Table Of Contents:

1) The Impact of HIV/AIDS on the Performance of the Health Sector: A Case Study of Gutu Mission Hospital, Zimbabwe
M. J. Chimbari and J. F. Mangoma

2) Report on the Social and Economic Impact of HIV/AIDS on Rural Households in Masvingo Province: The Case of Gutu District M. M. Mhloyi

3) Adolescent Girls’ Susceptibility and Vulnerability to HIV and AIDS: The Case of Murehwa District, Zimbabwe Naomi N. Wekwete and Nyasha Madzingira

The Impact of HIV/AIDS on the Performance of the Health Sector: A Case Study of Gutu Mission Hospital, Zimbabwe
M. J. Chimbari and J. F. Mangoma

EXECUTIVE SUMMARY
Background

This study was funded by the Organization for Social Science Research in Eastern and Southern Africa (OSSREA) under the theme “The HIV/AIDS Challenge in Africa”. The study investigated the impacts of HIV and AIDS on the performance of a district mission hospital in Zimbabwe. It complements an earlier study that provided an overview of the impacts of HIV and AIDS on the
health sector, at national level. The present study was conducted at a time when Zimbabwe was experiencing serious economic problems that negatively affected performance of all public sectors. Thus, the socio-economic and political environment prevailing at the time that the study was conducted were important confounders whose effects could not easily be teased out from the effects of HIV and AIDS alone.

Methods

A case study approach on Gutu Mission Hospital was used. A combination of several data collection tools was used to gather both quantitative and qualitative data. These included in-depth interviews, structured questionnaires, focus group discussions, passive observations and use of data routinely collected by the health information department at the hospital. Although permission to conduct the study had been granted by the provincial medical director and by the hospital executive, participation of individuals in the study was upon their verbal consent. Data analysis was based on assessment of the following hospital performance dimensions: clinical effectiveness, patient centredness, production efficiency, staff orientation, safety and responsive governance.

Findings

Clinical effectiveness Almost 40% of inpatients at the hospital had HIV infections and these patients were a major drain of hospital resources. The length of stay of patients in the hospital averaged 5.46 days and the patient outcome was negatively affected by erratic supply of essential drugs and other hospital sundries. The Out Patient Department (OPD) was congested because there were many follow up cases mostly for HIV and TB infections. For the years 2000 to 2003 the follow up cases for HIV ranged from 139 to 633 while for TB they ranged from 962 to 1771.

Patient centredness

It appears patients generally appreciated services offered by the hospital although they could not get all the drugs they needed. This indicates that they appreciated the economic environment in which the hospital was operating. It seems, though, that health services were mainly limited to affording patients, particularly in cases where prescriptions had to be purchased by the patients.

Production efficiency

Production efficiency was compromised by shortages of some essential drugs, high operational costs because of the large proportion of inpatients with HIV infections, poor staffing levels and a congested OPD.

Staff orientation

The staffing situation at the hospital was bad with 15 nurses and 2 doctor posts vacant. Key posts like that of x-ray and pharmacy technicians were not on the establishment. Members of staff were generally demotivated and burnout due to long hours of work was indicated. Every nurse and nurse aide interviewed said they experienced at least one of the following symptoms of burnout: general tiredness, backache, poor concentration, persistent headaches, stress and hostility to both patients and workmates. Eleven out of 13 nursing staff died of HIV related illnesses between 1997 and 2003 indicating that HIV has also affected staff. All those that died of HIV related illnesses had exhausted their sick and vacation leave days by the time of their deaths. This further stresses a health system experiencing acute staff shortages.

Safety

The observed increased number of patients with HIV infections requires that there be high safety standards. Unfortunately standards observed were suboptimal due to shortage of protective clothing. Some accidents like needle stick injuries that must be reported in order to provide staff with prophylactic treatment were not reported because of general unawareness among staff and fear of being tested for HIV.

Responsive governance

The home-based care (HBC) programme contributed towards decongestion of wards but pressure built on the OPD as the HBC programme was inadequately supported resulting in increased follow up cases. The antenatal antiretroviral programme (AAP) seemed to be doing well.

Conclusions

It was concluded that HIV related illnesses and TB negatively affected the performance of Gutu Mission Hospital to a sub-optimal level. However, the authors acknowledge that the harsh economic environment prevailing in the country at the time of the study had serious confounding effects that could not be easily teased out.

