of the sessions, the local leaders are now addressing PMTCT issues in their village meetings and PMTCT support groups in the community are now established and getting support from the general community and NAC. Conduct male motivation campaigns Save the Children supported MoH&CW staff at the nine clinics to conduct male motivation campaigns. A total of 325 men were mobilized and gathered across the 9 RHCs in Matibi 2. Discussions were centred on male motivation especially related to PMTCT. The following means and ways of male involvement in PMTCT were discussed: 6
Couple counseling Giving them roles and responsibilities in the program Involving them in PMTCT activities like dramas, role plays Accompanying mother and baby to Health Centre or counseling institutes Involving men as treatment partner for his wife and or baby, and necessity for involvement in pre-art sessions Using him as a treatment reminder for wife and baby Taking decisions on safer sex, discussing with partner condom use Accompanying wife to health centre for FP method Male motivation was cited as a key intervention in PMTCT by MoH&CW as it promotes the following: Partner counseling, testing and disclosure. Helps women to act on prevention messages easily Helps couples to make informed decisions on reproductive goals and prevention strategies Improves client satisfaction and adoption, continuation and successful method use in FP Successful ART and PMTCT leading to negative baby Misconceptions and taboos on PMTCT are addressed Couple counseling: (1) Provides an opportunity to encourage couple to practice safer sex (2) Health workers can emphasize each partner s responsibilities for protecting the health of their family (3) Encourages compliance to any recommended intervention (4) Helps to identify discordant couples thus facilitating discussion on appropriate interventions Eliminates the problems of disclosing HIV status to partner As a result of the male motivation campaigns 75 men opted for HIV testing: a) Men were aware of significance of early booking, institutional deliveries, couple counselling and testing b) Men admitted that out of ignorance they were not seeing the impact of their negligence towards pregnant women but because of the knowledge gained during the campaigns they were able to change their mind set towards pregnant women c) The involvement of local leadership and influential people assisted in acceptance of the project and it was agreed by all that no women should give birth at home. Quantitative analysis at end line showed a major improvement in the percentage of male partners tested (42 in Q1 at baseline stage and 132 in Q4 at end line) The represents an 7
increase from 9% to 23% of male partners tested. Graph 1 shows changes in the 5 quarters from baseline to end line. Graph 1: Male Partners Tested Outcome 2: Reduced Loss to follow up During the health care worker trainings adherence issues were addressed and PMTCT mothers also received adherence counseling in support group sessions. Ensuring access to CD4 tests for mothers on ARV prophylaxis every 6 months and for DBS testing for HIV exposed infants at six weeks as well for those that we have tested negative a rapid HIV test at 9 months is critical. Save the Children assisted with collection of CD4 and DBS blood samples from the RHCs to the district laboratory for analysis. The VHWs worked closely with the RHCs to ensure follow up of exposed infants and also giving support to PMTCT mothers during breastfeeding and giving education to such mothers on IYCF. However training was conducted towards the end of the project, hence the need to extend this work so as to provide maximum support to the VHW system so as to enable: Follow up on exposed infants and encourage pregnant mothers to book early. Collecting data and reporting on monthly basis at the clinic. Initiation of baby weighing and supporting PMTCT support groups through conducting group sessions after every fortnight. The project evaluation (Annex 5) found that infants below 2 months were tested for HIV increased from 54% to 57%. The percentage of infants started on cotrimoxazole prophylaxis decreased from 107% at baseline to 81%. 30 infants above 9 months were tested using rapid 8
tests as compared to 23 at baseline. 22% of mothers were started on cotrimoxazole prophylaxis. Graph 2 below shows an analysis of infant PMTCT data per quarter. Graph 2: Infant PMTCT Data for 2012, Train and support existing VHW to integrate basic PMTCT into MNCH services Save the Children supported the MoH&CW to conduct training for 104 VHWs (27 males and 77 females) from health facilities in Chiredzi district. Facilitators were drawn from the MoH&CW Chiredzi district and the Chikombedzi Mission hospital. Save the Children offered technical support and direction. The revised 2010 VHW training manual was used for the training and other sources related to PMTCT approved by the MoH&CW. During the training emphasis was put on the major roles to be played by VHW in PMTCT and these were highlighted as: To encourage women to book early To encourage males to accompany their partners to the health facility To follow up mother and promote ART adherence Encourage mothers to exclusively breastfeed To follow up exposed babies To remind HIV positive mothers of their review dates Advice about family planning and referral to OI clinic 29 kits and 29 bicycles were distributed to VHWs in the catchment areas of the 9 RHCs to increase their mobility in their catchment areas. Reports by the VHWs at the clinics were submitted as a result of the stationery provided to them. 9
