A Process Evaluation of the Isoniazid Preventive Therapy Program in Sanyati District, Mashonaland West Province, Zimbabwe 2019

Abstract

Introduction: The Isoniazid Preventive Therapy (IPT) is a public health program dedicated to reducing mortality due to TB through early screening for active TB among people who are HIV-positive and early initiation on IPT of all who are eligible. A review of the 2019 Sanyati District IPT program data indicated that not all clients eligible for the IPT were initiated on the IPT program. In January, June, September, and December, 3% of IPT eligible HIV-positive clients were initiated on IPT; in March, May, and October, 2%, in April, July and November, 1%, in February, 5% and in August 2019, 4%. Only 4% of all IPT illegible HIV positive clients were initiated on IPT in 2019 against a target of 100% set by the Global Fund. A 31% dropout rate was recorded from the 94 clients initiated on IPT. Of the 26 health facilities in Sanyati District including five Kadoma City Council Clinics, only 16 health facilities were offering Antiretroviral Therapy (ART) initiation and IPT services. The IPT program in Sanyati District has never been evaluated, therefore a process evaluation of the IPT programme in the district was conducted to recommend strategies to improve on initiation of all eligible IPT clients.

Methods: A process evaluation among 16 health facilities which were offering IPT and ART services in Sanyati District was conducted using the logic model and the IPT program theory. The evaluator employed a mixed methods approach, using interviewer administered questionnaires, key informant guides to collect data and a review of IPT registers and all the documents used for the IPT program. The Statistical Package for Social Sciences (SPSS) software was used to generate frequencies, means and proportions, narrative, content, and thematic analyses were used for qualitative data analysis. The evaluation was approved by Mashonaland West Provincial Ethics Committee and permission was obtained from Sanyati District Health Executive and the Health Studies Office.

Results: Data from 81 health workers in health facilities offering IPT services in Sanyati District were analysed. Majority of health workers 39% (31/81) were Primary Care Nurses (PCNs). Only two of 16 health facilities had inadequate health workers. The median years in service for the interviewed key informants was 2(Q1=1; Q3=2.5) years. Only seven IPT guidelines and 11 TB/HIV Co-management guidelines were available, and they were not adequate for the 26 health facilities in the district. Tuberculosis screening tools, Directly Observed Therapy (DOT) registers and the Isoniazid (INH) medicines were all available more than the district requirements. Health worker mentorship, social mobilisation, support and supervision as well as IPT review meetings were not done in 2019. Only 4% (94/2350) of the HIV-positive clients who were illegible for IPT were initiated on IPT. No meetings were held on IPT in the district and only 10% (224/2350) of HIV-positive clients were screened for TB in 2019.

Conclusion: The IPT program in Sanyati District had inadequate inputs; not all processes were achieved and, most of the program outputs were not met as most clients who were eligible for IPT were not initiated on IPT. There was lack of health worker mentorship as well as quarterly support and supervision visits by the program managers. We recommended training of health workers on IPT, production and distribution of IEC material and procurement of IPT guidelines and motorization of health workers who were involved in IPT follow ups.