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Acknowledgements

This report was prepared by the World Bank team comprised of: Marelize Gorgens (Task Team Leader), Melusi Ndhlalambi (Senior Public Health Specialist); Dr Gerald Shambira (Consultant); Chenjerai Sisimayi (Health Specialist/Consultant) and Caroline Mudondo (Consultant).

Many others from inside and outside the World Bank provided input, comments, guidance, and support at various stages of implementation and reporting. These include: Dr Mhlanga (Director for Preventive Services, Ministry of Health and Child Care [MoHCC]); Dr Zizhou (Principal Investigator, Provincial Medical Director, MoHCC); Mr Amon Mpofu (Co-Principal Investigator, Director of Monitoring and Evaluation, National AIDS Council); Dr Kudakwashe Takarinda (Co-Investigator, MoHCC); Isaac Taramusi (Co-Investigator, National Aids Council, M&E Coordinator); Ms Fatima Mhuriro (National SRH & HIV linkages Program Coordinator, MoHCC); Mr Brilliant Nkomo (Interim Strategic Information Manager, MoHCC); and Ms Farai Sekeramayi Noble (World Bank Program Assistant, Harare Country Office). CordAid and Crown Agents provided incentives payment services for the intervention component.

The Ministry of Health and Child Care and the World Bank task team would like to thank all the PHEs, DHEs and primary care facilities in the intervention districts for their participation and involvement:

DISTRICT CONTACT PERSON ALTERNATIVE MASHONALAND Sanyati Rosemary Tsitsi Banda Alexio Denhere (Acting DNO) WEST Makonde Margaret Gavara Shleen Kanyenda PROVINCE Kariba Rusia Rashamira (DNO) Stephen Siachakanzwa PMD’s OFFICE PNO Farayi Marufu Majory Manjoro MASVINGO Masvingo Margaret Gumbo Annette B Breda PROVINCE Chivi Constance Chiteure Zhou Shumbayawonda Mwenezi Henry William Mataru Esther Dube Chiredzi Zitarei Leornard Bhasera Virginia Tapererwa Gutu Shepherd Kuchicha Eddies Joe PMD’s OFFICE PNO Afra Chiwanza Miriam Washaya Timirira Zindava MASHONALAND Marondera Marian Fadzi Dembezeko Regina EAST PROVINCE Mutoko Shingirai Masunda Lucy Dadirayi Dengezi Chikomba Esnath Mugumira Sunungurai Nyanhi Wedza Lucia Murima Alice Matiza PMD’s OFFICE PNO Eunice Takura Loice Mwedziwendira MATABELELAND Umzingwane Anelia Ndlovu Tsoelopele Dube SOUTH Beitbridge Farai Samson Khosa (CHN) Taurayi Chikutye Monica Miriam Mbawa (DNO) Matobo Norman Gideon PMD’s OFFICE PNO Joyce Sibanda-Dube Mildred Senda

Special thanks to the following Provincial Medical Directors (PDMs): Dr Simukai Zizhou in Mashonaland East; Dr Amadeus Shamu in Masvingo; Dr Rudo Chikodzero in Matabeleland South and Dr Wenceslous Nyamayaro in Mashonaland West.

iii

List of Acronyms

AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy ASRH Adolescent Sexual and Reproductive Health CHN Community Health Nurse DFID Department for International Development (U.K. government) DNO District Nursing Officer HIT HIV training HIV Human Immunodeficiency Virus IUCD Intrauterine Contraceptive Device MoHCC Ministry of Health and Child Care NAC National Aids Council OI Opportunistic Infection PHC Primary Health Care PLHIV People Living with HIV PMD Provincial Medical Director PMTCT Prevention of Mother-To-Child Transmission PNO Provincial Nursing Officer RBF Results-Based Financing SOP Standard Operating Procedure SRH Sexual and Reproductive Health STI Sexually Transmitted Infection UNAIDS Joint United Nations Programme on HIV and AIDS UNFPA United Nations Population Fund VMMC Voluntary Medical Male Circumcision WHO World Health Organization

List of Figures

FIGURE 1: EXPENDITURE ON INCENTIVES. BY DISTRICT, ALL ROUNDS ...... 11 FIGURE 2: PERCENTAGE PERFORMANCE ASSESSMENT SCORES BY ROUND IN MASHONALAND EAST PROVINCE (LEFT) AND MASHONALAND WEST PROVINCE (RIGHT) ...... 12 FIGURE 3: PERCENTAGE PERFORMANCE ASSESSMENT SCORES BY ROUND IN MASVINGO PROVINCE (LEFT) AND MATEBELAND SOUTH PROVINCE (RIGHT) ...... 12 FIGURE 4: PROPORTION OF HOSPITALS WITH UP TO DATE VERSIONS OF SPECIFIC SERVICE GUIDELINES OBSERVED AS AVAILABLE DURING VISITS FOR ROUNDS 2–4 ...... 14 FIGURE 5: PROPORTION OF HOSPITALS WITH UP TO DATE VERSIONS OF SPECIFIC SERVICE GUIDELINES OBSERVED AS AVAILABLE DURING VISITS FOR ROUNDS 2–4 ...... 14 FIGURE 6: STOCK-OUTS OF RAPID HIV TEST KITS, ARVS FOR ADULTS AND CHILDREN IN THE PREVIOUS 3 MONTHS ..... 15 FIGURE 7: STOCK-OUTS OF FAMILY PLANNING COMMODITIES ...... 15 FIGURE 8: MODEL OF PROVIDING HIV TESTING AND COUNSELLING AND MODERN CONTRACEPTIVE METHODS, BY ROUND ...... 17 FIGURE 9: PROPORTION OF HOSPITALS PROVIDING “INTEGRATED” HIV-SRH SERVICES, BY ROUND ...... 18 FIGURE 10: PROPORTION OF CLIENTS WHO RECEIVED AN “INDEX SERVICE PLUS ONE” BY ROUND (PHC ONLY) ...... 18 FIGURE 11: EXTENT OF INTEGRATION BY PROVINCE BY ROUND (PHC ONLY) ...... 19

List of Tables

TABLE 1: RBF DISTRICTS (HIV-SRH TRAINING AND INTERVENTION SELECTION STATUS) ...... 5 TABLE 2: SUMMARY SCORES FOR EACH PARTICIPATING DISTRICT ...... 10 TABLE 3: USE OF INCENTIVE PAYMENTS, ALL ROUNDS AND DISTRICTS ...... 10 TABLE 4: SUMMARY OF HIV-SRH INTEGRATION CHECKLIST SCORES BY DISTRICT FOR SUPERVISION ROUNDS 1–4 ...... 11 TABLE 5: TYPE OF INTEGRATION AMONG PHC FACILITIES, BY ROUND ...... 16 TABLE 6: TYPE OF INTEGRATION AMONG HOSPITALS, BY ROUND ...... 17 TABLE 7: INDICATORS OF HIV-SRH INTEGRATION AMONG HOSPITALS BY ROUND ...... 19

Table of Contents ACKNOWLEDGEMENTS ...... III LIST OF ACRONYMS ...... IV LIST OF FIGURES ...... V LIST OF TABLES ...... VI EXECUTIVE SUMMARY ...... 1 1. INTRODUCTION AND BACKGROUND ...... 4 2. IMPLEMENTATION ARRANGEMENTS ...... 7 2.1 SUPERVISION CHECKLISTS ...... 7 2.2 TRAINING AND ORIENTATION WORKSHOPS ...... 7 2.3 IMPLEMENTATION ARRANGEMENTS AND COORDINATION ...... 7 2.4 IMPLEMENTATION CHALLENGES ...... 8 3. RESULTS FOR 4 ROUNDS OF SUPERVISION ...... 10 3.1 ALLOCATION AND USE OF FINANCIAL INCENTIVES FOR HIV-SRH ...... 10 3.2 SUMMARY OF SUPERVISION SCORES BY DISTRICT ...... 11 3.3 AVAILABILITY OF SRH SERVICES IN HIV SERVICE DELIVERY POINTS BY DISTRICT ...... 13 3.4 AVAILABILITY OF ESSENTIAL SRH SERVICES AT HOSPITALS ...... 13 3.5 AVAILABILITY OF SERVICE GUIDELINES ON INTEGRATED HIV/SRH BY SERVICE DELIVERY POINT ...... 13 3.6 MEDICINES AND CONSUMABLES ...... 14 3.7 REFERRALS ...... 15 3.8 HUMAN RESOURCES TRAINING AND SUPERVISION ON HIV-SRH ...... 16 3.9 SERVICE DELIVERY/MODEL OF INTEGRATION ...... 16 3.10 HIV/SRH SERVICE INTEGRATION INDICATORS ...... 18 4. LESSONS AND RECOMMENDATIONS ...... 20 5. CONCLUSION ...... 21 6. APPENDICES ...... 22 6.1 APPENDIX 1: LIST OF PARTICIPATING PROVINCES, DISTRICTS AND FACILITIES ...... 22 6.2 APPENDIX 2: SUPERVISION TOOL FOR INTEGRATED SRH/HIV SERVICES IN ZIMBABWE (PHC) ...... 25 6.3 APPENDIX 3: SUPERVISION TOOL FOR INTEGRATED SRH/HIV SERVICES IN ZIMBABWE ...... 33 6.4 APPENDIX 4: WINNING DISTRICTS SCORES AND INCENTIVES PAID ...... 55 6.5 APPENDIX 5: SUPPORT SUPERVISION SCORES FOR 4 ROUNDS BY DISTRICT ...... 56

vii

Executive Summary

Introduction and Background

For the past decade or so, integration of sexual and reproductive health (SRH) and human immunodeficiency virus (HIV) services has received widespread support by international and national health development agencies. The Glion Call to Action of May 20041 outlined the need for linkage between family planning and prevention of mother-to-child HIV transmission (PMTCT) services. This resulted in a call by the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) for increased linkages between SRH and HIV services to improve access to contraceptive methods and prevent HIV infection in women and children. Since 2014, there has been an international policy shift in support of integrating SRH and HIV services, and several sub- Saharan countries, including Botswana, Ethiopia, Kenya, South Africa, Zambia, and Zimbabwe prioritized integration in their national HIV strategic plans.

