Dissecting the Role of Donors in Capacity Building for HIV/AIDS Treatment,Care and Support: A Case Study of an Antiretroviral Therapy Programme in Zimbabwe

Abstract

Donor involvement in development activities in the Global South has been questioned for failing to capacitate communities in the recipient country. Therefore, the need to establish whether the Médecins Sans Frontières (MSF) antiretroviral treatment (ART) programme in Zimbabwe contributed to capacity building for HIV and AIDS support, care and treatment triggered this study. A qualitative methodology involving semi-structured interviews with purposively selected participants was adopted. As a result of the MSF programme, community-based clinics created ART support groups which facilitated easy access to medication and health-related information. Dispensing of medication and testing could also be done in these clinics, which were previously the district hospitals. These interventions reduced waiting periods and long-distance travel to access HIV and AIDS care, support and treatment, thus improving the healthcare quality. Community-influenced strategies are recommended to sustain these improvements.

Introduction

HIV and AIDS remain one of the most important global public health concerns, especially in sub-Saharan Africa where prevalence rates are still very high. While the HIV-positive cases are estimated at 39 million, AIDS still claims 630,000 lives each year. Most of these are from the disadvantaged, marginalised and vulnerable populations (UNAIDS, 2023). Curbing the spread of this virus and keeping AIDS cases where they are is pivotal, thus requiring sustainable programmes focusing on treatment, care and support (Kim, 2018; UNAIDS, 2023). Given the huge burden of HIV and AIDS, it amounts to 38.4 million people globally living with the disease (UNAIDS, 2022b), needing care, treatment and support. Inconsistent universal access and adherence to treatment and support remain commonplace in many low-income countries, regardless of the billions of dollars invested in HIV and AIDS programmes such as voluntary counselling and testing, health education and antiretroviral (ARV) therapy (Campbell and Cornish, 2010; Tran and Nguyen, 2012). The colliding AIDS and COVID pandemics, coupled with socio-economic hardships, severely affected the AIDS response, rendering communities more vulnerable (UNAIDS, 2022b). Hence, capacity building could be the mainstay for creating resilient and empowered communities and care workers to manage HIV and AIDS. Therefore, it is imperative to analyse the role of donors in capacity building in communities to understand their strategies and effectiveness.

While some governments in this region have been able to build capacity for managing HIV and AIDS programmes, in countries such as Zimbabwe, donors are playing a pivotal role. Because donor involvement in development activities in developing countries such as this one has always been questionable, especially regarding capacity for locals such that post donor-departure they can stand on their own (Karikari, 2002; Wolf, 2007), this study contributes to the debate by exploring the role of donor funding in building capacity for HIV and AIDS programmes in this country. It is, therefore, key to establish whether the available programmes in the region have the capacity to manage HIV and AIDS, given their importance in this space. Capacity building is vital in managing HIV and AIDS, as it may foster resilience, enhance access to healthcare services, and promote education and awareness. Empowered communities are better equipped to support those who are affected by HIV and AIDS, contribute to stigma reduction and drive collective action towards prevention, treatment and ultimately minimise their effects.

The literature is replete with information on the role of non-governmental organisations (NGOs) and donors in capacity building; however, there is no conclusive agreement as to whether they have facilitated capacity building or not. In a study by Mervis (2012), which examined the NGOs in complementing government efforts towards achievement of the millennium development goal of combating HIV and AIDS by 2015, it was found that NGOs had implemented government policies both in rural and urban areas; however, there was lack of coordination of functions between NGOs and the government, which affected national responses such as having HIV and AIDS programmes in some areas while others did not. In another study, Skovdal et al. (2013) found that community groups were developing local and collective solutions to structural problems, often independently of external NGOs, but recommended synergy and collaboration between local community groups and networks with other external HIV service delivery sectors. However, in another study, Skovdal et al. (2017) found that partnerships with NGOs enable community groups to respond more effectively to HIV as well as boost their motivation and morale. However, in a study by Campbell et al. (2013) on community participation as a critical enabler of an effective HIV and AIDS response, it was noted that external interference in indigenous relationships risks undermining the localisation and bottom–up initiative and activism. Cuadros et al. (2019) conducted a detailed spatial analysis of the geographical structure of the HIV epidemic in Zimbabwe to include geographical prioritisation as a key component of their HIV intervention strategy. The study found that HIV-infected populations lacking ART coverage and viral suppression were concentrated in the main cities and urban settlements, and they suggested that there is a need to tailor HIV programmes to address specific local needs to efficiently achieve epidemic control in Zimbabwe (Cuadros et al., 2019). Therefore, the role of NGOs in HIV and AIDS remains a contentious issue which warrants further research.

