����Presenter : Dr Clorata Gwanzura ��DSD, TB/HIV and Community Collaborations Medical Officer�Ministry of Health and Child Care, Zimbabwe�����Co-Authors�Mupanguri C, Matare T, Mabuku J, Apollo T

Differentiated Service Delivery Programme Monitoring during Scale – Up _ A description of Innovations from Zimbabwe, 2017 - 2022

Background

• Differentiated service delivery (DSD) for HIV
• is a person centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of various groups of people living with and vulnerable to HIV while reducing unnecessary burdens on the health system (IAS)
• DSD was first offered in Zimbabwe in 2009 when the Ministry of Health and Child Care (MOHCC) launched the Outreach model nationwide
• At the same time, implementing partners (IP) began piloting the Community ART Refill Groups (CARG) model

• Scale-up began in 2017 after the first revision of the Operational and Service Delivery Manual
• Models of DSD for ART then included the Fast Track Refill, Facility Club Refill, CARG, and Outreach models.
• Newer models Recently adopted models such as the Omalayitsha model, Drop-in-Centers and the Community ART Distribution Model.
• Statistics
• About 472,104 PLHIV enrolled in DSD models as at June 2023
• Fast Track and CARGs models have the most contributions

• Any programme success can only be measured through diligent tracking and analyzing progress made towards the achievement of specific targets, goals and objectives

​

• M and E system in place allows organisations to implement and manage programmes strategically
• M&E frameworks, data collection, aggregation and analysis of the results to make data-driven decisions

​

• When Zimbabwe expanded DSD models in 2017, the country also became a member country to the HIV Coverage, Quality, and Impact Network (CQUIN) that is convened by ICAP at Columbia University

​

• A multi-country learning network focused on accelerating the implementation of high quality differentiated care for HIV
• CQUIN’s goal is to increase the number PLHIV initiating and sustaining highly effective HIV treatment with sustained viral suppression

​

Monitoring and Evaluation (M&E) for DSD

Step 1: Monitoring Framework

• Under the CQUIN platform, we participated in the co-creation of a monitoring framework for DSD implementation
• All possible indicators for tracking, data points and data sources for all the proposed indicators were identified
• Countries would then choose and prioritise indicators to track
• The MoHCC SI team together with the DSD technical working group (TWG) chose and prioritised 4 indicators
• DSD model uptake & coverage,
• Client satisfaction and,
• Health care worker (HCW) workload
• The programme further went on to develop quality standards for monitoring implementation from these indicators

​

Step 2: Plan for Data Generation/Collection/Reporting

• The adaptation of the national M & E system including tools was going to take time, so we developed a separate quarterly data collection and reporting tool
• Zimbabwe has clinical implementing partners (IPs) supporting all 10 provinces of the country
• Generating and collecting data already
• Have staff in the health facilities
• The IPs were sensitized on the tool, followed by its deployment as a standard DSD reporting tool beginning 2019

Data Collection and Reporting Tool

• The tool is an excel sheet designed for reporting of data for each facility
• disaggregated by DSD model and by sex
• Quarterly uptake and cumulative enrolments
• A validation and sensitization meeting was conducted
• Strategic information officers from the three (3) main implementing partners and their consortiums were sensitized with support from EGPAF
• Tool deployed for use late 2018, reports started coming in Q1 2019
• Initial analyses were done together with IPs and issues identified with addressed to better improve the tool and data integrity
• Field for newer/pilot models
• In 2019, the MoHCC added data points to collect Multi-month dispensing among all PLHIV in the same districts as new requirements came up.
• Data is collected on PLHIV receiving <3mos, 3-5mons and 6+mos

*Electronic Health Records for all health conditions

** Operational and Service Delivery Manual

2017

2018

2019

2020

2021

2022

2023

M& E Framework and indicator prioritization

​

Reporting tool developed and launched

Addition of MMD Reporting to tool

Reporting running parallel to the national system with a gradual transition to national M&E system only reporting (2021 – 2023)

Innovative Approach for DSD

Start of DSD Scale-up in the country

Significant DSD incorporation and refinement in progress

HIV Clinical Guidelines and OSDM** revised and updated

​

National HIV tools revise for alignment

Comprehensive tools Revision

• DSD in patient level tools
• DSD Register
• DSD indicators added to national DHIS2 reporting

(all paper-based)

HIV ART Module major incorporation into EHR*

​

Some DSD components incorporated

National M and E System

Timeline

With this tool in place, the program adapted the national paper based tools for DSD including adding data points for DSD in the patient care booklet and the electronic medical record while at the same time reporting DSD uptake and coverage indicators using the monthly return form and the DHIS2

• We could now track progress with DSD implementation
• DSD coverage from 2019 to date
• MMD dispensing among PLHIV
• Immediate improvement in capability maturity model staging for the facility and patient coverage
• Programme maturity staging within the CQUIN Learning Network

Green most mature to Red least mature

Consistency during Data Triangulation

• During DSD scale-up the country also conducted DSD Reviews for implementing health facilities across provinces
• The conduct of the DSD review is an intensive process of working with multiple stakeholders, focusing on defined geographic area, developing a specialized data collection tool and abstracting data facility-held patient level tools then analysis and disseminating
• The DSD coverage results for the year that we started using the tools were consistent between the 2 sources i.e. quarterly report and the DSD review
• Difference was within acceptable 10% range for the findings to be considered consistent for DSD coverage reporting

• Simplified systems running parallel to the national HMIS can still provide relevant and critical alternatives to answer immediate questions and needs
• The concurrence with results from DSD review meetings also attests to the reliability that can be attributed to the use of such systems
• The use of the tool in the interim
• Bought time and allowed for an “unhurried” adaptation of the national M and E system to cater for DSD monitoring
• Further informed the best indicators to include in the national M and E system and the way to collect and report.
• Working with stakeholders esp. implementing partners allows for greater leverage in successfully scaling up and monitoring programmes.
• The country was able to monitor DSD program performance and growth through this innovation, allowing timely interventions and course correction during the time of DSD implementation.

​

Lessons Learnt

• Data reporting will continue to run parallel to the IPs reporting system for another year to enable data triangulation until reliable data quality is guaranteed through the national health management information system.
• Patient-level data analysis from facilities using the electronic medical records system will also be commenced for further triangulation and improvement.

Next Steps

Acknowledgments

• Ministry of Health and Child Care
• PEPFAR
• USAID
• CDC
• The Global Fund
• Bill and Melinda Gates Foundation
• Implementing Partners
• The National AIDS Council
• Civil Society Organisations
• Recipients of care

Thank You