rumbi mugwagwa, pmtct unit, ministry of health and child welfare, zimbabwe july 2009 cape town,...
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Rumbi Mugwagwa, PMTCT unit, Ministry of Health and Child Welfare, Zimbabwe
July 2009Cape Town, South Africa
The Child Health Card as a linkage tool: experiences from
Zimbabwe
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Outline of presentation• Brief problem statement• Function of the Child
health card• Revision process• Content of the revised
card• Findings from the pre-
testing• Best practice• Recommendations
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Background – problem statement
• There was no way of identifying and tracking HIV-exposed infants for follow up HIV services within the system in Zimbabwe.
• Little information was provided to support mothers who care for HIV-exposed children or inform families of what services can be provided.
• No documentation of the additional HIV-services offered to HIV exposed children existed e.g. co-trimoxazole prophylaxis.
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The Functions of the national Child health Card
• The child health card is a key tool to assist health workers in providing integrated health care to children aged between 0 – 5 years old.
• The card provides information and education to help mothers look after their children and keep them healthy.
• The cards facilitate documentation of the integrated wide range of services received by individual children.
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The Objective and Revision ProcessObjective: “To strengthen and integrate HIV
services offered to HIV-exposed infants.”
Process involved:1. Multiple consultations and meetings were held with a
wide range of stakeholders to look at the needs and gaps with the existing child health cards.
2. A revised card was developed in 2004 and the card then pre-tested.
3. Once findings had been discussed, a new Child health card was designed along with a procedure manual.
4. Card approved by MOHCW and circulated for use in 2006.
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Pretesting of the card• A working group led by MOHCW was formed and
included a wide range of Stakeholders.
• Overall objective was to demonstrate the level of acceptability from both healthcare workers and the community of the revised card before final production at national level.
• Structured interviews were designed to give target groups the opportunity to react and describe elements of the card that were ‘good’ and ‘bad’.
• In total 493 people were interviewed of which 71% members of the community and 29% health workers.
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What was new on the cardNew picture • A man and woman: to encourage
male support for feeding and care of mother and child.
Updated infant feeding Messages• Promotion of EBF to six months for
ALL children. • Continue BF until at least 24 months
unless counselled otherwise.
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“At Risk Factors” at time of birth
Revised the “AT RISK Factors” and introduced the “MTCT” at risk box.
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Addition of infant feeding section.
Additional information added on care of children in view of HIV epidemic.
The new Infant Feeding and Care Panel
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What else is New on the Card
• Addition of a vitamin A schedule.• Updated immunisation schedule.• Provision for measuring additional growth and
nutritional measurements.• Provision for measuring APGAR Score.• Improved graphics.
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Summary of findings from pre-testing• According to the pre-test, the card was generally
acceptable.• The majority of negative feedback was on the inclusion
of HIV Information but it was still less than 19% of all people interviewed.
• Resistance was notably higher among health workers than the community. – Significantly more healthcare workers than
community members felt the HIV information should be removed from the card (30.3%, n=44 versus 13.5%, n=47 respectively; p<0.005).
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Current status of the use of the card
• Anecdotal evidence that the card remains still widely acceptable.
• Challenges have been that not all sections of the card are well filled in despite ongoing supervision and sensitisation on the use.
• No linked registers with the card – MOHCW has now designed a follow up register for HIV-exposed infants
• An evaluation of the card is due in July-Sept ‘09
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Lessons learnt• A participatory process involving the healthcare
workers, communities and those living with HIV ensured collective ‘buy-in’, ownership and relevance.
• Pre-testing the tool was an important step.• Need to keep the card to a manageable size.• Ongoing supervision required to ensure
appropriate utilisation of the card.• Such low tech interventions have benefits for
both healthcare workers, individuals and communities.
• The logistics for distribution of the card are critical to ensure nationwide availability.
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Best practice and conclusions• Effectiveness: Seen the increase in the nos. of
HIV-exposed infants being prescribed CTX – A recent national integration pilot saw a 210%
increase in CTX prescribing in one district which was in part due to the availability of the CHC.
• Efficiency: card can be used at multiple entry points e.g. EPI outreach, FCH clinics, OI/ART clinics. – In recent pilot, 94% of HIV-exposed infants were
identified through CHC.
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Best practice
• Relevance: important to document child health outcomes in high infant mortality and HIV prevalence countries.
• Replicability: easy to do in countries that already have a child health card; requires a formal participatory review process and use lessons learnt from countries such as Zimbabwe.
• Sustainability: low cost (20 cents), low technology intervention that builds on existing health systems.
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Recommendations• Simple tools need to be amended and developed to
facilitate provision of integrated appropriate care by healthcare workers.
• This requires national leadership, collaboration between stakeholders, and community participation to ensure local acceptability.
• Healthcare worker stigma around HIV may result in barriers to appropriate care for the community and requires further exploration.
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Acknowledgements• Ministry of Health and Child Welfare: PMTCT and
Nutrition units• Elizabeth Glaser Pediatric AIDS Foundation team• Family AIDS initiative partners• Healthcare workers and communities in Zimbabwe• USAID• DFID