It is crucial in this situation to comprehend how funders contribute to the capacity building of HIV and AIDS programmes. This article, therefore, wants to close the literature gap about Zimbabwe as studies by Bedelu et al. (2007) focused on a model of decentralised HIV and AIDS care in Lusikisiki, South Africa and Pellecchia et al. (2017) and Decroo et al. (2017) focused on effects of community ART groups on retention in care among patients in Malawi and Mozambique, respectively, highlighting how Médecins Sans Frontières (MSF) capacitated communities. It may give insights necessary for optimising the capacity of HIV and AIDS treatment, care and support systems in resource-limited contexts by studying the contributions, challenges and implications of donor funding.

This descriptive phenomenological study aims to analyse donors’ role in building the capacity of communities and care workers in HIV and AIDS care, treatment and support. To achieve this, the study explores the views and explanations of people in the case study of the MSF ART programme which was implemented in Zimbabwe from 2000 to 2013. The study reflects upon stories of change and describes and analyses the transition of MSF ART programme until it was handed over to the government of Zimbabwe’s Ministry of Health and Childcare (MoHCC) in 2012. The main question in this study is what strategies MSF uses to capacitate communities and care workers for HIV and AIDS treatment, care and support in Buhera and Tsholotsho districts in Zimbabwe. This study contributes to the debate relating to development aid effectiveness and donor–community partnership. It also adds to the debate on how donors are working with the communities to reach and sustain epidemic control of HIV and seroconversion to AIDS.

Access to ART

Since the beginning of the epidemic, 84. 2 million people have acquired HIV. The number of those who had access to ART increased from7.8 million in 2010 to 28.7 million by the end of December 2021(UNAIDS, 2022a). In the same year, 75% of all HIV-positive individuals received treatment, and 88% of this were aware of their condition. The fast spread of this treatment especially in low-income countries over the years has significantly decreased HIV-related morbidity and death and turned HIV into a chronic condition (Tran and Nguyen, 2012).

Zimbabwe has made tremendous progress towards attaining the UNAIDS 90–90–90 treatment targets and the 2020 Global Prevention Coalition Road map under its multisectoral response (MoHCC, 2020). However, there is unmet need for ART in Zimbabwe (UNAIDS, 2015), which still has a relatively high HIV prevalence (11.6%), especially for the highly active population aged between 15 and 49 years. With approximately 1.1 million people on ART, it translates to 89% of people living with HIV across the country receiving ART. The estimated AIDS deaths of people aged 15 and above is 17,000 and estimated orphans due to AIDS is 550,000 (Centre for Disease Control and Prevention (CDC), 2022). This shows that HIV and AIDS remain a critical public health challenge in this country underpinned by systematic challenges, among which is resource fragility. It remains a challenge to achieve the universal access target and ensure the quality of HIV and AIDS care and treatment services. Ongoing success towards controlling the HIV and AIDS epidemic could be enhanced by capacity building of the community and health workers, which is promised through the MSF ART programme (Robinson et al., 2024; Tshiyoyo, 2022). However, scant information is available about the performance of such programmes, which is why this study is important.

MSF started working in Zimbabwe in 2000 in partnership with the Ministry of Health and Child Care (MoHCC) at the central, provincial and district levels to provide access to ART for the first time to HIV and AIDS patients in Zimbabwe. According to the MSF Report of July 2012 (MSF, 2012), at the end of 2011, they supported about 48,430 clients on ARV treatment. Buhera had the highest number of beneficiaries, at 18,590. In Epworth, 14,220 beneficiaries were under treatment, while in Bulawayo and Gweru, 11,000 patients participated in the programme in each region. In Tsholotsho, 9000 patients were on ARV treatment. The MSF project in Beitbridge had 2500 patients. All the beneficiaries were fully integrated into the National Health Systems (NHS) (MSF, 2012), when the MSF programme was handed over to the government. This programme was selected for this study because it transitioned from donor funding to government funding under the MoHCC (Magocha et al., 2023).

