We present our findings on the communication of the test and treat all policy change in Zambia based on the policy makes and health provider perspectives. Emerging themes from the data included; communication strategy for HIV/AIDS policy change, implementation of policy change, effect of policy change on practice and acceptability of policy change. Although data were collected from various participant categories, no major differences in the discussions were noted and views specific to a particular participant category are noted within the manuscript.
1.0. Communication strategy for HIV/AIDS policy change to test-and-treat
1.1. HIV/AIDS strategic framework for 2017 to 2021
The policy makers mentioned that government had outlined a policy communication strategy that was operationalised through the HIV/AIDS strategic framework for 2017 to 2021. The strategic framework provides for coordination and management of the policy response to HIV/AIDS in Zambia. The coordination of the HIV/AIDS policy change takes place at national, provincial, district and community levels by aligning national priorities, expected outcomes and targets that all stakeholders should work towards. However, the frontline health providers revealed that the awareness strategies for HIV/AIDS policy change to test-and-treat-all that were put in place by the MoH through the strategic framework were inadequate. They narrated that the change to test-and-treat policy took them by surprise, as there had been limited prior information. They felt that the policy change was abruptly introduced in the health systems without orientation.
‘‘There is also a communication strategy, guided by HIV/AIDS strategic framework, on how each sector of the health system is going to be informed from the facilities, to community leaders to the people living with HIV to even those who would take care of those people living with HIV.’’ (KII 02 Policy maker MoH 02)
‘‘Even us health workers we were not ready for it. They just said, just go and test, so we had to put ourselves in their shoes, the clients; we had to explain that it was a government policy or program so we just had to do it without explaining its benefit.’’ (FGD 03 Primary health facility participant)
1.2. Communication channels of policy change
The policy makers stated that to communicate policy, MoH generates a circular that cascades to the provincial health offices, district offices, tertiary secondary through to primary health care facilities and vice versa. However, the frontline health providers indicated that these processes seemed not to have been fully utilized when introducing the test-and-treat policy. Even when the above channels of communication were followed, the communication of policy changes delayed to reach implementers and the community. Some providers stated that verbal instructions via phone calls as well as informal messages about the change in policy to test-and-treat were given before written instructions were provided to the health facilities.
‘So, policy ideally is communicated from the district, the district gets it from the province, province from the ministry. But with new technology now many are the times where you just see a WhatsApp message, oh! This is from the ministry but we always like to wait for official communication from the district before we act on anything…’’ (KII 07 Secondary health facility manager)
1.3. The role of the media in communicating the policy change to test-and-treat-all
1.3.1. National television and radio stations
The frontline HCWs mentioned that the media played an important role in communicating the test and treat policy to both the public and facilities. The test and treat policy change were first communicated to the public through the national television by the president of the republic of Zambia. It was reported that it was during the presidential pronouncement that some of the frontline HCWs got to know about the HIV test and treat policy. Following the presidential pronouncement many media houses such as print and radio amplified the sensitization of the test and treat policy. The health care providers indicated that since the president had to make this announcement on national television to reach the entire country, it signified the importance government attached to this particular policy change.
‘‘I personally got it from TV that there is test and treat there was no communication from management, am sure most of us got it from TV…’’ (FGD 01, Tertiary health facility participant)
‘Sensitization was done using TV and radios, but it's like many people did not understand what it meant. A lot of people we were still in denial despite being told, about that test and treat policy. But it took some time when it started it wasn't easy after sometime people came to understand and by now I can say it's only about 10% of people who are still refusing the test and treat’ (KII 08 DHO manager 01)
1.3.2. Information education and communication, and other print media
The policy makers mentioned that newspapers, brochures, and posters were used to communicate the test and treat policy change to the public. However, the frontline health care providers felt that distribution of print media did not reach certain populations as some people in most remote areas were unable to read and had no access. They thought using print media to communicate the test and treat policy change was ineffective for certain sections of society. For instance, few people from the community could afford to buy newspapers. The majority of the people who read newspapers are senior government officials as they are routinely provided to them as part of their office privilege. The providers also mentioned that late delivery of print media affected real time communication of the policy change. It was suggested that use of online print media especially via social media platforms like Facebook, Instagram, WhatsApp, and messenger should have been used as it could be accessed by those with smart phones as they said:
‘‘I can't say ah no we were not involved in developing IEC materials, again what comes first is English posters, these our people cannot read, even local language sometimes it becomes political which language to hang up. The message on pictures sometimes needs to be explained. Even me I think I don’t know if you ask me details on posters...’’ (KII 12 primary health facility manager 02)
‘‘The social media television, radios or WhatsApp, Facebook or SMS all this is very effective, even young people like these online issues there is also a lot of gossip so they can get the information using distractors…’’ (FGD 01 Tertiary health facility participant)
2.0. Implementation of test and treat HIV policy change
2.1. Historical context and knowledge and history of HIV/AIDS health policy changes
All the participants were cognizant of HIV/AIDS health policy changes in Zambia over the years. Policy makers and health facility managers were more knowledgeable on history of HIV policies; while those from primary and secondary levels were not keen about when and why polices were changed or phased out. Though not in order, participants were able to mention many previous HIV policies. The commonly cited policies were DCT, option B+ under maternal health and VCT which they felt had was present in all policies due to its emphasis on the counselling aspect. The participants in all the health facilities felt that they were still actively using the VCT but only applied it differently. This is because counselling was being offered to all clients as they provided test and treat. The points of services were also still being referred to as VCT rooms.
