A Longitudinal Review of National HIV Policy and Progress Made in Health Facility Implementation in Eastern Zimbabwe

Dr

Malebogo Tlhajoane

(She/Her)

Research Fellow

Faculty of Epidemiology and Population Health

The London School of Hygiene & Tropical Medicine

I have a BSc in Biology from Union College, Schenectady (NY), an MSc in the Control of Infectious Diseases from LSHTM, an MRes in Biomedical Research, and PhD in Infectious Disease Epidemiology from Imperial College London

Overview

Our research centred on HIV policy adoption in Zimbabwe and its related implementation within health facilities. We compared health facility data at two time points to examine changes in service provision, and assess whether there was a noticeable increase in the number of patients receiving HIV care and treatment

This research was produced to assess a transition from CD4 count 350 to 500 over the time period of data collection.

This research examines how the transition policy worked in practice, especially at the health facility level and for individual patients. How the policies were translated into practice and whether there were any significant shifts in service provision and the numbers of patients accessing care.

While we have looked a lot at how research gets put into policy, less attention has been paid to how policy gets put into practice. Yet how policies are translated into practice is very significant knowledge to improve policy adoption and patient outcomes. It helps to find out what works, what doesn’t work and how it can be improved to further increase the intended outcomes of that policy.

Key Findings

There were some differences in health facility service delivery between the two time periods. We found an increase in the proportion of facilities that offered free HIV testing and counselling services, ART and PMTCT services between 2013 to 2015. There was a significantly higher number of HIV tests conducted across all types of health facilities.
There were some stockouts reported in the facilities, specifically related to HIV test kits, whereas a low proportion of facilities reported stockouts of first line antiretroviral therapy and prophylactic drugs for opportunistic infections.
However, there was a reduction in the number of healthcare workers. We distinguished between the different kinds of healthcare workers, such as doctors, nurses, support staff. We observed significant reductions in the mean numbers of registered nurses and midwives, and a significant increase in the numbers of nursing assistants and nursing aides.
We also found low numbers of facilities that offered laboratory testing (excluding CD4 count testing) across both survey rounds. This was despite the policy and operational guidelines that encouraged expanded coverage of diagnostic services. So whilst the policy and operational guidelines tried to increase levels of access to laboratory testing, they remained low.

    How to apply research

    Every community is heterogeneous, and there will be specific challenges to introducing a new policy into any new community. Need to understand what would work there and what would be needed specifically for each context.
    To do the above, it would be beneficial to engage with the healthcare workers and other key stakeholders to develop implementation strategies for new policies. For example, the challenges healthcare workers faced due to the implementation could be communicated to policymakers to facilitate the implementation process.
    To engage with Zimbabwe stakeholders, we bought together stakeholders from the different organisations and at different levels across the community and health care facilities, and shared with them our findings, which encouraged discussion and knowledge sharing on how to overcome challenges, creating a learning environment. This was achieved through a workshop scenario that generated a lot of understanding for how things could be improved. We also shared a brief with the different stakeholders to attain their feedback.
    Create a similar operational service delivery manual to what the Zimbabwe Ministry of Health developed for this initiative as it helps to explain the ‘how’ to healthcare practitioners. This manual should outline the policies and explain the vision of where we are trying to go – but also detail what a healthcare practitioner must do to implement the change and enact the policy with a step-by-step approach for implementation. It also provides researchers with a framework to assess specific parts of the policy’s implementation and can help to quantify at the patient level too.

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      About this research

      This journal article was part of a collaborative effort

      Tidings Masoka

      Edith Mpandaguta

      Rebecca Rhead

      Kathryn Church

      Alison Wringe

      Noah Kadzura

      Nimalan Arinaminpathy

      Constance Nyamukapa

      Nadine Schur

      Owen Mugurungi4

      Morten Skovdal

      Jeffrey Eaton

      Simon Gregson

      Both rounds of the policy analysis and health facility survey were funded through the ALPHA Network grant from the Bill and Melinda Gates Foundation: “Deaths Among HIV Infected Adults in African Populations since the Introduction of Antiretroviral Treatment” OPP1082114. This analysis was funded by the Wellcome Trust through a PhD studentship awarded to M Tlhajoane