In Zimbabwe, the Ministry of Health and Child Care (MoHCC) commissioned a Rapid Assessment which resulted in the government launching national integrated SRH and HIV service delivery guidelines in 2010. The national guidelines outlined the minimum package of services to be provided at all levels of the health system. The guidelines were based on the need to: (1) offer comprehensive (integrated) SRH and HIV services with clear facilitated referral pathways (intra-provider, intra- facility, and inter-facility); and (2) thereby maximizing collective outcomes.

Integration of HIV and reproductive health services in Zimbabwe

The World Bank and other partners have been supporting specific activities in Zimbabwe as part of a broader roll-out of the national HIV-SRH integration framework. Since September 2012, the MoHCC, with support from UNFPA and the World Bank launched an impact evaluation entitled, “Estimating the efficiency gains made through the integration of HIV and sexual reproductive health services in Zimbabwe.” The evaluation question is, “Does integrating HIV and SRH services save money without decreasing the quality of patient care?” The objectives of the Impact evaluation are to: a) Assess whether the government’s programme on SRH and HIV services has led to increases in integration in service provision; b) Determine barriers and facilitators for integration; c) Measure the impact of integration on total cost attributable to selected SRH and HIV services; and d) Measure the impact of integration on the quality of service provision as defined by multiple matrices including client satisfaction and healthcare provider experience.

The approach for integration involved is: (1) Completion of HIV-SRH training2 in all districts; and (2) implement incentivized supportive supervision in 50% of baseline districts, randomly selected.

1 Glion Call to Action (mat 2004). http://www.unfpa.org/resources/glion-call-action-family-planning-and-hivaids-women-and-children (accessed 09 January 2017) 2 DNOs received training but are not responsible for service delivery. There were no programs to roll out the training to services providers at PHC level, therefore most training the service providers received on the job training during Enhanced Supportive Supervision. Other trained DNOs changed stations and since there was no roll out of training, remaining cadres did not have sufficient training on SRH/HIV Linkages. Trained personnel at DHs may not be fully using the skills they received from the training due to department rotation.

The baseline survey established that there was a lack of natural endogenous integration of SRH and HIV services. Also, the training on HIV-SRH integration undertaken by MoHCC was incomplete and not done with health staff from all facilities.

This led to a decision by the Ministry of Health and Child Care, in collaboration with the National AIDS Council (NAC) and the World Bank, to (1) complete training with health staff from health facilities in all 31 study districts that were part of baseline3, and (2) to implement a random promotion/encouragement effort by implementing integration-focused supportive supervision intervention with incentives that would provide an exogenous stimulation of HIV-SRH integration in half of the 31 districts where baseline data were collected, randomly selected. The integration- focused and incentive-based supervision intervention provided incentives for the best and most improved district in every round in order to encourage the health staff in the 15 intervention districts to improve their integration efforts.

The MoHCC took a specific decision to not incorporate these tools into the Results-Based Financing (RBF) quality improvement tools until these tools have been tested and proven through this impact evaluation, using the quality improvement checklists developed for this intervention. As the table below indicates, some of the districts involved in this study were RBF districts at the time randomization was done, while others were not. This allowed for comparison of impact of the use of the checklists across RBF and non-RBF districts. It is worth noting that since there was not equal participation in RBF by all health facilities, this could have been a confounder. There will be a need to analyse performance of facilities in the RBF and compared to facilities not participating in the RBF program.

Results: Integration-focused Supportive Supervision with Incentives

A total of 4 (out of 5) planned supervision rounds were implemented between July 2016 and December 2017 and produced the following key results, based on the findings derived from the checklists used in each round: a) “Intra-facility” and “intra-provider” integration approaches became the most common integration models. Facilities offered HIV-SRH integrated services in all rounds. Hospitals increasingly used an “intra-facility integration” model, with multiple services provided by different health care workers at a single location on a single day (94% of hospitals by round 4). Among primary care facilities there was a shift in rounds 3 and 4 from “intra-facility” integration to “intra-provider” integration, meaning that a single health care worker provided multiple services. There was wide variation in the reported proportion of staff “trained” in providing integrated HIV-SRH services, with a median of 33.50% based on self- reported response from the person in-charge.4 b) Integration of service delivery showed a modest increase. The supervisors reported that a modest increase was observed in integration of services in the treatment districts over time.

3 In 2014, the study team took note of the fact that due to a lack of funds, MoHCC did not complete the training of health service providers in implementing the new HIV-SRH guidelines. To provide a common basis for the evaluation, it was therefore agreed that three- day trainings in HIV-SRH integration would be held with health service providers from 18 previously-untrained intervention and control districts. The target for training was at least 35 participants from each district and 5 people from each district hospital. 4 The revised HIV training (HIT) manual has a module on SRH and HIV linkages so providers that received training on since 2015 have also received a component of SRH and HIV linkages. HIT Trainers received TOT on SRH and HIV in December 2014. The new ASRH (Adolescent Sexual and Reproductive Health) manual has a chapter on integrated linkages and providers who attended the training in ASRH also gone through SRH and HIV linkages.

However, this change cannot be ascribed to the intervention because levels of change in the counterfactual districts for similar data was not measured using the index. c) Variations were observed in the availability of SRH and HIV services, medicines, and commodities. While most services were available at most facilities throughout the intervention period, provision of psychosocial support for PLHIV (People Living with HIV) was a new service not previously provided. Although few hospitals reported providing it in round 1, the rate increased to 56% by round 2 and to 83% by round 4. On the other hand, reporting on stock-outs of medicines and commodities presented a more mixed picture, with a trend towards reduced (or eliminated) stock-outs for key family planning commodities and HIV rapid test kits, while stock-outs of paediatric ARVs at hospitals increased from 6.9% in round 3 to 16.7% in round 4.

It should be noted that this report is only one component of the overall impact evaluation. The results reported here only covers supervisor observations during supportive supervision visits to the treatment districts and should be interpreted alongside the baseline and endline results of the evaluation. The baseline and endline results of the study have been summarized in the final evaluation report entitled XXX, available here: XXXX [insert OKR link once evaluation report is finalised].

1. Introduction and Background

In 2010, the Ministry of Health and Child Care (MoHCC) in Zimbabwe launched national guidelines on the integration of SRH and HIV that outlined the types of integration possible and the ways in which HIV-SRH integration could be improved.

The process of rolling out the new integration guidelines was envisaged to strengthen three types of HIV-SRH integrated service delivery: a) Intra-provider integration: On-site integrated HIV-SRH service delivery (“one-stop shopping”) in which comprehensive services are provided at one location—usually by one provider, in the same room, and at the same visit. b) Intra-facility integration: The “supermarket approach” in which HIV-SRH services are offered by several providers in different rooms at the same facility during one visit to the facility c) Inter-facility integration: Selected SRH and/or HIV service delivery is offered outside the facility with facilitated linkages and referrals. This might be necessary for services that cannot be provided at a single location.

Before the government of Zimbabwe began rolling out HIV-SRH integration service guidelines and training of health care workers on HIV-SRH linkages, the following question needed to be addressed: “Does integrating HIV and SRH services save money without decreasing the quality of patient care”? The World Bank was requested to support the government to undertake an impact evaluation to answer this question.

At its inception, this impact evaluation was designed as a difference-in-difference quasi- experimental design with data collection at two points in time (baseline and endline). Each facility, at every point of data collection, would be assigned an integration score and the costs of services at those facilities would be determined—the hypothesis being that the facilities with the largest changes in their integration scores would see the largest reductions in the costs of delivering services. This design was dependent on there being natural temporal variation in changes in integration scores.

Baseline data were collected between October 2014 and March 2015 within 190 facilities5 in four randomly selected provinces. In 2014, after the baseline data collection effort, it was noted that there was a lack of natural variation in integration of SRH and HIV services. It was also noted that in 2014, the impact evaluation team noticed that due to a lack of funds, the MoHCC did not complete the training of health service providers in implementing the new HIV-SRH guidelines. To provide a common basis for the evaluation, it was therefore agreed that three-day trainings in HIV-SRH integration would be held with health service providers from 18 previously-untrained intervention and control districts. The target for training was at least 35 participants from each district and five people from each district hospital.

The lack of exogenous variation in integration practices also led to a decision by the MoHCC to bolster the evaluation by implementing an intervention to exogenously stimulate integration in 15 randomly selected districts across the four provinces in which baseline data were collected. The following districts were randomly selected to receive this intervention in provinces outlined in the

5 These included 31 district hospitals, 4 provincial hospitals, 6 central hospitals, 149 primary care facilities (urban and rural) and 1 family planning clinic in Matebeland South, Mashonaland West, Masvingo, 4 table below and in the randomization, balance was achieved in terms of previously trained and untrained districts, and districts that were part of Results-Based Financing (RBF).

Table 1: RBF Districts (HIV-SRH Training and Intervention Selection Status) Integration training? RBF district at the time that HIV-SRH impact District name (March to Nov 2014) randomization was done evaluation Zvimba Yes Yes Control Seke Yes Yes Control Insiza Yes Yes Control Hurungwe Yes Yes Control Mudzi Yes Yes Control UMP Yes Yes Control Bikita Yes Yes Control Chegutu Control Goromonzi Control Gwanda Control Murehwa Control Zaka Yes Control Bulilima-Mangwe (combined district as only one DH) Yes Control TOTALS in control districts 7 9 13 Beitbridge Yes Yes Intervention Chivi Yes Yes Intervention Umzingwane Yes Yes Intervention Gutu Yes Yes Intervention Kariba Yes Yes Intervention Marondera Yes Intervention Matopo Yes Intervention Masvingo Yes Yes Intervention Mutoko Yes Yes Intervention Chiredzi Yes Intervention Hwedza (Wedza) Intervention Mwenezi Yes Intervention Chikomba Yes Intervention Makonde Intervention Sanyati-Mhondoro-Ngezi combined district (old Kadoma district) Yes Intervention TOTALS in intervention districts 9 11 15

The intervention was built around the concept of integration-focused supportive supervision with incentives. As such, the intervention designed and conducted integration-focused supportive supervision visits at all levels (national, provincial and district levels) during each of four rounds. To foster commitment and motivation to integrate services, a financial incentive was paid to a winning district (i.e. with the highest score and with the most improved score) in each province on a per- round basis. The incentive money was then invested in activities that would enhance integration of services (e.g., supplies, equipment, human resources incentives, and infrastructure improvements) as per how the districts decided to use the incentive funds. Ethics approval was granted for this change. The organization serving as incentives administration service provider was changed from CordAid to Crown Agents partway through the intervention.

