Zimbabwe ranks as the second-most developed countries within the Southern African Development Community. Great inroads have been made to provide decent health care to the general population. The combined effort from the Ministry of Health and Child Care and partners to reduce the prevalence rates for various diseases including malaria, tuberculosis and HIV is especially noteworthy. Infant mortality has been on the decline, too. However, more efforts are needed to stabilize the health delivery system.
PSI/Zimbabwe has been operating in partnership with the Ministry of Health and Child Care since 1996. With an initial focus on HIV and AIDS prevention through the social marketing of condoms, the program has now grown significantly to include numerous services such as – HIV testing and counseling, STI treatment, voluntary medical male circumcision, TB screening, ART provision, family planning and cervical cancer screening. PSI/Zimbabwe also supports the Ministry of Health and Child Care with long-lasting insecticide-treated net distribution for the prevention of malaria and the social marketing of WaterGuard sodium hypochlorite solution for the prevention of water-borne diseases.
PSI/Zimbabwe believes in hiring, nurturing and retaining the best possible local talent and currently has nearly four hundred local staff located across the country.
Strict measurement of performance feeds into the design of innovative, targeted and cost-effective interventions. Through the provision of services and products in 2012, PSI/Zimbabwe averted:
- 947,90 reproductive health DALYs
- 435,209 malaria control DALYs
- 728,163 HIV DALYs
- 5661 child survival DALYs
Furthermore it added 268,919 CYPs for clients accessing family planning services in 2012.
PSI/Zimbabwe seeks to improve health in Zimbabwe through the provision of the following services and products:
Voluntary Medical Male Circumcision
Voluntary medical male circumcision (VMMC) has a protective effect of 60 percent against HIV. As a partner in the national program, PSI/Zimbabwe offers voluntary medical male circumcision in 35 districts at fixed sites and through outreach and mobile services. PSI/Zimbabwe circumcises about 10,000 men and adolescents countrywide every month. The school holiday campaigns and workplace program are the main thrust in reaching the primary target.
Demand creation activities such as community dialogues, interpersonal communication sessions, edutainment and mass media are employed to increase uptake of VMMC. The use of public personalities as role models has also helped in demand generation. PSI/Zimbabwe works closely with the traditional circumcising communities to offer safe medical male circumcision. A new site with a capacity to circumcise 100 men daily opened in Harare’s Central Business District in 2013.
Condom Social Marketing
PSI/Zimbabwe uses private-sector marketing strategies to increase demand for and access to attractively packaged and affordable high-quality male condoms called Protector Plus. By distributing through traditional (pharmacies, health clinics) and non-traditional (bars, hotels, brothels, kiosks, retail shops and salons) outlets, PSI/Zimbabwe reaches populations that may not otherwise have access to commercial condom brands. Demand is generated by fostering behavior change through appropriate mass media and interpersonal communication campaigns. In 2014 PSI/Zimbabwe is launching colored and flavored condoms as extensions to the Protector Plus brand. PSI/Zimbabwe sells 30 million Protector Plus condoms yearly.
In addition PSI/Zimbabwe sells an average of 1,400,000 female condoms for prevention of HIV, sexually transmitted infections (STIs) and unintended pregnancies to most at-risk low-income populations yearly. PSI/Zimbabwe uses innovative strategies, such as hair salon initiatives and sex worker mapping, to market female condoms. Since 2001, PSI/Zimbabwe has trained female hair stylists from more than 1,500 salons in low-income areas to promote correct and consistent use of the Care female condom. Sex workers are also offered training on condom use to protect them from HIV/STI transmission and unintended pregnancies as well as to cascade the information to their peers. In promoting male involvement, barbers have also been initiated in the program.
New Start Testing and Counseling
HIV testing and counseling (HTC) is a crucial element of public health efforts to reduce HIV incidence and to improve access to HIV treatment and care. PSI/Zimbabwe offers HTC services through networks of directly and indirectly managed (or franchised) sites across the country. To date, 16 static sites are operational in Zimbabwe and each site also provides services on an outreach basis. Since the inception of the HTC program in Zimbabwe in 1999, well over 3,000,000 people have accessed New Start testing and counseling.
Post-Test Support Services
PSI/Z’s New Life program provides post-test support services to people living with HIV and AIDS at nine static partner sites. Services include psychosocial counseling, support options to clients living with HIV and anti-retroviral therapy adherence counseling. Most-at-risk populations, supports groups of people living with HIV, and workplaces benefit from the New Life program.
The ART program supports government’s efforts towards the attainment of universal access to treatment for people living with HIV in Zimbabwe. PSI/Zimbabwe started offering ART services in 2013 in Bulawayo, Harare and Mutare as part of the treatment as prevention strategy.
