Analysis of sexual and reproductive healthcare utilisation among young people in Zimbabwe.

Doctoral Degree. University of KwaZulu-Natal, Durban.Despite the development and implementation of an adolescent and youth sexual and reproductive health (ASRH) strategic plan in 2010, Zimbabwe has the third-highest HIV prevalence amongst sexually active teenagers in Southern Africa. The country can potentially suffer future socioeconomic decline due to adverse health outcomes resulting from the current risky sexual and reproductive health behaviour among its youth and adolescents. The attainment of the United Nations’ Sustainable Development Goals (SDGs) may be compromised owing to this predicament. The thesis analysed the utilisation of adolescent and youth sexual and reproductive health services and their outcomes in four essays. The first essay investigated the socioeconomic factors that influence ASRH service utilisation, the resultant outcomes and their distribution. The essay updated existing literature by providing recent evidence on ASRH specific socioeconomic determinants and their equity connotations, which has been lacking since the implementation of the ASRH strategy in 2010. The essay applied the logistic regression and concentration index techniques on the Zimbabwe Demographic Health survey (ZDHS) data. Findings revealed that inequalities favouring advantaged groups widened in STI treatment, HIV testing, STI treatment, as well as in condom and contraceptive use. Progress was made in early childbearing, which declined among the uneducated. Another positive development was the disproportionately higher HIV infection among females, which declined by almost half between 2005 and 2015. The second essay analysed the impact of the government’s ASRH strategy on the utilisation of ASRH services. The essay’s contribution was its quantitative insight into whether a multi-pronged approach or commitment of more resources results in better ASRH outcomes. The difference-in-differences impact evaluation technique was applied to ZDHS data collected in 2010 and 2015. Results indicated that service utilisation for HIV testing and treatment of sexually transmitted infections (STIs) increased. The ASRH strategy also reduced HIV prevalence. These impacts differed by education status and place of residence. Results also showed that provinces that received more resources did not attain better ASRH outcomes, suggesting that future focus should be on the quality of services. The third essay sought to characterise the risk preferences of youth. Its contribution lies in using prospect theory to fit youth risk-taking in the domain of sexual and reproductive health as a departure from the normally assumed expected utility theory. Primary data was collected from university students in Zimbabwe using a socioeconomic questionnaire and pairwise lottery choice tasks based on hypothetical ASRH interventions with uncertain outcomes. Prospect theory parameters were estimated using patterns of the respondents’ choices over the lottery tasks. This is the first study, to the researcher’s best knowledge, that estimates ASRH risk parameters within the prospect theory framework. Bivariate techniques, ordinary least squares and interval regression methods were used to examine socioeconomic differences in risk preferences. Results indicated that the ASRH behaviour of youth fits within prospect theory. Bivariate and multivariate regression analyses showed that income, prior sexual and reproductive health knowledge, and alcoholism were associated with risk and loss aversion. The fourth essay investigated the long-term consequences of ASRH practices from the female youths’ perspective as the hardest hit gender. The essay’s contribution lies in unearthing the magnitude of lifelong effects of failure to utilise ASRH interventions during adolescence, which is missing from Zimbabwean literature. The essay applied propensity score matching and multivariate regression techniques on ZDHS data collected in 2015. Findings revealed that non-utilisation of ASRH services leads to lower educational attainment, lesser chances of career development, poverty, as well as the contracting of STIs and HIV infections. Overall, these findings have several implications. Firstly, health policymaking must consider inclusive ASRH strategies that target currently excluded youths in rural areas, uneducated and poor households, and consider their unique risk preferences. In addition to that, future ASRH strategies should focus on service quality and increased coverage to improve outcomes and attain SDG targets. Secondly, the nature of youths’ risk preferences entails that ASRH awareness campaigns be positively framed to improve uptake of ASRH services. In addition to that, policymakers need to facilitate youth economic emancipation to increase economic prospects, which improves economic reference points that are critical facilitators of risk aversion. Lastly, future ASRH strategies need to have better coordination and monitoring since they involve different implementers. Furthermore, the ASRH strategy needs to be integrated into other sectors' goals that it impacts, such as education and labour

Determinants of maternal healthcare utilization in Zimbabwe

Zimbabwe and other developing countries struggle to achieve millennium development goals originally set for 2015. To assist health policy making, there was an investigation of how demographic, socioeconomic and cultural factors determine maternal healthcare services use in Zimbabwe. A logistic model for four different maternal healthcare services using data from the 2005/6 Zimbabwe Demographic Health Survey was estimated. Secondary education increases the odds of use of maternal health services by at least 2 times at 1 percent level of significance whilst access to information increases the odds by 1.52 at the 5 percent level of significance. Women in urban areas are more likely to give birth at healthcare facilities OR 3.49 compared to their rural counterparts at 1 percent significance level. Women from highest income households are more likely to give birth at health facilities than those from poorest households OR 6.44 at 1 percent level of significance whilst the pattern is consistent for other services as well. Other important determinants are age, education, wealth, polygamy and religious affiliation. Generally, policy makers have to appreciate that these factors affect different maternal health services differently. Consequently, strategies to improve the uptake of maternal healthcare like mass media and health workers, particularly for disadvantaged sections of the population like rural areas and the uneducated, should be targeted at specific components rather than planning umbrella strategies