The performance assessment for each facility was based on a standard checklist administered at facility level by district and provincial teams. Later (in rounds 3 and 4), the incentives structure was modified to include a second category of the most improved district (i.e., the district with the biggest positive improvement (difference) in scores between the previous and current round assessments). The scoring was weighted such that the primary care facilities contributed 70% to the total district score while the district hospital contributed 30%. Another important aim of the intervention was to study the usefulness of the checklists through this impact evaluation and to determine if they should be integrated into the pre-existing checklists used in the RBF process already in operation in a number of the districts.

In the end, a total of 4 (out of 5) planned supervision rounds were conducted between July 2016 and December 2017, and the incentive mechanism was implemented in each round. This report documents the implementation, discusses challenges faced, and shares some recommendations for future interventions on implementing supportive supervision with incentives for integration of SRH and HIV services in Zimbabwe.

2. Implementation Arrangements 2.1 Supervision Checklists

Integration-focused supportive supervision visits were conducted using checklists developed for the purpose – one for PHCs and one for district hospitals (the checklists are in appendices 2 and 3). The checklists were adapted from the UNFPA-supported programme and pre-tested at Kadoma District Hospital. In addition, an independent organization was selected to serve as the administrating body for the incentive component of the intervention.

2.2 Training and Orientation Workshops

District and provincial supervision teams were trained on how to administer the supervision checklist tool. A three-day orientation workshop on integration-focused supportive supervision with incentives was conducted with district and provincial health officers including District Nursing Officers, Community Health Nurses, Reproductive Health Officers, and Provincial Nursing Officers. The workshop covered several key topics including HIV-SRH integration, performance indicators for integration, standard operating procedures (SOPs), and supportive supervision checklists.

2.3 Implementation Arrangements and Coordination

The Ministry of Health and Child Care provided overall coordination of the planning and implementation phases of the intervention. The World Bank, the Joint United Nations Programme on HIV and AIDS (UNAIDS), and UNFPA provided technical support of the intervention design, and the development of tools and training. At the district level, the District Nursing Officer (DNO) worked closely with the Community Health Nurse and the Reproductive Health Nurse to plan and execute supervision visits to intervention primary health care (PHC) facilities. At provincial level, the intervention was done by a team led by the Provincial Nursing Officer (PNO) who worked as a liaison and coordinated planning and implementation of supervision visits. Visits were also made by national level personnel to two randomly selected districts per province per round.

How scores were compiled: For each visit, the facilities were scored on these domains and a total percentage scored calculated. The scores were then weighted (70% weighting to primary care facilities, 30% weighting to the district hospital).

How winning districts were notified: Within two weeks of compilation of district scores for each round, the national HIV-SRH linkages coordinator at the MoHCC head office informed the province of the winning district and the incentive amount. Communication was sent through the Provincial Medical Director (PMD), copying the PNO and the District Medical Officer. The PMD reserved the right to choose how to inform the winning district – whether by letter or at a meeting of all districts. Irrespective of how the winning district was informed, all the districts in the province were informed of the winning and most improved district for that round and also of the scores of all participating districts.

What funds could be used for: Districts were not allowed to spend more than 25% on staff incentives. (See appendix 4 for detailed guidelines for how funds could be used.) The districts awarded the financial incentive were to submit a budget and work plan using a stipulated guideline to the HIV-SRH linkages coordinator via the Provincial nursing officer. The World Bank reviewed the submitted plans and budgets, issued approvals of the plans, and provided an instruction to its vendor to transfer funds. The District Nursing Officer was responsible for documentation and submission of acquittals of the incentives paid to the payment vendor. 7

It is important for interventions like this to ensure that coordination and communication among various stakeholders is managed at all levels. The programme appointed a focal person (often the Reproductive Health Officer or District Nursing Officer) to be the point person to communicate with the provincial and national offices as well as with facilities and the incentive administration service provider. Districts with active coordinators experienced only limited challenges with communications and transmission of checklists.

2.4 Implementation Challenges

Several implementation challenges and bottlenecks occurred.

First, the period allocated for intervention implementation was deemed too short to complete all five planned rounds. The activity started midway of the impact evaluation and the fifth supervision round could not be completed due to cumulative delays in submission, approval, and execution of supervision visits as well as submission of completed checklists. In addition, due to competing programs, it was felt that there was inadequate time to complete all four rounds which resulted in inability to conduct 3 rounds as planned in 2017 because the DNOs could not adhere to the stipulated dates.

The shortage of human resources and inadequate training meant that not every service provider at PHC levels was trained by district management; the same people conducting SRH/HIV integration are responsible for other programs that require them to travel as well.

Second, some components of the intervention process often took longer than anticipated. For example, completed checklists and work plans were often submitted late, and, in some cases, were not submitted at all. This was due to several factors, particularly competing tasks assigned by MoHCC and connectivity challenges involved in transmitting the long checklists. One of these competing activities was the national biometric voter registration process. The MoHCC teams in Mashonaland West and Masvingo and Matabeleland South Provinces responsible for implementing the intervention (i.e. carrying out the supervision) were temporarily hired to help with the national biometric voter registration process. The unavailability of these officials caused delays with the intervention implementation process. This delayed the submission of checklists and financial acquittals. Where district checklists were sent to the provincial office, they would often spend weeks before there was transport to Harare. Courier service (FedEx) which was introduced to expedite submissions was not available in some provinces or, when available, pick up times were not arranged successfully.

With significant number of officials acting, the national MoHCC HIV-SRH Integration Coordinator spent a lot of time following up on work plans and budgets from these acting officials who often did not have details of the intervention. Related to this challenge, the incentives administration service provider (i.e., Crown Agents) had to resort to using its field teams in these districts to follow up with districts to get documents for payment of allowances and incentives.

Third, MoHCC arranged transport to conduct visits was sometimes hindered by inadequate equipment and resources (e.g. vehicles). Teams would receive the fuel vouchers but would have to wait for weeks until a vehicle could be available for their use.

Fourth, the supervision tool was rather long and laborious; it also had some duplicative details. The tool needs to be simplified, shortened, and incorporated into other MoHCC supervision tools. A decision was made to not incorporate these tools into the Results-Based Financing (RBF) quality improvement tools until they were tested and proven under this impact evaluation. 8

Fifth, switching the vendor (from CordAid to Crown Agents) for the administration of supervision field allowances and incentives to winning districts created some implementation delays (about three weeks), and visits had to be suspended until the new service provider was hired.

Sixth, in the preparation of this report, it was reported by one person in MoHCC that some partners felt left out in planning and implementation of the intervention.

Seventh, the role of NAC and MoHCC in planning national supervision visits and convening and attending meetings was also noted as an area that needed clarification in advance to avoid role conflict.

Eighth, assessment and scoring of the supervision tool was done by the local district teams within their own districts. This had the potential to influence objectivity in scoring each facility’s performance since each province scored the facilities in its districts. Staff in a given facility did not score their own facility. Instead, provincial-level staff scored district-level facilities. While this can be an empowering approach for provincial-level team members, it carries a significant degree of risk with respect to reliability of score as pre-existing relationships could have influenced assessments. This potential bias was partially mitigated by using provincial supervision checklists for verification purposes.

3. Results for 4 Rounds of Supervision

3.1 Allocation and Use of Financial Incentives for HIV-SRH The financial incentive in each round for the winning and most improved district(s) in each province enabled district teams to focus on delivering on SRH-HIV integration indicators and to procure essential supplies, consumables, equipment, and infrastructural renovations that enhanced implementation of integration guidelines (Table 2).

Table 2: Summary scores for each participating district Province Round 1 Round 2 Round 3 Round 4 District District District with with most District with Highest with most Highest improved Highest most scoring most Highest improved scoring score (R3- scoring improved district improved scoring score (R2-R1 district R2 score) district score (R4- (%) score district (%) score) % (%) % (%) R3 score) % Mashonaland Hwedza N/A Chikomba Chikomba Chikomba Mutoko Chikomba Marondera East 83.2 90.3 8.4 93.2 11.6 94.2 1.51 Mashonaland Sanyati N/A Sanyati Kariba Sanyati Kariba Sanyati Sanyati West 79.9 81.3 5.4 84 4.7 90.1 6.11 Chivi N/A Chivi Chivi Gutu Chiredzi Chivi Masvingo Masvingo 84.3 92.7 8.4 94.1 11.7 94.33 5.84 Matabeleland Matobo N/A Umzingwane Umzingwane Beitbridge Beitbridge Beitbridge Matobo South 75 92 22 88.9 17.1 91.2 6.01

Table 3 below shows the use of payments in all rounds and districts. A total of US92,000 was disbursed to 13 districts. Districts hospitals received about US$31,824 (35%), while PHCs received US$42,971 (47%). A total of US$17,205 (19%) was used for district-wide unallocated expenditure. About US$20,790 (23%) was used for staff incentives, whereas US$71,210 (77%) was used for other expenditures including supplies, consumables, and equipment.

Table 3: Use of Incentive Payments, All Rounds and Districts Allocated For % of Allocated To Staff Incentive Other Expenditure Total Total District Hospital 7,985 23,840 $31,824 35% Primary Healthcare Facility 11,930 31,040 $42,971 47% District-Wide Unallocated 875 16,330 $17,205 19% Total $20,790 $71,210 $92,000 Percentage of Total 23% 77%

The financial incentives had two notable impacts. First, they supported efforts to deliver on HIV-SRH integration indicators. They also allowed for the procurement of essential supplies, consumables, equipment, and infrastructural renovations that focused on integrated implementation of national guidelines. Figure 1 below shows the proportions of expenditures of incentive financing on staff and other expenses, by district and over all rounds.

