ZIMBABWE COUNTRY EXPERIENCE ON SRH AND HIV LINKAGES / INTEGRATION LEVERAGE BY CARMMA (Campaign for Accelerated Reduction of Maternal Mortality in Africa) PRESENTED AT ICASA Addis Ababa, Ethiopia 6 December 2011 BY Dr. Owen Mugurungi: Director AIDS and TB Unit Ministry of Health and Child Welfare – Zimbabwe 1

Outline of the Presentation Zimbabwean HIV and SRH context Rationale for SRH and HIV in Zimbabwe Brief Presentation on a Good Practice in SRH and HIV integration 2

3 Zimbabwe Total pp 12 million PLHIV: 1.1 million

Adult HIV prevalence 13.7% ANC sero-prevalence 16.1% An estimated 1,1m Zimbabweans are HIV +ve * Of these, 151, 749 are children 0-14years* New pediatric HIV infections are estimated at 14,976* (90% from MTCT) 1,090 patients dying weekly due to AIDS Source: DHS 2005/6 & MOHCW HIV estimates 2009*

Context (SRH)  Fertility rate among 15 – 19 yr olds rose from 99/1000 women in 1994 to 112/1000 in 1999, and then declined to 99/1000 women in 2005/6 (ZDHS 2005/6)  CPR increased from 38% in 1984 to 60% in 2006 (ZDHS 1988, 2005/6); latest 65% according to MIMS 2009  Unmet need for contraception is 13% (ZDHS 2005/6)  Institutional Delivery declined from 72% in 1999 to 68% in 2006 (ZDHS 1999, 2005/6) and currently stands at 61% (MIMS 2009)  ANC coverage increased from 81% in 1999 to 94% in 2006 (ZDHS 1999, 2005/6); currently 93% (MIMS 2009)  Skilled Attendance at Birth declined from 73% in 1999 to 69% in 2006 (ZDHS 1999, 2005/6), currently 60% (MIMS 2009). 5

Zimbabwe Maternal and Perinatal Mortality Study: 2007 Maternal Mortality Ratio = 725 per live births Perinatal Mortality rate = 29 per 1000 births 6 Key Causes of Maternal Deaths% AIDS Defining conditions25.5 Post Partum Haemorrhage14.4 Hypertension/Eclampsia13.1 Puerperal Sepsis7.8 Abortion complication5.8 Malaria5.8 Obstructed Labour3.3 Ectopic Pregnancy2.0 Key Causes of Perinatal Deaths% Unexplained intrauterine death 17.4 Preterm birth33.6 Intrapartum asphyxia and birth trauma 26.0 Infection3.3 Intrauterine growth restriction1.3 Antepartum haemorrhage1.5 Congenital abnormality1.6 Maternal Hypertension3.6

Integrating SRH & HIV in Zimbabwe Rationale  Achievement of universal access to RH and HIV prevention, treatment, care and support by 2015 (MDGs 4, 5 and 6)  In the spirit of CARMMA, promote and advocate for renewed and intensified implementation of the Maputo Plan of Action for Reduction of Maternal Mortality in Africa and for the attainment of MDG 5 by 2015  Growing understanding on benefits of integration of SRH and HIV programmes and services e.g.  Improved access to SRH and HIV services  Reduction in duplication of efforts  Reduced competition for scarce resources and  Greater support for dual protection 7

Progress Made Towards SRH and HIV Integration 1. Launched the CARMMA on the 30th of June 2010, under the theme “Zimbabwe Cares: No Woman Should Die While Giving Life!” – Objective: Trigger renewed national and stakeholder efforts to accelerate the availability, accessibility and utilisation of quality health services, including those related to sexual and reproductive health, critical for the reduction of maternal and neonatal mortality. 8

2. Undertook a Rapid Needs Assessment on status of SRH and HIV integration in 2010 and validated in March 2011  Obj: To assess HIV and SRH bi-directional linkages at the policy, systems, and service-delivery and community levels and identify current critical gaps in policies, programmes and services that would inform comprehensive programme on advancing SRH and HIV Linkages  Developed a workplan and mobilised resource for scale up of efforts on linkages.  Among the activities on the workplan is to increase of capacity of health care service providers to implement integrated SRH and HIV services 9 Progress Made Towards SRH and HIV Integration

The Good Practice: Integrated SRH and HIV Training The Initiative Training of health care providers in Integrated Maternal and Neonatal Care and Comprehensive PMTCT 2010 to date Purpose To equip health care service providers with the knowledge and life-saving skills in integrated maternal and neonatal care services, HIV prevention and ART to prevent MTCT.

Rationale for Training The absence of integrated training for health care workers Severe shortage of human and financial resources, has led to missed opportunities in providing comprehensive services to mothers and children and reduced the effectiveness of both MCH and HIV interventions. Parallel SRH and HIV training programmes targeting the same care provider High staff attrition for experienced personnel brought about the need for continuous training.

Objectives of the Training Update health care service providers on good ANC, labour and delivery, postpartum, and essential new- born care. Train health service providers on integrating management of pregnancy, labour, delivery, and the postpartum care and new-born with prevention of MTCT. To strengthen the monitoring and evaluation of integrated maternal, neonatal and PMTCT services by training health workers in proper completion of MCH and HIV registers.

Major Implementation Activities Collaboration between PMTCT programme within the AIDS and TB Unit and the RH Unit of the Ministry of Health and Child Welfare Merging and adaptation of selected PMTCT, HIV care, antenatal care and emergency obstetric care leading to the development of an Integrated Training manual on Maternal, Neonatal and Comprehensive PMTCT, Training of health care workers using the manual

Achievements Collaboration between the RH and AIDS/TB units in the Division of Preventive Services to develop the integrated training manual. 30 national level health service providers and 300 provincial level health service providers received training, and roll-out of training to the district level on- going. Training program has optimized use of human and financial resources and reduced diversion of health workers from service provision for training. Training enhanced the capacity of the health delivery system for integrated MNH and PMTCT services, supervision, planning and monitoring and evaluation.

Achievements cont….. Placement of a SRH and HIV linkages focal person in the Department of Preventive Services crucial in achieving the coordination between HIV and SRH programmes Advocacy and support from partners important in the initiation and implementation of training program Integrated training allowed the optimal use of limited resources and reduced diversion of health workers from their normal activities.

Challenge Operational norms and physical set-up of health facilities which have been oriented towards vertical provision of services and weak supervision systems remain challenges to be overcome.

acknowledgements Ministry of health and Child Welfare UNFPA WHO Bilateral organisations Zimbabwe National Family Planning Council National AIDS Council 17

Siyabonga Merci! Thank you! Mazvita!