THE ROLE OF WOMEN IN REDUCING ABSOLUTE POVERTY IN RURAL ZIMBABWE: A Case Study of Bindura District (2008 to 2011)

ABSTRAC

Cost effectiveness analysis of clinically driven versus routine laboratory monitoring of antiretroviral therapy in Uganda and Zimbabwe.

BACKGROUND: Despite funding constraints for treatment programmes in Africa, the costs and economic consequences of routine laboratory monitoring for efficacy and toxicity of antiretroviral therapy (ART) have rarely been evaluated. METHODS: Cost-effectiveness analysis was conducted in the DART trial (ISRCTN13968779). Adults in Uganda/Zimbabwe starting ART were randomised to clinically-driven monitoring (CDM) or laboratory and clinical monitoring (LCM); individual patient data on healthcare resource utilisation and outcomes were valued with primary economic costs and utilities. Total costs of first/second-line ART, routine 12-weekly CD4 and biochemistry/haematology tests, additional diagnostic investigations, clinic visits, concomitant medications and hospitalisations were considered from the public healthcare sector perspective. A Markov model was used to extrapolate costs and benefits 20 years beyond the trial. RESULTS: 3316 (1660LCM;1656CDM) symptomatic, immunosuppressed ART-naive adults (median (IQR) age 37 (32,42); CD4 86 (31,139) cells/mm(3)) were followed for median 4.9 years. LCM had a mean 0.112 year (41 days) survival benefit at an additional mean cost of $765 [95$7386 [3277,dominated] per life-year gained and $7793 [4442,39179] per quality-adjusted life year gained. Routine toxicity tests were prominent cost-drivers and had no benefit. With 12-weekly CD4 monitoring from year 2 on ART, low-cost second-line ART, but without toxicity monitoring, CD4 test costs need to fall below$3.78 to become cost-effective (<3xper-capita GDP, following WHO benchmarks). CD4 monitoring at current costs as undertaken in DART was not cost-effective in the long-term. CONCLUSIONS: There is no rationale for routine toxicity monitoring, which did not affect outcomes and was costly. Even though beneficial, there is little justification for routine 12-weekly CD4 monitoring of ART at current test costs in low-income African countries. CD4 monitoring, restricted to the second year on ART onwards, could be cost-effective with lower cost second-line therapy and development of a cheaper, ideally point-of-care, CD4 test

Impact of the adolescent and youth sexual and reproductive health strategy on service utilisation and health outcomes in Zimbabwe.

Poor reproductive health among youth and adolescents threatens their future health and economic wellbeing in Zimbabwe amidst a high HIV/AIDS prevalence. This study evaluates the impact of a multi-pronged adolescent sexual and reproductive health (ASRH) strategy implemented by government of Zimbabwe between 2010 and 2015 to improve ASRH in terms of the uptake of condoms and HIV testing as well as outcomes in terms of sexually transmitted infection (STI) prevalence and HIV prevalence. We combine the difference in difference and propensity score matching methods to analyse repeated Zimbabwe demographic health survey cross-sectional datasets. Young people aged 15-19 years at baseline in 2010, who were exposed for the entire five-year strategy are designated as the treatment group and young adults aged 25-29 at baseline as the control. We find that the ASRH strategy increased HIV testing amongst youth by 36.6 percent, whilst treatment of STIs also increased by 30.4 percent. We also find that the HIV prevalence trajectory was reduced by 0.7 percent. We do not find evidence of impact on condom use and STI prevalence. The findings also suggest that although HIV testing increased for all socio-economic groups that were investigated, the effect was not the same. Lastly, we do not find evidence supporting that more resources translate to better ASRH outcomes. We recommend designing future ASRH strategies in a way that differentiates service delivery for youths in HIV hotspots, rural areas and out of school. We also recommend improving the strategy's coordination and monitoring, as well as aligning and enforcing government policies that promote sexual and reproductive health rights

Unit costs in 2008 US$.

*<p>Annual drug costs of keeping a patient on this specific combination of drugs continuously for 365 days.</p>†<p>Per diem hospital costs from Adam T, Evans DB and Murray CJL, 2003 were reflated to 2008 USD($).</p>‡<p>Other unit costs for diagnostic investigations (including X rays, TB smears, CSF analysis etc) and non-routine biochemistry and haematology tests are not listed here but were obtained from National Referral Laboratories prices list.</p

Cost-effectiveness acceptability curves.

<p>Cost-effectiveness acceptability curves.</p