Figure 1: Expenditure on Incentives. By district, all rounds

100% 90% 80% 70% 69% 75% 75% 75% 75% 75% 75% 75% 75% 75% 60% 82% 79% 89% 50% 40% 30% 20% 32% 25% 25% 25% 25% 25% 25% 25% 25% 25% 10% 18% 21% 11% 0% Percentage Percentage of Incentive Payment Budgeted(USD)

District Staff Incentive Other

3.2 Summary of supervision scores by district

Out of the 15 districts targeted for intervention, 13 completed four rounds of integration-focused supportive supervision with incentives. Masvingo and Matopo districts did not conduct the second and third rounds of visits, respectively. Table 4 below shows the overall district percentage scores over the 4 rounds of the intervention. As can be seen from Figure 2 and Figure 3,several districts were either double winners (most improved and highest scoring) and others were consistently the highest scorers or most improved. Since performance scores were published to all facilities, there was reported competition among certain districts for top spots.

Details of facility level scores are attached in Appendix 5.

Table 4: Summary of HIV-SRH integration checklist scores by district for supervision rounds 1–4 Province District Round 1 Round 2 Round 3 Round 4 Mashonaland Chikomba 81.93 90.31 93.23 94.24 East Hwedza 83.24 78.99 88.91 81.59 Marondera 76.09 80.65 87.73 89.24 Mutoko 77.89 78.63 90.20 90.14 Mashonaland Makonde 78.97 77.43 80.46 84.26 West Sanyati and Kadoma (combined 79.88 81.29 84.03 90.14 district) Kariba 67.21 72.59 77.26 71.71 Masvingo Masvingo 73.63 Missing 78.88 84.72 Gutu 81.81 86.84 94.08 93.45 Chiredzi 67.98 75.96 87.70 89.57 Mwenezi 68.91 76.09 82.15 85.74 Chivi 84.13 92.69 90.91 94.33 Matabeleland Umzingwane 69.92 91.96 83.68 88.13 South Beitbridge 74.52 71.83 88.93 91.24 Matobo 75.10 79.96 75.60 81.61

Figure 2: Percentage performance assessment scores by round in Mashonaland East Province (left) and Mashonaland West Province (right)

100 100 90 90 80 80

70 70

60 60

score 50 50 score

40 40

30 30

20 20

10 10

0 0 1 2 3 4 1 2 3 4 Chikomba Hwedza Makonde Sanyati Kariba Marondera Mutoko

Figure 3: Percentage performance assessment scores by round in Masvingo Province (left) and Matebeland South Province (right)

100 100 90 90 80 80 70 70 60 60 50 50 score score 40 40 30 30 20 20 10 10 0 0 1 2 3 4 1 2 3 4 Gutu Chiredzi Mwenezi Chivi Umzingwane Beitbridge Matobo

3.3 Availability of SRH Services in HIV service delivery points by district

The following HIV services were almost universally available among hospitals: a) HIV counselling and testing services b) Pre-ART and ART (Anti-retroviral treatment) for PLHIV c) Post-exposure prophylaxis

Fewer hospitals reported providing psychosocial support for PLHIV. However there appeared to be an increase over the last 3 rounds of visits from 55.6% (round 2) to 83.3% (round 4).

All primary care facilities were offering HIV counselling and testing services during the period of the intervention. The majority (>95%) were providing pre-ART and ART for PLHIV. All except one facility in Masvingo offered family planning/modern contraceptives other than condoms.

3.4 Availability of essential SRH services at hospitals

Family planning services were available throughout the period of the intervention except for mission hospitals which do not routinely provide these services. Relatively fewer facilities offered pregnancy testing. There was a wide variance in prevention and management of gender-based violence, with fewer facilities in Chiredzi (26%) offering this service compared to percentages for the facilities in Makonde and Matobo districts.

3.5 Availability of Service Guidelines on integrated HIV/SRH by service delivery point

Among the hospitals there appeared to be an improvement in the availability of service guidelines on integrating SRH and HIV programmes and services from round 2 (66.7%) to round 4 (94.4%). A similar trend was also observed concerning the availability of cue cards, which clinical staff use to assist in providing a minimum package of HIV and SRH integrated services. The percentage rates for the availability of key HIV and SRH at the actual service delivery areas in a facility also followed a similar pattern.

Figure 4: Proportion of hospitals with up to date versions of specific service guidelines observed as available during visits for rounds 2–4 AVAILABILITY OF SERVICE GUIDELINES (Q1 TO 4)

100 90 80 70 60 50

PERCENTAGE 40 30 20 10 0 Round 2 (%) Round 3 (%) Round 4 (%) Family planning 31 41.4 88.9 HIV (ART, HTS, PMTCT,PEP) 82.2 93.1 100 SRH guidelines 60 86 94.4 EMOC 26.7 48.3 83.3 Infection control 46.7 62.1 88.9

The availability of service guidelines fluctuated in three out of the four provinces. On the other hand, Mashonaland East province recorded a sustained increase in the availability of these guidelines. Matopo District in Matabeleland South did not undertake round 3 visits.

Figure 5: Proportion of hospitals with up to date versions of specific service guidelines observed as available during visits for rounds 2–4 100 90 80 70 60 % 50 40 30 20 10 - Mashonaland East Mashonaland West Masvingo Matabeleland South

Round 1 Round 2 Round 3 Round 4

3.6 Medicines and Consumables

Stock-outs of key medicines and consumables may be used as a proxy indicator of integration of services. No stock-outs of HIV rapid test kits were reported in the 3 months prior to the round 4 14 visits. It is worth noting that among the hospitals, 16.7% reported a stock-out of paediatric ARVs in the 3 months prior to the round 4 visits, up from 6.9% in round 3.

Figure 6: Stock-outs of Rapid HIV test kits, ARVs for adults and children in the previous 3 months 18 16 14 12 10 % 8 6 4 2 0 Round 2 Round 3 Round 4

HIV test kits ARV adult ARV Child

As shown in Figure 7 below, there was an observed decline in stock-outs from round 2 to 4. No stock-outs of male condoms were reported in round 4. However, it is noteworthy that, while stock- outs of key family planning commodities such as the combined pill and injectables declined, there were still reported stock-outs in about one-third of the hospitals even as of round 4.

Figure 7: Stock-outs of Family Planning Commodities 40 35 30 25

% 20 15 10 5 0 Round 2 Round 3 Round 4

Combined Pill Male Condom Injectable

3.7 Referrals

The availability and use of standard referral forms that could be used for clients seeking HIV, STI (Sexually Transmitted Infection), maternity, cervical cancer screening, VMMC (Voluntary Medical Male Circumcision), and other services ensures effective and efficient client referrals and feedback among service providers. The availability of standard referral forms appeared to increase over the 15 period of the intervention—from 55.6% in round 2 visits to 88.9% in round 4. The majority (>80%) of facilities reported that they had a record keeping system to keep track of referrals, but this was not objectively observed.

3.8 Human Resources Training and Supervision on HIV-SRH

The intervention examined the proportion of staff members trained on providing integrated HIV-SRH services by facility. There was wide variation in the reported proportion of staff “trained” in providing integrated HIV-SRH services. The most commonly reported proportion was that half the staff had been trained. There was no notable change by the end of the intervention in the proportion reported as “trained.”

Integration-focused supportive supervision visits to hospitals in each round noted the availability of the minutes of meetings that included SRH and HIV integration in the previous round. The proportion of hospitals reporting holding these meetings rose from 57.8% in round 2 to 72.2% in round 4.

3.9 Service Delivery/Model of Integration

Supervisors who conducted the supervision visits observed how the PHC offered SRH-HIV integrated services in that round. The most common model of integration was “intra-facility integration” in which services were provided at same location by different health care workers on the same day. Overall, 94% of the PHCs practiced this model of integration. There was a notable increase in the proportion of hospitals practicing “intra-provider integration” in the third and fourth rounds of the intervention.

Table 5: Type of integration among PHC facilities, by round R1 (%) R2 (%) R3 (%) R4 (%) Type of integration Provided at the same location by the 0 0 6.9 16.7 same healthcare worker on the same day (intra-provider integration) Provided at the same location by the 0 2.2 6.9 0 same healthcare worker on a different day (intra-facility integration) Provided at the same location by 0 97.8 86.2 83.3 different healthcare workers on the same day (intra-facility integration) Provided at the same location by a 0 0 0 0 different healthcare worker on a different day (intra-facility integration) Referred to a different service 0 0 0 0 delivery point within the same facility (intra-facility integration) Referred to a separate facility (inter- 0 0 0 0 facility integration)

Table 6 shows that the most commonly used model of integration at hospital level is “intra-facility” but provided on different days. This implies that the client must return for other services on a day other than the day of their original visit to the hospital. A slight improvement was noted in that the

16 proportion of hospitals referring clients to a different service delivery point declined from 6.3% in round 1 to zero in round 4. The decline in referrals to a different delivery point is consistent with the result that clients reported receiving the index service plus one service at hospital level. The results in Table 6 also indicate declines in all areas except services provided at the same location by a different healthcare worker on a different day, which increased from round 1 through round 3 but then declined to a lower level than in round 4.

Table 6: Type of integration among hospitals, by round R1(%) R2(%) R3(%) R4(%) Type of integration Provided at the same location by the same healthcare worker on the 3.1 2.2 0 0 same day (intra-provider integration) Provided at the same location by the same healthcare worker on a 6.3 4.4 3.5 0 different day (intra-facility integration) Provided at the same location by different healthcare workers on the 18.8 13.3 13.8 11.1 same day (intra-facility integration) Provided at the same location by a different healthcare worker on a 65.6 75.6 79.3 61.1 different day (intra-facility integration) Referred to a different service delivery point within the same facility 6.3 4.4 0 0 (intra-facility integration) Referred to a separate facility (inter-facility integration) 0 0 0 0

Primary care facilities were assessed on how they provided HIV counselling and testing and modern contraceptives as an indicator of the type of integration used by that facility. There appears to have been a shift in rounds 3 and 4 from “intra-facility” integration to “intra-provider” integration. This is illustrated in Figure 8 below.

