1. Rumbi Mugwagwa, PMTCT unit, Ministry of Health and Child Welfare, Zimbabwe July 2009 Cape Town, South Africa The Child Health Card as a linkage tool: experiences from Zimbabwe

2. 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

3. 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.

4. 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.

5. The Objective and Revision Process Objective: 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.

6. 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.

7. What was new on the card New 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.

8. At Risk Factors at time of birth Revised the AT RISK Factors and introduced the MTCT at risk box.

9. Addition of infant feeding section. Additional information added on care of children in view of HIV epidemic. The new Infant Feeding and Care Panel

10. 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.

11. 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).

12. 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

13. 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.

14. 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.

15. 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.

16. 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.

17. 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