Strengthen post natal care and follow up of HIV+mothers and exposed new borns through VHW. As described above SCZ supported the MoH&CW to conduct training to144 VHW in the district and 29 VHWs from the 9 supported clinics received bicycles and VHW kits to support their activities. The VHW kits were comprised of the following items to support post natal care and follow-up: unit DESCRIPTION Quantity Each Salter Scale 1 Each Round Neck T shirts 1 Each Sling Bag 1 Pack of 12 Underpad 1 Each Gauze Bandage 5cmx4.5m 4 Each Safety Pins 5 Sachet Oral Rehydration Salts 10 Each Face Towel 1 Bottle Paracetamol Tablets(500) 1 Bottle Antiseptic Solution 750 ml 1 Bottle Petroleum Jelly 300 ml 1 Pack Gauze Swabs 1 Pack of 100 Examination Gloves 1 Bottle Methylated Spirit 750ml 2 Bottle Jik/Bleach 750ml 1 Each Tetracycline Hydrochloride 5g 5 Each Green Soap 1kg 1 Each Triangular Bandage 3 The VHW kits were purchased under the guidance of MoH&CW. The 29 VHWs were also supported with uniforms for easy identification and acceptance in the communities. VHWs were also supported with stationery in order to produce reports on time. The monthly VHW return form crafted by MoH&CW was adopted during the project for reporting purposes. However due to the delay in trainings of VHWs it was difficult to measure the success of PMTCT activities conducted by VHWs in the communities. Outcome 3 Strengthen monitoring and reporting mechanisms at district, RHC and community level SCZ s Design, Monitoring and Evaluation Department comprised of the Manager, Coordinator and two DME Officers worked hand in hand with program staff to ensure that there was timely and meaningful progress and measurement of project objectives. The SCZMonitoring and Evaluation teams worked closely with the MoH&CW and conducted follow up visits to the 10
RHCs to perform a data verification process and assist RHC nurses on the proper use of registers and also supported them to conduct data validation at RHC level before sending the data to the district office. The teams also conducted review meetings as a way of monitoring the grant milestones and also as a platform to share current challenges in reporting. In addition these other M&E activities were conducted. Gap Analysis SCZ M&E led an assessment aimed at identification of PMTCT gaps at institution and community level. The gap analysis was conducted using two approaches; review of secondary data (MER 14 and 28 data from MoH and EGPAF), and primary data collection which included FGDs with community representatives and VHWs and Key Informant interviews with nursing staff and traditional leaders. The results of the gap analysis acted as the platform for project design. Major gaps in PMTCT were highlighted and this assisted in designing the activities of the project. In addition partnerships in the rolling out of PMTCT interventions within the district were also highlighted so as to avoid duplication of activities. The detailed gap analysis report highlighting major findings were shared with BMSF, NEDICO and BMSF regional consultants. Data Management Training The gap analysis revealed serious concerns in data collection, recording, and validity of PMTCT data both at health facility levels and the district information office. There is a noticeable gap in that the MER 14 indicators are being wrongly calculated. To address these problems a training to build the monitoring capacity of health care workers and the district office health information personnel was conducted in July 2012. Thirty- two (32) participants attended the 5 day training which was facilitated by the MoH&CW Provincial and National M and E officers. Participants were drawn from all 25 rural health care facilities of both government and nongovernmental institutions. During the training participants had a data validation exercise using statistics submitted by the clinics which were obtained from the district offices. The validation process was discussed and from this exercise common errors were identified and discussed. By the end of the exercise participants appreciated the importance of data management and it was recommended that health care workers conduct data validation exercises at their respective centres and send an addendum to the district information office so that adjustments can be made starting from January to June 2012. Some challenges noted were the ever changing data collection tools on PMTCT without orientation. This was noted as a gap that needs to be rectified. Save the Children supported the MoH&CW in conducting data validation in the nine pilot clinics from the month of October 2011 to June 2012. Validated data from the last quarter of 2011 that is (October to December) was used as baseline for the project. Data management training assisted the nurses to rectify areas of weakness that were noted by SCZ during a follow up meeting including: 11