Figure 8: Model of providing HIV testing and counselling and modern contraceptive methods, by round 100 90 80 70 61.9 60 54.1 54.7 51.6 % 50 44.7 45.3 43.5 38 40 30 20 10

0 samelocation,different samelocation,same samelocation,different samelocation,same samelocation,different samelocation,same samelocation,different samelocation,same healthworker healthworker healthworker healthworker healthworker healthworker healthworker healthworker

Round 1 Round 2 Round 3 Round 4

In the analysis, a cut-off point of 200/275 (72%) was used to define a hospital as providing integrated services. Using this definition there was an increase in the proportion of hospitals that were classified as integrated from 34.4% in round 1 to 100% in round 4 (Figure 9 below).

Figure 9: Proportion of hospitals providing “integrated” HIV-SRH services, by round 100 100 90 80 75.9 70 60 53.3 % 50 40 34.4 30 20 10 0 Round 1 Round 2 Round 3 Round 4

The mean scores among the primary facilities had a relatively wide range: varying from 70.6% in Kariba to 91.2 % in Hwedza. There was also some variation within the same province, for example in Masvingo where primary care facilities in Chivi had a mean score of 90.4% compared to 78.4% in Mwenezi.

All primary care facilities were offering HIV counselling and testing services during the period of intervention. The majority (>95%) were provided pre-ART and ART for people living with HIV. All facilities except one in Masvingo offered family planning/modern contraceptives other than condoms. Relatively fewer facilities offered pregnancy testing. There was a wide variance in prevention and management of gender-based violence, with fewer facilities in Chiredzi (26%) offering this service compared to the facilities in Makonde and Matobo districts.

3.10 HIV/SRH service integration indicators

Figure 10: Proportion of clients who received an “index service plus one” by round (PHC only) 100.00 81.20 83.60 80.00 74.50 62.80 60.00 % 40.00

20.00

- ROUND 1 ROUND 2 ROUND 3 ROUND 4

Facility records at primary care facilities were assessed on the percentage of clients who received an index service plus any other appropriate SRH/HIV service. There was an overall increase in the proportion of clients who received an “index service plus one” from 62.8% in round 1 to 83.6% in round 4.

Figure 11 below shows that there were differences by province in the extent of integration as well as the changes over the period of the intervention. This could reflect differences in the reach, adoption, and implementation of integrated-focused supportive supervision with incentives by the provinces.

Figure 11: Extent of Integration by Province by Round (PHC Only) 100

60 % 40

0 Round 1 Round 2 Round 3 Round 4

Mashonaland East Mashonaland West Masvingo Matabeleland South

Several indicators were assessed at hospitals during the integration-focused supportive supervision visits. There was a notable increase in the services reported as having been provided in an integrated way. The proportion of patients who received an index service plus any other appropriate SRH/ HIV service during their visit to the hospital increased from 70% in round 1 to 94% in round 4 (Table 7). This trend is also observed among other indicators that monitored provision of family planning services in the context of opportunistic infections and ART (OI/ART).

Table 7: Indicators of HIV-SRH integration among hospitals by round R1 R2 R3 R4 Indicator Mean Score Mean Mean Mean %, Standard Score %, Score %, Score %, Deviation SD SD SD (SD) Percentage of clients who receive an index 70±28.2 76±19.2 87.2± 19.8 94± 11 service plus any other appropriate SRH/ HIV service during their visit to the facility district hospital Percentage of Service Delivery Points offering 4 70±14.1 85±18.4 87±14.6 92±14.2 or more SRH and HIV services among hospitals Percentage of OI/ART Service Delivery Points 65.0±21.2 74.8± 28.8 83.4±72.4 87.3± 16.0 offering family planning services including information and referrals Percentage of Service Delivery Points offering a missing 72.8±24.1 84.4±24.2 87.3±14.0 minimum package of sexual and gender-based violence management services (i.e., STI treatment, HIV counselling & testing, post- exposure prophylaxis, counselling and emergency contraception services) for clients/ victims Proportion of Service Delivery Points offering 65±21 68.6±27.1 82.6±29.3 92.2±11.6 SRH and HIV services including screening and counselling services for any of the most common cancers of the reproductive system (cervical cancer, breast cancer, prostate cancer)

4. Lessons and Recommendations

The intervention report received collective feedback and validation from facility, district, province and national level stakeholders, and the following lessons and recommendations were made: a) Timely disbursement of incentives to winning districts is essential to keep staff motivated. b) There is a need for flexible arrangements to accommodate special districts such as Chiredzi c) and Makonde which are vast and do not permit supervision trips to selected clinics in one visit. d) Hospital service providers should receive their own training separately or need to increase the number of representatives. Additionally, hospitals are encouraged to set aside time for the trained personnel to train their colleagues on skills they would have received. e) Districts and funding partners to set aside funds for rolling out training to service providers at PHC level. f) There is need to build more structures to increase space for integrated services. g) There is need for a systematic approach for acquittals and notice of receipt for incentives. h) The program should use impartial cadres (e.g. provincial officers) to supervise and award scores for the participating districts.

5. Conclusion

Since the launch of national guidelines for the integration of SRH and HIV services in Zimbabwe in 2010, rigorous research about implementation of the new guidelines was paramount for Zimbabwe. Despite being designed after the baseline study and not covering all impact evaluation areas, the intervention helped motivate facility and district teams and optimized implementation of HIV-SRH integration guidelines. It is important for an intervention such as this to ensure that coordination and communication among various stakeholders is managed at all levels. The findings indicate that HIV-SRH integrated-focused supportive supervision with incentives required skilled healthcare workers to perform it. The intervention successfully trained healthcare workers and managers on HIV-SRH integration in line with the national service delivery framework, standard operating procedures, performance measures and tools (checklists) for assessing integration.

The use of standardized checklists (one for the district level and another for primary healthcare facilities) seems to have been a good practice. Despite implementation challenges, integrated- focused assessment of performance, done routinely and through standardized assessment by districts and provincial/national teams, seems to have improved. However, since this report focuses on intervention implementation only, no comparison to control districts was done, and the baseline and endline data were not included in it. This will be done in the overall evaluation report.

6. Appendices

6.1 Appendix 1: List of participating Provinces, Districts and Facilities Province District Facility Mashonaland East Chikomba Sadza District Hospital Mwerahari Nharira Lancashire Unyetu Mushipe Hwedza Wedza Chigondo Chikurumadziva Marondera Marondera Provincial Hospital Mahusekwa Chiota Dombotombo Masikana Mudzimuirema Mutoko Mutoko District Hospital Kowo Nyadire Makosa Madimutsa Matedza Mashonaland West Makonde Chinhoyi Provincial Hospital St. Ruperts Alaska Doma Hombwe Matoranjera Kenzamba Nyamungomba Chikonohono

Sanyati Sanayati District Hospital Mafindifindi Muuyu Dondoshava Bumbe Geja Muzeze Rimuka Bururu

Kariba Kariba District Hospital Nyamhunga Negande Kanyati 22

Province District Facility

Siakobvu

Masvingo Masvingo Morgenster Mission Hospital Nemwama Clinic Bondolfi Rural Hospital Shonganiso Clinic Mukosi Clinic Nyikavanhu Rural Health Centre Bere Clinic

Gutu Gutu District Hospital Chinyika Dambara Chiwore Denhere Mazura

Chiredzi Chiredzi District Hospital Damarakanaka Chomopani Rutandare Chambuta Pahlela

Mwenezi Neshuro District Hospital Maranda Mazetese Munyanyi Chirindi

Chivi Chivi District Hospital Masinire Takavarasha Davira

Matabeleland South Bietbridge Beitbridge District Hospital Chamunangana Shashe Dulibadzimu Makakabule Majini Tongwe Matobo Maphisa District Hopsital St. Joseph's Matobo Rural Beula Cyrene Masiye Camp

Province District Facility

Umzingwane Esigodini District Hospital Mzingwane High School

6.2 Appendix 2: Supervision tool for Integrated SRH/HIV Services in Zimbabwe (PHC)

Supervision tool for Integrated SRH/HIV Services in Zimbabwe – Rural Health Centre or Urban Clinic

World Bank & UNFPA/UNAIDS joint project on Linking HIV and Sexual and Reproductive Health and Rights in Zimbabwe *Please complete 3 copies (one copy for the facility/department, one for the supervisor and one for linkages coordinator at MoHCC Head Office)

Name of Province District Facility name Facility code Date

List of people being supervised, their designations and contact details Name Department/Service Designation Contact Details Delivery Point

List of people doing the Supervision, contacts and their Designations Name Designation Contact Details

1a.Which of the following essential HIV services are available in this health Centre? Score each service and put the total

Service Commodit Information Commodity Comments Not y only (1) /Counseling and available (1) Information/ (0) Counselling (2) HIV counseling and testing Services

TB screening

Other OI screening and prophylaxis

Treatment for opportunistic infections

Pre ART & ART for PLHIV

Post exposure prophylaxis

Psycho-social support (registers, support groups, IEC materials)

Prevention for and by people living with HIV (registers, CHASA, CARGS) HIV prevention information and services for general population

Positive health, dignity and prevention (client charter displayed, client exit interviews, wellness programmes) for PLHIV STI screening, diagnosis and treatment

Condom provision

PMTCT (four prongs) Primary prevention of HIV Prevention of unintended pregnancy Prevention of mother to child transmission of HIV Treatment and Care for pregnant women and their families Specific HIV information and services for key populations (sex workers, truck drivers, migrants, people living disabilities, etc.) Voluntary Medical Male Circumcision

Prevention and management of STI s

TOTAL MARKS OUT OF 32

1b. Are all the services listed currently available or have been available within the last month? Yes No 1c. If No, why are the services not available?______

2a.Which of the following essential SRH services are available in this health centre? Score each service and put the total

Service Commodit Information/ Commodity Comments Not y only (1) Counseling and available (1) Information/ (0) Counselling (2) Family planning /modern contraceptive methods other than condoms Pregnancy testing Maternal and newborn care Prevention and management of gender-based violence

Prevention of unsafe abortion and management of post-abortion care Emergency contraceptives Infertility services STI prevention and management Post-exposure prophylaxis for victims of gender-based violence Integrated Youth Friendly Corner TOTAL OUT OF 20

2b. Are all the services listed currently available or have been available within the last month? Yes No 2c. If No, why are the services not available?______

3. If HIV testing and counselling and modern contraceptive methods are both available at the health centre how are the two services provided to clients/patients?