‘‘Remember these things have been happening for a long time, there has been testing but it become now compulsory that everybody who come must be tested and tested counselled though it started with VCT and DCT...’’(KII 04 Tertiary health facility manager 01)
‘‘VCT is still there some people still walk into a facility on their own position to offer to have a test yeah. You can differentiate test and treat really to…, the only difference is that there is no gap now ok, no waiting for cd4 count to drop that’s the major difference with test and treat’’ (KII 05 NAC manager 01)
2.2. Stakeholder engagement in test and treat health policy change
The facility managers described that the government engaged various stakeholders such as public services organizations, companies and civil organizations to encourage people to take-up HIV tests including access to self-testing. Partners who were running different HIV programs in the health facilities were also engaged to support the test-and-treat policy. These partners such as PEPFAR, CDC played a vital role in providing resources to advertise and explain the HIV policy change to test-and-treat. Similarly, community-based structures through local health committees were engaged to support the policy change to test-and-treat. However, the participants felt that the engagement was mostly top-down, and not much room was provided to improve this relationship given the rapid change in policy and short time to implementation. A frontline HCW and health facility manager said:
‘‘I would really say they need to look at this … when a policy first of all at formulation level they should really involve the grass root, implementers of this policy. As the policy is being formulated, find that it is passed and it has to be implemented again let the orientation begin with the key implementers’’ (KII 07 Secondary health facility manager)
2.3. Healthcare worker training for implementation of test-and-treat all policy
Both the health facility managers and frontline providers indicated that there was some training that was intiated for those providing HIV care in the facilities. These training were undertaken in form of orientations given to a few selected health staff from tertiary and secondary health facilities. Some facilities were selected as pilot centres for test-and-treat policy before national wide scale-up. The facilities provided valuable lessons before the policy was expanded to other primary facilities. However, some participants felt that not much was head about this pilot, as it seemed to only cover a few health facilities. Key lessons were not communicated to the providers in other facilities. Further, the policy makers agreed that information in the health facilities at all levels of care concerning this policy was not uniform due to different levels of individual service provision and staff capacity. The tertiary levels had in most cases highly specialised officers due to required service standards including concerning HIV management and vice versa for lower levels of health facilities.
‘‘…So, throughout the country Yes; the test and treat policy is it being practiced, ah the variance in implementation may be there; what I mean is we have guidelines on how the test and treat may be implemented but, in some areas, it’s is a bit difficult to implement in such a way because they may not be receiving drugs directly from MSL (medical stores for life); they may not have lab facilities right there but in essence the test and treat is implemented everywhere.…’’ (KII 02 Policy maker MoH 02)
2.4. Materials and resources to support test and treat HIV health policy change
The facility managers and providers explained that there was a differential support in terms of resources depending on the level of the facility as well as the volume of patients that were being attended to. However, most of the participants felt that majority of the health facilities did not receive the adequate supplies and commodities to support the scale-up of the test-and-treat policy. They stated that this resulted in many facilities experiencing stock-outs of key supplies for the policy at the time of scale-up. When the policy was pronounced, the front-line providers indicated that they struggled with resources for initiating HIV services starting with basic medical utilities such as testing kits and baseline investigations. Further, the providers reported that the primary health care facilities which were usually found in the slums with high volume populations more material supplies to be able to provide the services for test-and-treat. A primary health facility manager said:
“I would be honest to say I don’t know when the formulation began and whether maybe when the formulation began, we were or I personally was not in the district then, maybe meetings took place and what, but… from my knowledge I may be wrong I don’t think we were involved We were not supported …. ….no, we were not supported. I can say for test and treat the key things we were struggling with even now things like urine stick, ok you want to have at least that dip stick you need as you are initiating the client…” (KII 07 Secondary health facility manager)
“. So now the Ministry of Healthsupplied us with more testing kits, through our partners like CDC and CIRDZ; they employed more peers as treatment supporters also counsellors. So, we received more Counsellors, more testing kits; yes, so we were able to do all the activities.” (KII 11 Primary health facility manager 01)
2.5. Financing test and treat HIV health policy change
The policy makers narrated that government had committed funding to the implementation of the test-and-treat policy change. However, the felt committed funds were still inadequate to carter for scale-up. For this reason, all participants indicated that funding from the partners was critical to sustain some of the policy changes in terms of service provision to HIV patients and management of care. The policy makers narrated that many partners were supporting the test and treat policy in community-based HIV programs. They increased funding and even funded staff to do part-time work to offset increased workload in selected high-volume primary level health facilities. However, both policy makers and health providers felt that having most funding for HIV services in the hands of donors was unsustainable given that this was a lifelong disease and it bordered on the economic development of the country. The partner support also included recruitment of staff at the health facilities, remuneration of staff, providing incentives, availing resources for policy monitoring and evaluation.