Report on the Social and Economic Impact of HIV/AIDS on Rural Households in Masvingo Province:
The Case of Gutu District M. M. Mhloyi

EXECUTIVE SUMMARY

This study was undertaken in Gutu District in Masvingo Province, which is experiencing some of the highest HIV infection rates in the country. The objectives of the study were to: a) examine the impact of increasing morbidity and mortality on production and consumption patterns (food security, education, health status) in Gutu District; b) examine the mechanisms adopted by households to mitigate these impacts; c) identify and characterize households highly vulnerable to the adverse impact of HIV/AIDS; and d) provide policy recommendations on the form of assistance required by seriously affected households.

The study revealed that HIV/AIDS has an impact on individuals, households and communities. Individuals infected by HIV often suffer from anger, blame, guilt, fear of rejection and death, stigma and isolation. They also cease to be productive to the extent that by the time they are seriously ill they do not have any source of income, a situation which undermines their ability to get health care services, afford food, and support their families. Demographically, HIV/AIDS has reduced household size while altering the composition of the households. About 56% of all the households reported having orphans, 15% were maternal orphans while 30% and 11% were paternal and dual orphans, respectively. Grand-mother-headed households and sibling-headed-households have emerged and these are the most vulnerable households. Socio-economic effects were also identified. Household income was reported to have declined. This resulted from the fact that breadwinners were either sick or had died. In addition, income had been reduced because households’ productive time had been diverted to caring for the sick. The available income was also diverted to illnesses. Although the study showed that food security declined in affected and unaffected households in Gutu, affected households were the hardest hit. For instance, while maize production declined by 30% in unaffected households, it declined by 38% in affected households; millet production declined by 29% and 34% in unaffected and affected households, respectively. For example, the production of groundnuts declined by 50% and 90% in unaffected and affected households, respectively. In addition to the fact that some affected households had sold even draughts power and other agricultural implements in order to raise money to care for the sick; agricultural output in Gutu District declined in both affected and unaffected households because of perennial droughts, limited access to inputs such as treated seed and fertilizer which are largely unavailable and unaffordable. The quality of life at household level has invariably deteriorated. The decline in household income also led to the decline in school enrolment of the orphans; however, it was noted that school enrolment declined in both affected and unaffected households. While 82% of school going children in unaffected households were enrolled in 2004, about 66% of children from affected households were attending school. Education suffered the most because heads of households maintained that when resources are limited, it is only logical to cut out school while investing in food which the respective households cannot do without. At school, affected school children were reported to have problems of absenteeism, lack of concentration and isolation. The study revealed that orphans suffer more from economic problems which also in turn, gave rise to some of the limited psychological problems which such orphans had. The study showed that orphans received adequate psychological support and their psychosocial status was fairly comparable to that of their non-affected counterparts. At community level, it was shown that morbidity and mortality had increased in Gutu District with 53% of the households reporting having a serious illness within the three months prior to the survey. On the average, about 33% of the households reported having experienced a death since 1999. However, the study revealed that the home-based care in the district could best be described as “progressed home-based dying” which is women centred. This was largely because the carers did not have support in the form of transport and materials for use in the caring. On the other hand, the sick persons did not have adequate food or treatment. However, women were reported as bearing the brunt of caring starting from youth. As young girls, women often dropped out of school to care for the sick parents and continued to head households after the death of the parents. As wives, women cared for their husbands who normally got sick earlier than them. At old age, women cared for their daughters who were either left alone by dead husbands, or who were sent to their natal homes when they got sick. After the death of their children, old women cared for orphans; it is a life cycle of suffering. The reported increase in morbidity and consequent mortality was also reported to have increased the number of orphans. In addition, the community was reported to be losing a lot of productive time visiting the sick and attending funerals; thus, community production commensurately declined. There were limited adaptive strategies in place. At household level, it was noted that widows were more likely to engage in income generating activities such as selling clothes and other marketable goods. It was reported that some women even resorted to begging; this was reported largely for grandmothers. It was also noted that some young girls resorted to commercial sex work which was often intended to support the family with food, clothing and school fees for those still in school. Unfortunately, such young women were reported not to use condoms often for fear of turning away customers. Most of the commercial sex work is carried out at a very busy growth point, Mupandawana, which services the community under study, and which is in turn serviced by public transport which goes to many parts of the country; this makes this growth point one of the epicentres of HIV infection in the country. In addition, commercial sex work will inevitably expose the orphans to HIV infections, an inherent inter-generational transfer of HIV infection which largely emanates from the fact that parents do not plan for their children after their death. In fact, planning for children is undermined by perennial poverty, devaluing currency. Some orphans are also exploited by the extended family members who inherit the property of the deceased. The community needs to be trained to write wills which can be implemented by village heads in order to protect orphans from such exploitation. The food problem is largely alleviated by food aid from government and nongovernmental organizations. However, such handouts were considered as inadequate. Some households worked for food; however, this was largely reported for those households which had experienced a death; households with an illness found it difficult to work away from home. It was recommended that affected households, particularly grand-mother-headed and child-headedhouseholds, should be assisted with agricultural inputs. Affected children need full educational support, while the girl child needs special attention. It was also recommended that the infected and their children must be assisted to start and run income generating activities. Such interventions would assist the infected to get incomes for their treatment, food and other needs, while assisting the transfer of skills from parents to children who might remain more financially stable. Effective home based care should relieve the girl child at least for the hours she needs to be at school. Since grandmothers were identified as the most caring persons for orphans, they need assistance in the form of food, clothing and fees for the children. The grandmothers need to have access to medical care to enable them to live longer and care for the orphans. The country should create a supportive environment for HIV positive people by providing anti-retroviral (ARV) drugs. It should be noted that provision of these drugs would greatly reduce the number of person years of orphanhood which are more costly to the nation than the drugs. Provision of ARV would also facilitate people’s disclosure of their sero-positive status, which will in turn make people appreciate that HIV/AIDS is among them. The increased perceived risk which would emanate from people’s knowledge of HIV/AIDS as a disease which affects anyone will enhance people’s desire to protect themselves. It is also necessary to support home based care programmes and link them with hospitals in order to provide a continuum of care that is needed by those who suffer from AIDS and have to oscillate between home and hospital. Supported home based care programmes must involve both men and women. Communities must be educated on home remedies for different ailments that affect HIV infected people. The provision of ARV drugs, home remedies and other treatment would enhance people’s desire to get tested, which would in turn enhance HIV prevention. Finally, it is necessary for the country to aim at eradicating, or at least, reducing poverty from its current levels. Once people have more disposable income, some will not expose themselves in search of money, and those who are infected will be able to afford their medical expenses and positive living thereby being able to live longer. In turn, person years of orphanhood and destitution will be reduced.