Type of integration (Score only 1 method of delivery) Provided at the same location by the same healthcare worker on the same day (Score = 4) 27

Provided at the same location by the same healthcare worker on a different day (Score = 2) Provided at the same location by different healthcare workers on the same day (Score = 3) Provided at the same location by a different healthcare worker on a different day (Score = 1) SCORE

4. HIV/SRH service integration indicators Supervision team to calculate. SCORES: 80-100% = 5marks, 60-79% = 3, 50-59% =1, Below 50% =0

5a. Observe: In general, how does the health centre offer SRH/HIV integrated services?

5b. Comment on what you will have observed______

______

6. Do you have Service Guidelines to help you provide quality integrated HIV/SRH services? Yes No

If Yes, check whether the guidelines are available and score each. Guideline Score Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Service Guidelines on Integrating SRH and HIV Services, 2013 Cue Cards on minimum packages for SRH and HIV integration

i) Do you have the following national guidelines? Score for only up to date versions Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Family planning HIV (ART, HTS, PMTCT, PEP) SRH guidelines EMOC Infection control j) How many staff members(clinicians) are working in this health centre ______k) How may staff members(clinicians) are working at this health Centre are trained in integrated HIV/SRH services ______l) What proportion of staff members were trained on providing integrated HIV/SRH services in this health centre: ______

SCORING Comment No form = 0 Yes, forms available but not seen = 1 Yes, forms available and seen = 2 Are there standard referral forms, which are sent with referrals from this facility? (STI, HIV, maternity, cervical cancer screening, VMMC etc)

12a. SCORING No record keeping system = 0 Yes, system available but not seen = 1 Yes, system available and seen = 2 Is there a record keeping system to keep track of referrals this facility?

12b. If record keeping system is available briefly, describe the system______

______

Stock-outs 29

13a. In the past 3 months have you experienced any stock-outs of the following products? Stock-outs - HIV If Yes, score = If yes, specify 0 Stock-outs - HIV If No, Score =1 A ARV Prophylaxis B ARVs for infants C ARVs for adults D HIV Rapid test kits E Lancets for finger pricking

13b) In the past 3 months have you experienced any stock-outs of the following FP products? Stock-outs If Yes, score = 0 If yes, specify If No, Score =1 A Contraceptives-COC B Contraceptives-POP C Male condoms D Female condoms E Implants F IUCD

Supervision 14a. Are there any minuted meetings held that included SRH and HIV integration in the last round? Yes/No?(Yes = 1, No = 0) SCORE______14b. Check the minutes and what was discussed (highlight major issues discussed and any action points) ______15. Number of times supervised in the last round where supervision included SRH/HIV linkages (excluding current visit)______

m) Please rate each of the following as to how large a constraint it is to offering linked SRH and HIV services at this facility.

not a small medium large I don’t constraint constraint constraint constraint know

Shortage of equipment for offering integrated services Shortage of space for offering private and confidential services Shortage of staff time Shortage of trained staff

Inappropriate/insufficient staff supervision Low staff motivation User fees Some other constraint? (specify):

17.How do you rate the impact of linking SRH and HIV services on the following service dimensions. Rate each dimension below and tick appropriately)?

Decreasing Increasing Not Don’t changing know Costs of services (facility) Cost of services (client) efficiency of services Stigmatization of HIV clients Stigmatization of SRH clients Workload for providers Time spent per client Space for privacy Need for equipment, supplies, and drugs Overall Quality of the services Other (please specify)______

18. What lessons have you learnt in providing integrated services? (Participation, integration, intersectoral, use of auxiliary staff)

______n) Any other recommendations concerning SRH/HIV service integration?

Recommendation Action Responsible Time frame

o) Do you have any questions or concerns regarding HIV-SRH integration? ______Total Score OUT of 95

Thank you very much

6.3 Appendix 3: Supervision tool for Integrated SRH/HIV Services in Zimbabwe

Supervision tool for Integrated SRH/HIV Services in Zimbabwe Hospitals

Name of Province District Facility name Facility code Date

List of people being supervised, their designations and contact details Name Department/Service Designation Contact Details Delivery Point

List of people doing the Supervision, contacts and their Designations Name Designation Contact Details

Please ask questions 1 and 2 to the overall in charge of clinical duties at the hospital i.e. the hospital matron

1a.Which of the following essential HIV services are available in this hospital? Score each service and put the total Service Commodit Information/ Commodity and Comments Not y only (1) Counseling Information / available (1) Counselling (2) (0) HIV counseling and testing Services Pre ART & ART for PLHIV

Post exposure prophylaxis

Psycho-social support (registers, support groups, IEC materials) Prevention for and by people living with HIV (registers, Community HIV AIDS Support Agent(CHASA), Community ART Refill Groups(CARGS) HIV prevention information and services for general population Condom provision

PMTCT (four prongs) p) Primary prevention of HIV q) Prevention of unintended pregnacy r) Prevention of mother to child transmission of HIV s) Treatment and Care for pregnant women and their families Specific HIV information and services for key populations (sex workers, truck drivers, migrants, people living disabilities, etc.) Voluntary Medical Male Circumcision Prevention and management of STI s TOTAL MARKS OUT OF 22

1b. Are all the services listed currently available or have been available within the Yes last month? No

1c. If No, why are the services not available?______

2a.Which of the following essential SRH services are available in this hospital? Score each service and put the total Service Not Commodit Information/ Commodity and Comments available y only (1) Counseling Information/ (0) (1) Counselling (2)

Family planning

Maternal and newborn care

Prevention and management of gender-based violence

Prevention of unsafe abortion and management of post-abortion care Screening and management of cancers of the reproductive system (eg. Emergency contraceptives

Infertility services

STI prevention and management

Integrated Youth Friendly Corner

TOTAL OUT OF 18

2b Are all the services listed currently available or have been available within the Yes last month? No

2c. If No, why are the services not available?______

For service delivery points primarily providing HIV Services Note: This section to be completed in OI/ART

3a. What are the core SRH -related services currently provided at your service delivery point? (Select all that apply)

Services (Not available =0 Available = 1)

Modern contraceptive methods other than condoms

Pregnancy testing Emergency contraception Antenatal care Labour and delivery Postnatal and New-born care Child health (EPI, Growth Monitoring. IMNCI, Nutrition) STI/RTI screening, diagnosis and treatment Condom provision Cervical or breast or prostate cancer screening Post-exposure prophylaxis for victims of gender-based violence TOTAL SCORE OUT OF 11

3b. Are all the services listed currently available or have been available within the Yes last month? No

3c. If No why are the services not available?

______

3d. Check, are modern contraceptive methods other than condoms available at this service delivery point Yes/No? If Yes score = 2, If No score = 0

SCORE

4. Do you have Service Guidelines to help you provide quality integrated HIV/SRH services? Yes No If Yes, Check whether the guidelines are available and score each. Guideline Score Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Service Guidelines on Integrating SRH and HIV Services, 2013 Cue Cards on minimum packages for SRH and HIV integration

t) Do you have the following national guidelines? Score for only up to date versions Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Family planning HIV (ART, HTS, PMTCT,PEP) SRH guidelines EMOC Infection control u) How many staff members(clinicians) are working in this department/service delivery point ______v) How may staff members(clinicians) are working in this department/service delivery point are trained in integrated HIV/SRH services ______w) What proportion of staff members were trained on providing integrated HIV/SRH services in this department/service delivery point: ______

37 x) Stock-outs - HIV

If Yes, score = If yes, specify 0 Stock-outs - HIV If No, Score =1 A Cotrimoxazole for adults B Cotrimoxazole for infants C ARVs for infants D ARVs for adults E HIV Rapid test kits F Lancets for finger pricking

10b) In the past 3 months have you experienced any stock-outs of the following FP products? Stock-outs If Yes, score = 0 If yes, specify If No, Score =1 A Contraceptives-COC B Contraceptives-POP C Male condoms D Female condoms E Injectables F Implants G IUCD

10 b) SCORING Comment No form = 0 Yes, forms available but not seen = 1 Yes, forms available and seen = 2 Are there standard referral forms, which are sent with referrals from this department? (STI, HIV, maternity, cervical cancer screening, VMMC etc)

11 a SCORING No record keeping system = 0 Yes, system available but not seen = 1 Yes, system available and seen = 2 Is there a record keeping system to keep track of referrals this department?

11b) If record keeping system is available briefly, describe the system______

For service delivery points primarily providing SRH Services Note: This section to be completed in Maternity

12a) What are the core HIV services currently provided at your service delivery point? (Select all that apply)

Service (Not available =0 Available = 1)

PMTCT (At a minimum, PMTCT Prong 3: Access to antiretroviral drugs to prevent vertical transmission and for ongoing treatment for mothers) TB screening

Other OI screening and prophylaxis

Treatment for opportunistic infections

Male circumcision

STI screening, diagnosis and treatment

ART

Condom provision

Positive health, dignity and prevention(client charter displayed, client exit interviews, wellness programmes) for PLHIV HIV testing and counselling

SCORE OUT OF 10

12 b )Are all the services you mentioned currently available or have been available within the last month? Yes/No______12 c) If No, why are the services not available? 39

12 d) Check, are HIV rapid test kits available at service delivery point Yes/No____ If Yes score = 2, If No score = 0 SCORE

y) Do you have Service Guidelines to help you provide quality integrated HIV/SRH services? Yes No

If Yes, Check whether the guidelines are available and score each. Guideline Score Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Service Guidelines on Integrating SRH and HIV Services, 2013 Cue Cards on minimum packages for SRH and HIV integration

z) Do you have the following national guidelines? Score for only up to date versions Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Family planning HIV(ART, HTS, PMTCT,PEP) SRH guidelines EMOC Infection control

aa) How many staff members(clinicians) are working in this department/service delivery point ______

bb) How may staff members(clinicians) are working in this department/service delivery point are trained in integrated HIV/SRH services ______

cc) What proportion of staff members were trained on providing integrated HIV/SRH services in this department/service delivery point: ______

18 a) Stock-outs - HIV If Yes, score = If yes, specify 0 Stock-outs - HIV If No, Score =1 A Cotrimoxazole for adults Cotrimoxazole for infants B ARVs for infants C ARVs for adults D HIV Rapid test kits E Lancets for finger pricking

18 b) In the past 3 months have you experienced any stock-outs of the following FP products? Stock-outs If Yes, score = 0 If yes, specify If No, Score =1 A Contraceptives-COC B Contraceptives-POP C Male condoms D Female condoms E Injectables F Implants G IUCD ______18 c) SCORING Comment No form = 0 Yes, forms available but not seen = 1 Yes, forms available and seen = 2 Are there standard referral forms, which are sent with referrals from this department? (STI, HIV, maternity, cervical cancer screening, VMMC etc)

19 a) SCORING No record keeping system = 0 Yes, system available but not seen = 1 Yes, system available and seen = 2 Is there a record keeping system to keep track of referrals this department?

