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.
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.
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.
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.
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 systems, 16(1), 92.