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

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

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.

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.

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.

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.

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.

“At Risk Factors” at time of birth

Revised the “AT RISK Factors” and introduced the “MTCT” at risk box.

Addition of infant feeding section.

Additional information added on care of children in view of HIV epidemic.

The new Infant Feeding and Care Panel

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.

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).

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

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.

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.

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.

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.

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