19 b) If record keeping system is available briefly, describe the system______

This section to be completed in Family and Child Health Services 20. What are the core HIV services currently provided at your service delivery point? (Select all that apply)

Service (Not available =0 Available = 1)

PMTCT (At a minimum, PMTCT Prong 3: Access to antiretroviral drugs to prevent vertical transmission and for ongoing treatment for mothers) TB screening

Other OI screening and prophylaxis

Treatment for opportunistic infections

Male circumcision

STI screening, diagnosis and treatment

ART

Condom provision

Positive health, dignity and prevention(client charter displayed, client exit interviews, wellness programmes) for PLHIV HIV testing and counselling

SCORE OUT OF 10

dd) Do you have Service Guidelines to help you provide quality integrated HIV/SRH services? Yes No 42

21 b) If Yes, Check whether the guidelines are available and score each. Guideline Score Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Service Guidelines on Integrating SRH and HIV Services, 2013 Cue Cards on minimum packages for SRH and HIV integration

ee) Do you have the following national guidelines? Score for only up to date versions Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Family planning HIV(ART, HTS, PMTCT,PEP) SRH guidelines EMOC Infection control ff) How many staff members(clinicians) are working in this department/service delivery point ______gg) How may staff members(clinicians) are working in this department/service delivery point are trained in integrated HIV/SRH services ______hh) What proportion of staff members were trained on providing integrated HIV/SRH services in this department/service delivery point: ______

26. Adult Inpatients What are the core HIV services currently provided at your service delivery point? (Select all that apply)

Service (Not available =0 Available = 1)

PMTCT (At a minimum, PMTCT Prong 3: Access to antiretroviral drugs to prevent vertical transmission and for ongoing treatment for mothers) TB screening

Other OI screening and prophylaxis

Treatment for opportunistic infections

Male circumcision

STI screening, diagnosis and treatment

ART

Condom provision

Positive health, dignity and prevention(client charter displayed, client exit interviews, wellness programmes) for PLHIV HIV testing and counselling

SCORE OUT OF 10

26 b) Are all the services you mentioned currently available or have been available within the last month? Yes No 26 c) If No, why are the services not available?

26 d) Check, are HIV rapid test kits available at service delivery point Yes No

If Yes score = 2, If No score = 0 SCORE

ii) Do you have Service Guidelines to help you provide quality integrated HIV/SRH services? Yes No

jj) Stock-outs - HIV

28 b) In the past 3 months have you experienced any stock-outs of the following FP products? Stock-outs If Yes, score = 0 If yes, specify If No, Score =1 A Contraceptives-COC B Contraceptives-POP C Male condoms D Female condoms E Injectables F Implants G IUCD ______kk)

SCORING Comment No form = 0 Yes, forms available but not seen = 1 Yes, forms available and seen = 2

Are there standard referral forms, which are sent with referrals from this department? (STI, HIV, maternity, cervical cancer screening, VMMC etc) ll) SCORING No record keeping system = 0 Yes, system available but not seen = 1 Yes, system available and seen = 2 Is there a record keeping system to keep track of referrals this department?

30 b) If record keeping system is available briefly, describe the system______

For service delivery points routinely providing general health services Note: This section to be completed in Outpatients Department mm) What are the core HIV-related services currently provided at your service delivery point? Select all that apply: Service (Not available =0 Available = 1)

HIV testing and counselling

PMTCT (At a minimum, PMTCT Prong 3: Access to antiretroviral drugs to prevent vertical transmission and for ongoing treatment for mothers) TB screening

Other OI screening and prophylaxis

Treatment for opportunistic infections

Male circumcision

STI screening, diagnosis and treatment

ART

Condom provision

Positive health, dignity and prevention

TOTAL SCORE OUT OF 10

31b) What are the core SRH services currently provided at your service delivery point? Select all that apply:

Services (Not available =0 Available = 1)

Modern contraceptive methods other than condoms

Pregnancy testing

Emergency contraception

Antenatal care

Labour and delivery

Postnatal and New-born care

Child health

STI/RTI screening, diagnosis and treatment

Condom provision

Cervical or breast or prostate cancer screening

Post-exposure prophylaxis for victims of gender-based violence

TOTAL OUT OF 11

31 c) If HIV testing and counselling and modern contraceptive methods are both available at your general service delivery point, how are the two services provided to clients/patients?

Type of integration (Score only 1 method of delivery) Provided at the same location by the same healthcare worker on the same day (Score = 4) Provided at the same location by the same healthcare worker on a different day (Score = 2) Provided at the same location by different healthcare workers on the same day (Score = 3) Provided at the same location by a different healthcare worker on a different day (Score = 2) Referred to a different service delivery point within the same facility (Score = 2) Referred to a separate facility (Score = 1) SCORE

nn) Do you have Service Guidelines to help you provide quality integrated HIV/SRH services? Yes No

If Yes, Check whether the guidelines are available and score each.

Guideline Score Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Service Guidelines on Integrating SRH and HIV Services, 2013 Cue Cards on minimum packages for SRH and HIV integration

oo) Do you have the following national guidelines? Score for only up to date versions Not available (Score = 0); Available but not seen (Score =1); Available and seen (Score =2) Family planning HIV(ART, HTS, PMTCT,PEP) SRH guidelines EMOC Infection control pp) How many staff members(clinicians) are working in this department/service delivery point ______qq) How may staff members(clinicians) are working in this department/service delivery point are trained in integrated HIV/SRH services ______rr) What proportion of staff members were trained on providing integrated HIV/SRH services in this department/service delivery point: ______

ss) Stock-outs - HIV

If Yes, score = If yes, specify 0 Stock-outs - HIV If No, Score =1 A Cotrimoxazole for adults Cotrimoxazole for infants B ARVs for infants C ARVs for adults D HIV Rapid test kits E Lancets for finger pricking

37 b) In the past 3 months have you experienced any stock-outs of the following FP products? 48

Stock-outs If Yes, score = 0 If yes, specify If No, Score =1 A Contraceptives-COC B Contraceptives-POP C Male condoms D Female condoms E Injectables F Implants G IUCD ______tt)

SCORING Comment No form = 0 Yes, forms available but not seen = 1 Yes, forms available and seen = 2 Are there standard referral forms, which are sent with referrals from this department? (STI, HIV, maternity, cervical cancer screening, VMMC etc) uu) SCORING No record keeping system = 0 Yes, system available but not seen = 1 Yes, system available and seen = 2 Is there a record keeping system to keep track of referrals this department?

39 b) If record keeping system is available briefly, describe the system______

Note: After assessing the service delivery points please follow the instructions in italics and compute the indicators.

40 a) HIV/SRH service integration indicators Supervision team to calculate. SCORES: 80-100% = 5marks, 60-79% = 3, 50-59% =1, Below 50% =0

Indicator % Score i. Percentage of clients who receive an index service plus any other appropriate SRH/ HIV service during their visit to the facility(Randomly Select 10 patient records from the previous 3 months, 5 from OI/ART(ART green booklet, T12) and 5 from FCH(ANC and PNC registers) CALCULATION:(Number of clients who receive an index service and all other appropriate SRH and HIV services during their visit to the facility within the reporting period) / (Total number of clients who receive any SRH and HIV services during a visit to the facility within the reporting period) X 100 ii. Percentage of Service Delivery Points offering 4 or more SRH and HIV services CALCULATION: (Service Delivery Points offering 4 or more integrated SRH and HIV services during a given visit within the reporting period) / (Total number of Service Delivery Points(OI/ART/ Maternity/FCH/OPD/One Inpatients ward) offering SRH and HIV services within the reporting period) X 100 iii. Percentage of OI/ART Service Delivery Points offering Family Planning services including information and referrals CALCULATION: (Number of OI/ART Service Delivery Points offering family planning services including referrals) / (Total number of OI/ART Service delivery Points) X 100 iv. Percentage of Service Delivery Points offering a minimum package of Sexual and Gender-Based Violence management services (i.e. STI treatment, HIV Counseling Testing, Post-Exposure Prophylaxis, Counseling and Emergency Contraception services) for clients/ victims CALCULATION: (Number of Service Delivery Points offering post-sexual and gender- based violence services in the period under review including all three components i.e. STI treatment, Post-Exposure Prophylaxis and Emergency Contraception) / (Total number of Service Delivery Points offering clinical services in the period under review) X 100 v. Proportion of Service Delivery Points offering SRH and HIV services including screening and counseling services for any of the commonest cancers of the reproductive system (Cancer of Cervix, Cancer of the Breast, prostate cancer ) women CALCULATION: (Number of Service Delivery Points offering SRH and HIV services including screening and counseling for cancer of the reproductive system for men and women) / (Total number of Service Delivery Points providing clinical services) X 100 vi. Proportion of Service Delivery Points offering SRH and HIV services on for young women and men aged 15 – 24 years CALCULATION: (Number of Service Delivery Points offering SRH and HIV services for young women and men aged 15 – 24 years during the period under review) / (Total number of Service delivery Points offering clinical services in the period under review) X 100

40 b) Observe: In general, how does the hospital offer SRH/HIV integrated services? 50

Type of integration (Score only 1 main method of delivery) Provided at the same location by the same healthcare worker on the same day (Score = 4) Provided at the same location by the same healthcare worker on a different day (Score = 2) Provided at the same location by different healthcare workers on the same day (Score = 3) Provided at the same location by a different healthcare worker on a different day (Score = 2) Referred to a different service delivery point within the same facility same day (Score = 3) Referred to a different service delivery point within the same facility different day (Score = 2) Referred to a separate facility (Score = 1) SCORE