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      UN Sustainable Development Goals

      This research contributes to the following SDGs

      About this research

      Both rounds of the policy analysis and health facility survey were funded through the ALPHA Network grant from the Bill and Melinda Gates Foundation: “Deaths Among HIV Infected Adults in African Populations since the Introduction of Antiretroviral Treatment” OPP1082114. This analysis was funded by the Wellcome Trust through a PhD studentship awarded to M Tlhajoane

      This paper was co-authored

      Tidings Masoka

      Edith Mpandaguta

      Rebecca Rhead

      Kathryn Church

      Alison Wringe

      Noah Kadzura

      Nimalan Arinaminpathy

      Constance Nyamukapa

      Nadine Schur

      Owen Mugurungi4

      Morten Skovdal

      Jeffrey Eaton

      Simon Gregson

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      What findings means

      There were high levels of adoption of WHO guidance into the national HIV policies in Zimbabwe. Including the later recommendations that came between 2013 and 2015, when the threshold was changed.

      In additional research we conducted, when the CD4 threshold for HIV treatment was changed at the end of 2015, beginning of 2016, we found various strategies, manuals and guidance had been introduced to help implement these new policies. The Zimbabwean Ministry of Health created a comprehensive service delivery manual, which was almost a ‘how-to’ guide on what healthcare practitioners must do to implement the policies. While this research did not specifically examine this manuals effectiveness, it was very useful for the health facilities and for health practitioners.

      Another key strategy, also championed by the WHO, and included in this paper, was the decentralisation of ART services, which meant that they were small clinics that helped services access more hard-to-reach communities. But these small clinics were the ones who also reported limited access to laboratory services, and they were more likely to experience challenges with laboratory testing than the larger district level of hospitals. Likely due to the transportation of samples or ability to attain the right supplies or providing services at the smaller health clinic level.

      Findings in practice

      The data for this research came from Eastern Zimbabwe and was collected by the Manicaland Centre for Public Health Research. The Manicaland cohort also forms a part of a network know as the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) Network.

      The ALPHA Network and is a collaboration between 10 longitudinal studies in sub-Saharan Africa. Each of these partners collect the data from population-based cohorts, however, in some instances data has also been collected from health facility surveys.

      Methodology

      The research was conducted in a few steps. Firstly, there was a policy review of publicly available documents from the ministry of health and child care to understand the policies and how they changed over time.

      These policies were evaluated using a framework from the ALPHA network. This framework helped to extract the indicators which may influence the uptake of access to HIV services, and the set of eight objectives or operational guidelines were identified as areas of strategic importance in HIV service delivery by the Zimbabwe Ministry of Health.

      Then we looked at the implementation of the policy at 36 of the same health care facilities in Eastern Zimbabwe (including district hospitals, large health centres, small health centres and clinics) at two time points. This data was collected by the Manicaland Centre for Public Health Research.

      The differences between the services that were available was compared at one time point versus the other. The differences were assessed by looking at each of outcome variables. We performed paired samples, t tests, and the McNemar test to assess the differences.

      The limitations of the study include missing data for some indicators of policy implementation, which may distort the comparison between time periods as a complete case analysis was used to generate statistical estimates. A complete case analysis means that for this specific statistical test, we only include those health facilities that have complete data at both time points for that specific variable.

      The study was conducted in two predominantly rural districts of Manicaland, which is in Eastern Zimbabwe, and is currently the province with the lowest HIV prevalence in Zimbabwe. So other districts may have a different experience as there could be a higher number of patients requiring care due to differences in HIV prevalence.

      Want to read the full paper? It is available open access

      Tlhajoane, M., Masoka, T., Mpandaguta, E., Rhead, R., Church, K., Wringe, A., Kadzura, N., Arinaminpathy, N., Nyamukapa, C., Schur, N., Mugurungi, O., Skovdal, M., Eaton, J. W., & Gregson, S. (2018). A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe. Health research policy and systems16(1), 92.

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      for helping to prepare this research