While substantial progress has been made in expanding access to HIV and AIDS treatment and care services in other countries the challenges persist, particularly in Zimbabwe, because of limited resources (Rasschaert et al., 2012). Be that as it may, despite the significant financial and technical support provided by donors, questions remain regarding the effectiveness, sustainability and long-term impact of their interventions. In addition, the dependency on external funding sources raises concerns about the autonomy and self-reliance of local health systems. Thus, there is a pressing need to explore the role of donors in capacity building within the context of HIV and AIDS treatment, care and support programmes in Zimbabwe. This study seeks to address this gap by analysing the experiences, perceptions and outcomes associated with donor involvement in an ART programme, ultimately aiming to inform evidence-based strategies for strengthening indigenous capacity and resilience in combating the HIV and AIDS epidemic. This study is critical because Zimbabwe in its comprehensive national HIV strategic plan for the years 2021–2025, the state emphasises the need for collaboration beyond the government circles as a key contributor towards treatment, care and support (MoHCC, 2020). This plan highlights the gaps in efforts taken to manage these scourges. They include lack of implementation of innovative and high-yield HIV testing service models as well as weak linkage between HIV testing services and ART initiation (MoHCC, 2020).

This case study is, therefore, necessary as it provides insights which can assist in determining whether donors, such as MSF, are helpful in building the capacity that the communities and healthcare workers need for HIV and AIDS care, treatment and support in Zimbabwe’s Buhera and Tsholotsho districts. Using Garlick’s capacity-building framework, it highlights how MSF developed and strengthened individual, organisational and community capacities. The study is significant for policymakers and healthcare practitioners, as it may provide a deeper understanding of how donor-funded programmes can enhance local healthcare systems and improve access to essential services for vulnerable populations. It also emphasises the importance of integrating donor interventions into national health systems for long-term access to care. In addition, it contributes to the global discourse on capacity building for improving ART treatment, care and support.

Theoretical framework

This study is underpinned by the Garlick capacity-building framework, which identified five major elements of capacity building for regional Australia (McGinty, 2003). These elements are knowledge building, which is the capacity to enhance skills, utilise research and development, and foster learning. Leadership is the capacity to develop shared directions and influence what happens in the region (in this case what happens in the project). The third element is network building, which is the capacity to form partnerships and alliances; valuing community and its ability to work together to achieve their objectives, and finally, supporting information, which is the capacity to collect, access and utilise quality information (McGinty, 2003). When applied to this study, this theory provides insights into how MSF ART programmes managed to build the capacity of the individuals and communities in Buhera and Tsholotsho districts. In addition, the Garlick theory can help explain how MSF managed to lead and build the skills of individuals and communities. It also provides a valuable lens to understand how MSF managed to engage with the community and build partnerships as well as using information gathered from the individuals and communities to build capacity. In this study, capacity building is understood as a process in which different entities within a society (including individuals, organisations, institutions and society) reach the goal (such as treatment, counselling, performing functions or managing affairs) and maintain that ability (Kim, 2018). It also involves the creation of structures, resources, policies and procedures in organisations and networks to sustain and achieve relevant goals, cope with complexity and innovate (Robeson, 2009). Capacity building is built on partnerships and collaborations, as well as on how such efforts can be sustained in low- and middle-income countries (Dawson-Rose et al., 2020). At a time when UNAIDS advocates for support and effective resource community, community-led responses are proving to be game changers in reducing inequalities and supporting effective and resilient HIV responses (UNAIDS, 2022b). Therefore, it is imperative to explore capacity building as a critical enabler of HIV and AIDS care, treatment and support within communities.

Method

This study used a case study of the MSF programme on ART, which commenced in 2004, with programme activities implemented in six rural districts of Buhera, Epworth, Gutu, Beitbridge, Tsholotsho and Chikomba in Zimbabwe.

Consolidated criteria for reporting a qualitative research checklist were used to guide this study (Hughes et al., 2020). The following three domains were followed: research team and reflexivity (personal characteristics, relationship with participants), study design (methodological orientation and theory, participant selection, setting, data collection) and analysis and findings (data analysis and reporting) (Hughes et al., 2020). The study adopted an interpretivist paradigm, thus producing rich descriptive data based on the experiences of the health professionals and derived from participants’ own words (Taylor et al., 2015). Forty participants were purposively sampled for the study (Cresswell, 2013; Jensen and Laurie, 2016) and the number was determined after data saturation was reached (Jensen and Laurie, 2016; Magocha et al., 2023). These included 2 district administration officers (DAs), 2 district AIDS committee (DAC) members, 2 district medical officers (DMOs), 2 district nursing officers (DNOs), 4 project managers of different NGOs, 15 nurses and 6 MSF staff in Buhera and Tsholotsho. All these participants were selected because they were deemed as data-rich sources, therefore in a better position to offer valuable insights into the study as they are directly involved with the programme (Jensen and Laurie, 2016). Furthermore, seven informants were chosen from the provincial and national MoHCC offices. The key informants were considered to have more direct, personal knowledge of the subject under study, who can also be referred to as data-rich sources. Second, the research questions and objectives were used to purposively identify and determine the type of participants to be recruited for in-depth interviews. Face-to-face in-depth semi-structured interviews were conducted to answer the main research question: ‘What strategies does MSF use to capacitate communities and care workers for HIV and AIDS treatment, care and support in Buhera and Tsholotsho districts in Zimbabwe?’ This question was mainly asking for the participants’ experiences about whether the programme had capacitated individuals and communities, changes that they could attribute to the programme, and whether there is any progress that the programme made in HIV and AIDS care, treatment and support in Zimbabwe.