40 c) Comment on what you will have observed______

______

The following questions will be directed to the matron of the hospital Supervision 41 a) Are there any minuted meetings held that included SRH and HIV integration in the last round? Yes/No? (Yes = 1, No = 0) SCORE______41 b) Check the minutes and what was discussed (highlight major issues discussed and any action points) ______

vv) Number of times supervised in the last round where supervision included SRH/HIV linkages(excluding current visit)______

ww) Please rate each of the following as to how large a constraint it is to offering linked SRH and HIV services at this facility.

not a small medium large I don’t Comment constraint constraint constraint constraint know

Shortage of equipment for offering integrated services Shortage of space for offering private and confidential services Workload

Shortage of trained staff

Inappropriate/insufficient staff supervision

Low staff motivation

User fees

Some other constraint? (specify):

How do you rate the impact of linking SRH and HIV services on the following service dimensions. Rate each dimension below and tick appropriately)? Decreasin Increasin Not Don’t Comments g g changin know g Costs of services (facility) Cost of services (client) efficiency of services Stigmatization of HIV clients Stigmatization of SRH clients Workload for providers Time spent per client Space for privacy

Need for equipment, supplies, and drugs Overall Quality of the services Other (please specify)______

xx) What lessons have you learnt in providing integrated services?(Participation, integration, intersectoral, use of auxiliary staff)

______

______yy) Any other recommendations concerning SRH/HIV service integration? Recommendation Action Responsible Time frame

zz) Do you have any questions or concerns regarding HIV-SRH integration?

______

Total Score OUT of 275

Thank you very much

6.4 Appendix 4: Winning Districts Scores and Incentives Paid

Province Round 1 Round 2 Round 3 Round 4

Highest District Highest District with Highest District with Highest District with Total scoring with scoring most scoring most improved scoring most costs per district most district (%, improved district (%, score (R3-R2 district improved province (%, Amt) improve Amt) score (R2-R1 Amt) score) (%, Amt) (%) score (R4-R3 d score score) (%, score) (%, Amt) Amt)

Mashonaland Hwedza N/A Chikomba Chikomba Chikomba Mutoko Chikomb Marondera $24,000 East (83.2) (90.3) (8.4) (93.2) (11.6) a (94.2) (1.51) $5,000 $3,500 $1,500 $3,500 $3,500 $3,500 $3,500

Mashonaland Sanyati N/A Sanyati Kariba Sanyati Kariba Sanyati Sanyati $24,000 West (79.9) (81.3) (5.4) (84) (4.7) (90.1) (6.11) $5,000 $3,500 $1,500 $3,500 $3,500 $3,500 $3,500

Masvingo Chivi N/A Chivi Chivi Gutu Chiredzi Chivi Masvingo $24,000 (84.3) (92.7) (8.4) (94.1) (11.7) (94.33) (5.84) $5,000 $3,500 $1,500 $3,500 $3,500 $3,500 $3,500 Matabeleland Matobo N/A Umzingwa Umzingwane Beitbridge Beitbridge Beitbrid Matobo $24,000 South (75) ne (92) (22) (88.9) (17.1) ge (91.2) (6.01) $5,000 $3,500 $1,500 $3,500 $3,500 $3,500 $3,500

Total $20,000 $20,000 $28,000 $28,000 $96,000 Incentives Per Round (Combined)

6.5 Appendix 5: Support supervision scores for 4 rounds by district

Facility Name- Average R1 R2 Average R2 Average R3 Average R4 Facility Name- Rural Health R1 Score district Score, district R3 Score, district R4 Score, district Province District Facility Code District Hospital Centre (%) score, (%) (%) score, (%) (%) score, (%) (%) score, (%) ZW03010D Sadza DH 82 90.9 94.2 97 ZW030192 Mwerahari 84.2 96.8 93.7 95.8 ZW03010B Nharira 80 81.93 93 90.31 92.6 93.23 87.4 94.24 Chikomba Lancashire ZW030147 83.3 85 89.5 90.5

ZW030136 Unyetu 84.2 85 93.6 95.8

ZW030131 Mushipe 77.8 90.5 94.7 95.8 E0E2000001 Mt St Mary's DH 71.2 70.5 76.4 72.7 - Wedza 88 75.3 89.1 71.2 Hwedza 83.24 78.99 88.91 81.59

E0E2000009 Chigondo 92 84.2 97.9 94

ZW030445 Chikurumadziva 85.2 88.4 95.8 91

Mashonaland ZW03050A Marondera PH 73.5 73.4 80.65 83.6 88.4 East EOE300001 Mahusekwa 66 80.7 88.4 85.8 ZW03050B Chiota 92 76.09 85.5 88.7 87.73 94.2 89.24 Marondera Dombotombo ZW030561 81 86.3 90.5 90

ZW030525 Masikana 71 77.9 84.2 87

ZW030505 Mudzimuirema 76 88.4 95.7 91 ZW030811 Mutoko DH 81 69 88 88 ZW030898 Kowo 81 83 94.7 90 ZW03080D Nyadire 83.2 77.89 77.4 78.63 89.5 90.20 89.5 90.14 Mutoko Makosa ZW03080C 81 82 90.5 90.5

ZW030815 Madimutsa 65 88.4 92.6 93.7

ZW030826 Matedza 72.6 83 88.4 91.6

ZW040582 Chinhoyi PH 73.5 78.97 57 77.43 62 80.46 68.4 84.26 Mashonaland Makonde ZW04050B St. Ruperts 66.5 70.9 72 82.2 West ZW040575 Alaska 90 94.7 89 93.7

ZW040545 Doma 87 90.5 88 92.6

ZW040525 Hombwe 89 91.5 93 93.7

Matoranjera ZW040583 77 84.2 94 91.6 ZW040506 Kenzamba 87 90.5 92 92.6 ZW040584 Nyamungomba 85 85.2 87 88.4 ZW040562 Chikonohono 69 82 92 93.7 FOF3000002 Sanyati DH 70.5 61 76 86.5 ZW040384 Mafindifindi 89.5 92.6 82 96.8 ZW040329 Muuyu 86.3 88.4 83.2 89.5 ZW040302 Dondoshava 87 79.88 91.6 81.29 91.6 84.03 90.5 90.14

Sanyati Bumbe ZW040306 73.7 86.3 92.6 95.8 FOF3000003 Geja 94.7 94.7 93.7 92.6

Muzeze ZW040308 80 90.5 85.2 95.8

ZW040361 Rimuka 87.4 89.5 86.3 90.5

ZW040325 Bururu 72.6 86.3 85.2 82.1 ZW04040A Kariba DH 77.5 75.6 76.3 68 Nyamhunga ZW040461 61.5 67.21 69.5 88 68 72.59 77.26 71.71 Kariba Negande ZW040405 69.4 71.6 80 81.1

ZW040403 Kanyati 61 75.8 74.7 77.9

ZW040428 Siakobvu 59.3 68.3 68 66.2 Morgenster Mission not ZW08050D Hospital 79 done 63.2 78.88 72.4 84.72 not Nemwama Clinic ZW080506 74 done 88.4 86.3 Bondolfi Rural not ZW080591 Hospital 55 done 77.9 87.4 not Masvingo Masvingo Shonganiso Clinic ZW080592 86 73.63 done 89.5 90.5 not Mukosi Clinic ZW080502 78 done 90.5 90.5 Nyikavanhu Rural not ZW080507 Health Centre 63 done 88.4 93.7 not Bere Clinic ZW080530 72 done 78.9 91.6

ZW08040E Gutu DH 72 93 86.84 97.5 94.08 97.8 93.45 ZW08040D Chinyika 85 85 92.6 91.6 ZW080437 Dambara 84 81.81 77 88.4 85.3 Gutu Chiwore ZW080434 86.3 86 97.9 98.9

ZW080426 Denhere 87.4 89 90.5 91.6

ZW080494 Mazura 87.4 84 93.7 90.5 ZW08020A Chiredzi DH 67 70.5 75.96 89 87.70 86.9 89.57 ZW080291 Damarakanaka 67 80 86.3 90.5 ZW080235 Chomopani 60 67.98 81 87 90.5 Chiredzi Rutandare ZW080231 73 81 88.4 90.5

ZW080201 Chambuta 69 71.6 87 89.5

ZW080214 Pahlela 73 77.9 87 92.6 ZW08060A Neshuro DH 69 63.3 76.09 84.7 82.15 88.7 85.74 ZW080691 Maranda 76 89.5 94.7 93.7 68.91 Mwenezi Mazetese ZW080625 69.5 84.2 81.1 80

ZW080693 Munyamani 58 66.3 68.4 76.8

ZW080602 Chirindi 72 86.3 80 87.4 ZW08030A Chivi DH 79 89 92.69 93.5 90.91 90.9 94.33 ZW080323 Masinire 84 94.5 88.4 95.8 Chivi 84.13

ZW080307 Takavarasha 88 94.7 94.7 95.8

ZW080326 Davira 87 93.6 86.3 95.8 ZW06060A Esigodini DH 61.09 87.2 91.96 68 83.68 92.4 88.13 Umzingwane Mzingwane High 69.92 ZW060606 School 73.7 94 90.4 86.3 ZW06010A Beitbridge DH 52 77 71.83 81 88.93 85.1 91.24 Matabeleland 74.52 South ZW060177 Chamunangana 82 78.9 96 95.8

Beitbridge Shashe ZW060129 86 88.4 87 94.7

ZW060126 Dulibadzimu 78 85.2 87 89.5

ZW060176 Makakabule 87 85.2 96 95.8

ZW060104 Majini 86 80 94 93.7 ZW060130 Tongwe 86 94 93.7 ZW06050A Maphisa DH 54 68.4 79.96 56 75.60 66.2 81.61 ZW000005 St. Joseph's 90.5 86 82 91.6 ZW06050C Matobo Rural 80 75.10 84.2 86 90.5 Matobo Beula ZW000013 83.2 85.2 86 84.2 ZW000015 Cyrene 84 84.2 80 87.4

ZW000016 Masiye Camp 83 85 86 87.4