Sithokozile Maposa — Advance Africa Project, Zimbabwe
December, 2007
Sithokozile "Thoko" Maposa is a doctoral nursing candidate at Saint Louis University School of Nursing, St. Louis, Missouri. She has diverse experience in primary health care programming in Zimbabwe, Africa. She has consulted with community agencies to strengthen women's and adolescents' health care and provided technical assistance in integrating family planning and HIV/AIDS information and services in community-based and clinic-based settings.
Please tell us about your project /program experience integrating HIV/AIDS and sexual and reproductive health services.
In 2002-2004, I worked as a project manager for Advance Africa Zimbabwe, a USAID- funded project. The project provided technical support to build the capacity of community-based distribution (CBD) workers providing HIV/AIDS information and services, guiding the integration of family planning and HIV/AIDS services in selected mission hospitals, strengthening community linkages with hospital programs, and providing reproductive health program support in providing information and services to children orphaned or made vulnerable by HIV/AIDS. I was involved in the training of the family planning trainers. I networked with the Population Services International (PSI) project to expand access to HIV services in our sites, and worked with implementers to engage policy makers to support the programs to help maximize our effectiveness.
Can you provide background information on the HIV/AIDS and sexual and reproductive health situation in your country?
Zimbabwe has an HIV prevalence of 20% in the adult population with an estimated number of 1,800,000 people infected and more than 600,000 HIV orphans.
How did you decide on the approach to take?
We used findings of a 1999 CBD program evaluation survey and the results strongly suggested the need to equip the CBDs with skills, knowledge, and HIV information.
What were the dates of the project/program?
The project ended in 2005 with lessons learned presented at the Advance Africa End of Project Conference, Washington, D.C. in September 2005.
What was the problem you were responding to when you developed the program?
The Zimbabwe National Family Planning Council (ZNFPC) was concerned about the declining family planning Contraceptive Prevalence Rate contribution of the CBD program, expanding access to young people, men, and low parity women, and increasing HIV. Most of all we found out that the both family planning and HIV/AIDS providers needed skills to integrate HIV/AIDS services.
Who was involved in the discussion and decision-making on the approach to take to address the problem?
We realized that awareness of HIV did not translate to adoption of prevention given the high trends of HIV. As a result, before and during the implementation of the project we engaged CBDs in a series of nationwide dissemination consultative meetings, held regular meetings with other related health and non-governmental programs and community leaders and local authorities. We realized the presence and work of PSI in HIV testing and we worked with them to expand testing in the expanded CBD program areas. To account for the number of referrals from CBDs, PSI revised their data collection forms to include people referred by CBDs for HIV testing. ZNFPC worked with CBDs to improve the monitoring and evaluation of HIV/AIDS related information and service in the work of CBDs.
Did you involve the community in developing the program?
The community was involved from the beginning in the research and throughout the life of the project through their input in the survey as key informants, in the selection of the pilot districts, and suggesting partnerships. Because of our active networking strategy we were able to build capacity in collaborative work among all partners where there was a CBD program and built links with the mission hospitals project and the orphan project.
Are there links to community support groups?
CBD workers were expected to identify existing HIV services in their area and talk about their expanded roles in HIV/AIDS information and service referral. CBDs explained their new role to HIV testing service sites in their areas before referring clients. CBDs linked HIV- positive clients to community support groups for supportive counseling.
How did you work with the District Health Office in setting up the program; for example, in strengthening the systems and services?
We piloted the interventions whereby provincial teams worked with a multi-disciplinary project committee giving regular updates and together responded to issues of increasing access to services. Because of this involvement, the district local authority in Marondera, the pilot district in Mashonaland East province, provided additional funding to increase the number of community-based workers trained in HIV supportive counseling.
How did the project team decide on a system to balance work activities (e.g., addition of new activities with existing activities for the purpose of integration)?
We had a short-term and a long-term plan which we reviewed on a regular basis. The first year plan was focused on building and strengthening systems for supervision, building capacity through training, and improving logistics support to the programs. Therefore, we had a purposive sample of eight pilot districts (one per province) to learn from before expanding to 16 districts. Our work with the ZNFPC influenced our expansion plan to three mission hospitals and orphan projects.
Were there systems you developed to manage integrated services, such as client follow-up or special complicated cases?
Yes we developed and continually improved our CBD referral system for HIV testing and had to modify it when we realized that some clients preferred to seek information from CBDs rather than obtain a referral form. As a result, we were able to collaborate with our partners to account for those that specifically sought services because they heard about them from the CBDs.
Was there training needed in order to be able to offer integrated services?
Yes, there were three main training of trainers conducted to facilitate our ability to offer integrated services. A series of courses were offered including one on Family Planning in the Context of HIV that included a field work visit to a HIV testing center for trainers as well as trainees, an in-country Centre for African Family Studies, Nairobi-specialized training on management of community-based programs with a special emphasis on building and creating networks and partnership, and a community approach to community-based home care.
How do the providers and clients feel about the integrated activity?
The providers felt that an integrated activity was the most practical way, especially as it improved their involvement in local community awareness activities.
What obstacles did you encounter from a program standpoint and how did you address them?
We felt stretched as a project management team. Because of high staff turnover, there was a constant need to retrain trainers of trainers. This limited timely project implementation. Other obstacles not in our control were related to inflation.
Did you make adjustments to your approach as you went along? Please describe.
Yes we had to make a lot of adjustments to improve the monitoring and evaluation aspects of the project as we went along to ensure that we were able to capture project indicators. As a result, we had to recruit additional consultants in training; Information, Education, and Communication; and in database development and management to facilitate project implementation.
Did you have need for special resources to implement your approach (e.g., funding, staffing, supplies, and consultants)?
Yes. Some supplies were not available locally, such as bicycles and motorcycles, and these were ordered externally. We hired external project consultants to support monitoring and evaluation activities, adolescent health, and family planning training.
How did you evaluate the success of your activity?
We had a monitoring and evaluation plan and we measured our success by the number of clients referred for HIV testing, number of condoms and contraceptives distributed, the number of people and meetings held to discuss HIV/AIDS, and, in particular for the mission hospitals project, the condoms and contraceptives to HIV-positive and non-positive women.
Sithokozile Maposa
Saint Louis University
Department of Nursing