Since 2004 PSI/Zimbabwe has been engaged in TB activities including TB symptom screening using the recommended TB screening WHO questionnaire. In 2011, TB diagnosis services were introduced in four centers. There are currently two GeneXpert machines in Harare and Bulawayo for testing TB in sputum. By September 2013, 1,713 active cases had been diagnosed. PSI/Zimbabwe refers all active cases to public health institutions for treatment and follows up on the clients to make sure they have started treatment. PSI/Zimbabwe reports all TB cases to the National TB Programme.
Family Planning/HIV Integration
The family planning/HIV integration program was launched in 2009 as an integrated prevention strategy to prevent mother-to-child transmission of HIV and to promote dual protection, that is, the concurrent use of condoms with another effective modern family planning method. Family planning counseling and services are offered in the majority of the New Start and New Life sites (18 out of 25 sites) and through mobile outreach teams. The remaining seven sites currently offer family planning counseling only. Through the Sexual and Reproductive Health and HIV Prevention in Zimbabwe program running from January 2013 to January 2016, PSI/Zimbabwe will adopt some public sector institutions in a partial social franchise in family planning. These institutions will receive training in long-acting reversible contraceptives and support in the form of equipment and quality assurance support and supervision.
Cervical cancer is the most common cancer among women in Zimbabwe, accounting for 33.4% of all cancer cases among black women. It is estimated that more than 1,800 women are diagnosed with cervical cancer in Zimbabwe and about 1,300 die from the disease every year. PSI/Zimbabwe has launched cervical cancer screening and treatment in a bid to avert years of life lost due to cervical cancer. Cervical cancer screening using Visual Inspection with Acetic Acid and Cerviography and Cryotherapy services are now available at New Start centers in Harare, Bulawayo, Chitungwiza and Masvingo. Training of more service providers is currently in progress. Plans are underway to also offer services in Mutare, Chipinge, Chinhoyi and Triangle.
PSI/Zimbabwe has adopted the universal approach to distribute LLINs to households in medium-to-high malaria transmission districts. From 2011 to date PSI/Zimbabwe has distributed close to 2 million nets in 26 districts with about 1.2 million nets coming from the USAID’s President’s Malaria Initiative to support net distribution and the rest from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Mass media and behavior change communication activities, such as road shows and dramas, are being used to raise awareness and promote the correct and consistent use of the nets.
Water, Sanitation and Hygeine
PSI/Zimbabweaims to reduce incidences of diarrheal diseases primarily among children below five years of age, people living with HIV and AIDS, and the general community through the social marketing of WaterGuard point-of-use water treatment solution. In 2013 PSI/Zimbabwe distributed 357,861 WaterGuard solution bottles. In a move to ensure the sustainability and local accessibility of WaterGuard, PSI/Zimbabwe transferred production and distribution to its private sector partner in December 2013.
Research, Metrics and Information Systems
PSI/Zimbabwe uses various research methods for monitoring, impact measurement, segmentation and profiling of target audiences and improving quality of programming. The methodologies, both qualitative and quantitative, include the following;
- Population-based surveys (TRaCs) which are used for monitoring, segmentation and impact evaluation.
- MAP used for measuring access and performance of the products and services in the market.
- Framework for Qualitative Segmentation Studies utilised for segmentation and profiling of target audience.
- Mystery Client and Client Satisfaction Surveys for assessing the adherence to standard operating procedures and quality of services being offered.
- Brand Equity used to understand the position and performance of the brand in the market.
- Willingness to Pay Surveys to help gain an understanding of the price that the target audience is willing to pay for various products and services.
- Pretesting of all communication materials to assess their acceptability, comprehension and resonance with the target audience.
- Operations Research for various health areas to improve quality of programming and inform refocusing decisions.
Mobile health (mHealth) is a term used for the practice of medicine and public health, supported by mobile devices. PSI/Zimbabwe has implemented a number of mHealth solutions for monitoring and evaluation in order to generate more accurate, real-time data that can be applied for programmatic decision-making. Several systems have been developed and successfully scaled up in recent years. PSI/Zimbabwe uses tablets to manage and report client records for sexual and reproductive health services provided in franchise clinics and by mobile teams. An Interactive Reminder Information System was built to track patients in TB and HIV programs, as well as to send reminders to male circumcision clients for post-operation visits.
- The Global Fund To Fight AIDS, Tuberculosis and Malaria
- U.S. Agency for International Development
- United Kingdom Department for International Development
- Multi-regional Dutch Comprehensive
- John Hopkins University
- Zimbabwe Ministry of Health and Child Welfare
- National AIDS Council
- Zimbabwe National Family Planning Council
- Community-based organizations
- Simplified Asset Indices to Measure Wealth and Equity in Health Programs: a Reliability and Validity Analysis Using Survey Data from 16 Countries
Many program implementers have difficulty collecting and analyzing data on program beneficiaries' wealth because a large number of survey questions are required to construct the standard wealth index. We created country-specific measures of household wealth with as few as 6 questions that are highly reliable and valid in both urban and rural contexts.