‘‘…The ministry invested in this policy a lot. And partners came on board and we are grateful to this…’’ (KII 15 Policy maker MoH 03)
‘‘…. you know the country is divided into two parts, the northern region has six provinces: Copperbelt; central, north-western; Luapula; Muchinga and northern, these are supported by USAID. Then the others Lusaka, eastern, western and southern are supported by CDC. And each of these; they give funds to different organisations in these provinces, and thefunds they receive these organisations they are supposed to support the facilities under their care…’’ (KII 03 HIV partners - manager)
3.0. Changes brought about by the HIV policy change to test-and-treat
3.1. Human resources and infrastructure adjustment
The frontline HCWs and managers described how the test-and-treat policy silently changed the operations of the health systems from the primary, secondary and tertiary levels of health care. They explained that some of the changes brought about by this policy change included demand for human resource, operationalization; infrastructure physical readjustment of utilization of space in some facilities to accommodate the expanded services for counselling and screening; change in work schedules; increased working hours; patient interactions skills and service provision to patients just to mention a few. However, the policy makers mentioned that they did not anticipate an overhaul operation of the health systems due to the HIV policy change but expected services to run as usual. A policy maker said:
‘‘... It changed the way we provide services because it meant that services were now tailored towards addressing that policy; but it was not easy on the ground because the staff and buildings remained the same, so workload increased because as a clinician as someone is attending to clients when you see that there is positive you have to shift certain things in the facility so that they receive the treatment there and then, and it was difficult….’’ (KII 06 DHO manager)
4.0. Acceptability of test and treat HIV health policy
4.1. Accepatability of policy among health providers
Both the facility managers and frontline providers explained that the test and treat policy was widely accepted among healthcare workers as a long-awaited policy which had made HIV service provision easier. This is because they felt it contributed to reducing ill health of clients with advanced HIV. They thought early testing and treating of patients, as advocated for in the policy test-and-treat policy entailed putting the patients in better position to avoid opportunistic infections and mortality. Being able to manage HIV in its early stages meant that patient visitations to the facilities would be reduced, but also address congested HIV service infrastructure. The screening and checking procedures were made simple helping them to make accurate diagnoses after the HIV test results were known. A frontline HCW from a District Health Office said:
‘‘…Now we benefited because it helped us by finding out what is disturbing this patient and you put the patient on the correct drugs and the two weeks later the patient recovers; patients who could have been on the ward for a long time, in and out but once you put someone on correct medicines 2 weeks later, they are fit...’’ (KII 08 DHO HIV program manager 02)
4.2. Sense ofownership of HIV/AIDS policy change
The health facility managers and frontline providers mentioned that they felt little sense of ownership of HIV/AIDS policy change to test-and-treat. They saw this HIV/AIDS policy change as more of an agenda of the ministry; hence they did not feel responsible for its successful implementation. Further, the health facility managers reported that policy makers from the MoH and partners seemed to have taken it for granted that health facility personnel would perform and implement the new HIV policy change to test-and-treat with minimal supervision making some individual providers to be hesitant about making certain decisions. The lack of institutional changes to support policy change such as restructuring human resource operations to accommodate and sustain policy change made local capacity to own the policy challenging. Furthermore, presence of various partner organisation pushing the policy change agenda also made the providers to question ownership and the intentions of the policy. One manager had this to say:
“... to implement anything that is new you must supervise, if you don’t supervise many policies fall through but if you don’t it will not work, if you supervise It will work…first of all policy must be mentored then, number two it must be explained, and then must be implemented and implementation involves supervision, supervision especially when you are just introducing something new…” (KII 04 Tertiary health facility manager 01)
4.3. Policy change resistance from the community members
Both the facility managers and frontline providers explained that when the test-and-treat policy was first rolled out to the public, many community members thought that it was just imposed on them and so they resisted it. They narrated that they had to spend a lot of time negotiating to convince the clients seeking health services to accept being tested-and-treated. The policy makers on the other hand seemed to have ignored the possible resistance to the test-and-treat policy from public. They seemed to have taken it for granted that somehow community members would appreciate the value of this policy given its benefits. Further, the policy makers seemed to have focused more on the statistics and targeted achievements of the test and treat policy. One policy maker said:
‘‘…It was aimed at curative that all people found positive should be given ARVs for free, even testing is free and preventive level because we know those on HIV medications, we presumed would stop spreading the infection if they comply with treatment. From the numbers the policy is doing wonders a lot of people are on drugs now….’’ (KII 15 Policy maker MoH 03)
While an implementer had this to say:
‘‘…so, it was difficult and it is still difficult. We are struggling with the issue of retention into care; but are fighting hard by continuing with sensitisation, community peers who follow them and to just explain to them on the benefits of being on medication. But I cannot lie we are losing people on medication especially those we put on medication during the period of test and treat because they were not ready…’’ (KI 08 DHO HIV Programme Manager 01)