Sources of error in the infant dispensing register (some collectors were taking figures from resupply after 6 weeks and mixing them with figures from supply at 6 weeks, number of mothers booked for first ANC). PMTCT indicators were not clearly understood hence causing confusion to data collectors Incorrect use of registers (using wrong source documents) affecting completeness and consistence of data The nurses now have the knowledge on the importance of data quality and the significance of completing registers in the required manner using their notes and referring to guidelines on the registers. The district OI outreach teams are continuously conducting support visits assisting the nurses to improve on data collection, validation and management. Quarterly Review and Planning Meetings SCZ conducted three planned Quarterly meetings which act as forum for reviewing progress and planning for following quarter. The 9 pilot RHC staff shared major challenges affecting their RHCs. Meetings were attended by all partners, stakeholders and SCZ staff. The meetings were used to discuss activities for the coming quarter as well as sharing best practices. Monitoring and Supervision The project supported the timely collection of MER 14 data at all the RHC which feed in the development of the program reports with accurate data. Save the Children supported MoH&CW with vehicle or fuel and allowances to conduct support and supervision visits to the 9 RHCs. MoH&CW was also supported to distribute registers to use for data collection purposes at RHC level. Monthly PMTCT return forms were also collected from clinics to district MoH and SCZ offices. Major improvement was noted in the quality of data that was submitted by the clinics. However it was difficult to measure impact of the project due shorter period of implementation. Outcome 4: Increased SC, District and community s stakeholder s capacity in rolling comprehensive PMTCT interventions SC developed strong collaborative relationships with partners in the district to achieve the project results. SC collaborated with EGPAF in transportation of blood samples for DBS and CD4 cell count to the nearest referral center. Coordination meetings were conducted jointly with EGPAF and MoH&CW. Together with FACT Chiredzi SCZ managed to strengthen PMTCT support groups. FACT supported this activity with facilitators and training curriculum for the support groups. Save the Children supported Peer educators training curriculum development and facilitation during the training. As our major stakeholder MoH&CW gave 12
support to SCZ throughout the life span of the project. MoH&CW assisted with facilitation and curriculum development for all the trainings conducted. The ministry also supported with supervision of the clinics to ensure feed back was done after trainings and also ensure smooth running of the project at RHC level. The MoH&CW also acted as an advocate for SCZ and BMSF at district meetings. NAC assisted with facilitation and selection of VAAC committees at community level. Training was conducted in coordination with Regai Dzive Shiri which is an arm of NAC implementing behavior change strategy in communities in Chiredzi district. NAC also took a lead in meetings conducted in the district by organizations implementing HIV/AIDS project within the district. After terms of reference for all key implementing partners were developed and key indicators being monitored discussed, MoUs were signed by partners that were assisting SCZ with activities. Quarterly partner meetings were also conducted with stakeholders to monitor progress as well as mapping the way forward in the program activities described below. All relevant staff participating in projects implementation from partners operating as mandated All the partners were adhering with the agreement of MoUs as staff were made available in all program activities. Develop key result areas for all staff from different partners and high light indicators being monitored A workplan was produced together with partners with their key result areas clearly outlined and agreed upon. The key indicators to be monitored will be looked at and the indicator definition shared so that outcomes expected are clear and partner activities be confined to meeting of these outcomes. Discuss implementation logistics and allowances as well as payment modalities for Outreach staff, Nurses initiating ART, WAAC focal persons and Peer educators Modalities for payment of allowances were agreed by all partners and stakeholders based upon the prevailing MoH&CW rates and the SCZ facilitation policy. An implementation plan outlining linkages and operational modalities for each partner was developed. This enabled clear roles and responsibilities so to avoid operating in another partner s area of focus. 13