- Integration of Family Planning and HIV Services in Zimbabwe
A case study looking at the use of hormonal implants and dual protection messages in Zimbabwe.
- Safety and Efficacy of the PrePexTM Device for Malce Circumcision Performed by Primary Care Nurses in Zimbabwe
VMCC has been integrated as part of a comprehensive HIV prevention package in 14 priority countries in Eastern and Southern Africa. Male circumcision devices, such as PrePex, have the potential to make the procedure simpler and usable by non-physician providers at primary health care facility level, thus making VMCC more accessible and acceptable to clients, especially in rural areas. We assessed the safety and efficacy of the PrePex device for VMCC when used by primary care nurses in Zimbabwe.
- Safety and efficacy of the PrepexTM Male Circumcision Device Used by Non-Physician Clinicians
VMCC has been integrated as part of a comprehensive HIV prevention package in 14 priority countries in Eastern and Southern Africa. Most countries are still far off their national targets of reaching 80% of men aged 15-49 years due to supply and demand challenges. VMCC devices, such as PrePex, might make the procedure simpler, usable by non-physician providers and more acceptable and accessible to clients, potentially expanding coverage faster than with conventional surgery.
- Safety Profile of PrePexTM Male Circumcision Device in Adolescents in Zimbabwe
The safety and efficacy of the PrePex device for voluntary medical male circumcision (VMCC) has been demonstrated in studies in Rwanda, Uganda, and Zimbabwe, leading to the conditional prequalification of the device for use in adults 18 years and above by WHO in April 2013. The majority of VMCC clients in the 14 priority countries are adolescents under 18 years. Research to establish the safety and efficacy of the device when used in males under 18 years is urgently needed if the device is to be integrated with routine VMCC programming.
- Predictors for Uptake of Voluntary Medical Male Circumcision in Zimbabwe
Among the 13 priority countries for VMCC scale up, Zimbabwe has the potential to avert the highest proportion of new HIV infections with VMCC. Generating demand for VMCC is challenging. This is particularly true in Zimbabwe, where male circumcision is not part of the cultural norm. Understanding and addressing the barriers and motivators to VMCC uptake can inform effective demand-creation in Zimbabwe.
- Lessons Learned from Integration of Point of Care CD4 Cell Count Testing at PSI/Zimbabwe HIV Testing and Counselling Sites
Availability of CD4 count testing is an important determinant of time to treatment initiation. In Zimbabwe, access to CD4 testing services is limited, HIV positive patients often have to wait up to 30 days before accessing CD4 cell count testing in the public sector. Increasing availability of point-of-care CD4 cell count at the time of HIV testing has the potential to promote inkage to care and shorten time to initiation.
- Barriers and Motivators to Accessing Support Services Among Adult Female Survivors of Sexual Violence in Zimbabwe
PSI/Zimbabwe explored the barriers and motivators to accessing HIV post-exposure prophylaxis services among adult female survivors of sexual violence. This poster was created for 2014 International AIDS Conference in Melbourne, Australia.
- HIV Testing Uptake, Social Norms and Condom Use Trends Among Men and Women 15 to 49-years old in Zimbabwe
Zimbabwe is one of the countries with the highest HIV prevalence in sub-Saharan Africa at 15%. PSI Zimbabwe has a large network of facilities offering HIV Testing and Counseling (HTC) services reaching about 400,000 (about 17% of national outputs) annually. PSI does social marketing of condoms distributing over 1.6 million female and 28 million male condoms annually. PSI Zimbabwe monitors its efforts by conducting population based, cross sectional surveys monitoring HIV testing uptake trends, individual and community behaviour determinants for HIV testing uptake as well as trends in condom use .
- Going Mobile to Get Data Used: Lessons for Evaluation From the Development of Mobile Data Collection Systems
Population Services International (PSI) has implemented a number of mHealth solutions for monitoring and evaluation in order to generate more accurate, real-time data that can be applied for programmatic decision-making. Several systems have been developed and successfully scaled up in recent years. We highlight the advantages and challenges in implementing and scaling up mobile technology use. In Zimbabwe, PSI uses tablets to manage and report client records for sexual and reproductive health services provided in franchise clinics and by mobile teams. In Cameroon, an SMS-based system is used to collect weekly data on community case management and drug supplies for a large-scale child survival project. The adoption of these systems has improved the management and quality of routine monitoring data, reduced operating costs, and improved efficiency of our interventions through increased information use by program managers. Improved data will support evaluation of these programs in the future.