Adolescent Girls’ Susceptibility and Vulnerability to HIV and AIDS: The Case of Murehwa District, Zimbabwe Naomi N. Wekwete and Nyasha Madzingira


This report on “Girls Susceptibility and Vulnerability to HIV and AIDS” outlines girls’ perceptions of their HIV risk assessment and reasons why they are more vulnerable to HIV and AIDS. The study was triggered by findings from a previous study in the same area which revealed that the majority of the girls perceived themselves not at risk of HIV and AIDS, although nearly half the new HIV infections is among adolescents. The study was undertaken in Murehwa District, using both quantitative and qualitative methods of data collection. A total of 538 girls aged 15-19, in and out of school, were included in the study. The results revealed that a small percentage of girls admitted engaging in sexual activity; it is likely that they underreported their sexual experience. Of great concern, however, was the relatively high percentage of sexually experienced girls who reported that they were forced, raped, coerced or tricked into initiation of sexual activity. Despite the high levels of AIDS awareness, misconceptions and beliefs that are not factual still prevail among some of the girls. Girls’ self-efficacy in refusing sex, condom use, and communication was found to be moderate. Also the majority of the girls saw barriers in condom use. Most girls perceived themselves not at risk because they were not sexually active, although a significant percentage of the girls reported that the initiation of sex ‘just happened’. Significant differences in self-efficacy, barriers to condom use and perception of risk to HIV were found between schoolgirls and out-of-school girls, and also between the sexually experienced and the sexually inexperienced ones. Despite these individual characteristics that make girls more vulnerable to HIV and AIDS, economic and socio-cultural factors were also cited as contributing to the high risk. These include poverty, cultural practices, traditional and faith healers, leaders of some religious sects, sugar daddies and peer pressure. Given these findings, some of the recommendations proposed included the involvement of family and traditional leaders in addressing cultural beliefs and practices, prioritisation of HIV and AIDS prevention in education, reporting mechanisms of rape or forced sexual activity and the empowerment of girls with negotiating skills to safer sex.