Monitoring and Evaluation A gap analysis was conducted at the beginning of the project and the report on findings was shared with partners and stakeholders. Baseline data was obtained from the RHCs. The MoH&CW PMTCT monthly return form was adopted and was used for data collection during the course of the project. Data was shared between MoH&CW and SCZ. Evaluation of all training was done at the beginning, during and after trainings. Support and supervision visits were used to measure the impact of the trainings and assess if feedback was given. Quarterly review meetings were conducted in September and December 2012 with Matibi 2 staff and DHE members attending. It was noted that despite the interventions by the BMSF funding, some clinics were facing some challenges like shortage of PMTCT registers, ANC cards, late receipt of DBS results and poor male involvement as a result of job searching to neighboring countries such as South Africa and Mozambique. Support is still required to overcome some of the challenges and the laboratory scientist from the district was recommended to follow up the DBS results. The general sentiments were the wish for the project to continue since it was implemented in a short period of time. Reports were submitted to BMSF. At the end of the project an end of project evaluation was conducted see attached annex from end of project evaluation findings. Achievements, Key Lessons Learned, Challenges & Recommendations Achievement Highlights All the planned activities for the project were conducted. The project was well received by the MOH&CW as well as the community. The project managed to introduce the new strategies of male motivation and PMTCT support groups which MoH&CW had not yet done. The accreditation of the clinics will result in those clinics being the first ones to initiate ART in the Chiredzi district. The training conducted on IMAI/IMPAC and data management were facilitated by trained facilitators and MOH&CW head office officials. The nurses were able to receive the latest curriculum content. Strong stakeholder participation was achieved throughout the project lifespan. 14
Lessons Learned Involvement of RHC nurses during training of other community cadres such as peer educators and VHWs is crucial since they work together after the trainings. PMTCT support group meetings are providing a continuum of care for the HIV positive mother and exposed infants. Men were excited with the inclusion of the father s name on the new road to health card recently produced by MoH&CW and this might encourage their participation. PMTCT support group meetings are providing a continuum of care for the HIV positive mother and exposed infants. The need to educate men and create a forum for discussion of issues regarding PMTCT helped increase the knowledge of man and will improve male involvement in care and support of HIV positive mothers and exposed infants. Challenges Delays were encountered in implementing some activities that need direct involvement with the MoH&CW such as training for health care workers and VHWs due to competing priorities with MoH&CW district plan. Initiation of ART drugs was been delayed due to the accreditation assessment process that required the involvement of MoH&CW district and Provincial officers. The majority of ward focal persons were not forthcoming to support the PMTCT meetings citing challenges related to distances involved in accessing the RHC. There is a general nursing and midwifery skills upgrading program being undertaken by the MoH&CW targeting the Primary Care Nurse from the RHCs. This caused critical staff shortages leaving most of the institutions being manned by only one nurse. 15
Final Recommendations The project ended just as the clinics that were accreditated. Thus they did not receive any ARV drugs from the district pharmacy, resulting in the need to continue with the project so that we will be able to give tangible evidence of the changes emanating from the interventions by the project. The following support is required for the district MoH&CW and partners to strengthen health services and community support: 1. Supervision of RHCs 2. Bimonthly support visits and refresher training in counseling for peer educators 3. Computerization of clinics for improved data management 4. Training of additional nurses on ART initiation in order to ensure that clients receive services throughout the week 5. Support for male motivation campaigns 6. Follow-up and support of Village AIDS Action Committees 7. Continued support for PMTCT support groups 8. Support of RHCs with HB and PIMA machines for CD4 cell count and HB testing 9. The district OI/ART outreach team support OI & ART outreach activities 10. Support PMTCT support groups to do small scale projects such as PERMA gardens 16