Data analysis

A thematic approach was used to analyse data. Data were read and transcribed and interpreted by the researchers. ATLAS.ti software version 7.1.4. Burnard et al. (2008) was used to organise the data by highlighting texts, phrases, words and writing word(s) or phrases representing a category in the margin (Friese, 2012). The codes were created from the patterns that emerged. An initial coding frame was developed (Hughes et al., 2020). For the trustworthiness of the data, two coders worked separately and cross-validated their results. The initial themes that were derived from the codes were compared with the data and further redefined. These are used to present the findings which are discussed in the ‘Results’ section later in the paper. These themes were further explained and assigned meanings using thick description of data (Jensen and Laurie, 2016) in the form of opinions of individuals who were directly and indirectly involved with the MSF project.

Ethical approval

Ethical approval of the study was obtained from the North-West University Research Ethics Regulatory Committee on 4 November 2014 under Ethics No. NWU-00308-14-A9. In addition, permission was also sought from the MSF management and Chiefs to access the two districts. The purpose of the study was explained to all participants who were also informed about their right to withdraw from the study any time without any consequences since participation was voluntary, if they deemed it necessary. Participants were also given a consent form to complete. Interviews were held in offices and private spaces in the homes of the participants where only the interviewee and interviewer were present.

Results

The results focus on the role that development aid plays in capacity building of the MSF ART programme in Buhera and Tsholotsho districts. To ensure a structured approach to the presentation of the research findings, the empirical evidence was presented in themes.

Models of care

During the in-depth interviews with the key informants, participants stressed that MSF, together with the community, produced tailor-made ART delivery models that were meant to capacitate ART beneficiaries, hospitals and clinics to cope with escalating caseloads as well as meet the prevention and treatment needs of the ART beneficiaries. In addition, they said that the models of care were underpinned by the participation, empowerment and health education of individuals and communities. These models included Community ART Groups (CAG), decentralisation and community support groups.

The CAGs

The CAGs, as explained by the participants, are made up of small groups of 4–8 beneficiaries of the ART programme who stay in the same area. The CAG model was meant to address the challenges faced by vulnerable people living with HIV and AIDS in accessing treatment. Among the challenges are the costs of transport, distance travelled, time taken to and from the health centres and congestion at these stations. The key informants explained that the beneficiaries are supposed to collect their medication monthly; therefore, they take turns in doing so. The aim is to reduce congestion at the health facilities as well as help beneficiaries save resources such as money and time. Resultantly, the beneficiaries were saved from walking long distances to health centres One nurse had this to say:

. . . finally, right now we are doing this Community Art Groups by which we are trying to have one member of a small group coming in a rotation to collect drugs instead of all coming we would have one coming out of four, out of six, out of eight which would reduce the congestion which allows also to bring user friendliness to facilitate the life of a patient/clients. This has significantly reduced the number of defaulters because they no longer walk every month to collect pills. (Nurse, Buhera)

Initially, the CAGs started in three health centres in Tsholotsho: Nkunzi, Sipepa and Pumula. These locations were chosen because there were many people on ARV treatment who lived far away and had to travel there to collect their medicines and because public transport was lacking and expensive in those areas because of poor roads. (MSF staff, Tsholotsho)

While community members benefitted from their collaboration, the CAG capacitated the hospital and clinic staff because they could now work with manageable group sizes in a day, unlike before, when they had to serve large crowds of people. As the nurse in Buhera explained, these groups further improved ART adherence by the beneficiaries and lessened the burden of dealing with defaulters by the health staff:

CAG led to increased adherence to ART, has reduced workloads and congestion at clinics, minimised transport costs for patients, enhanced individual and community resilience, reduced stigma and enhanced health clinic and community partnerships. (Nurse, Buhera)

The participants reported that, first, CAG created a conducive environment for networking among group members and hence played a significant role in promoting the physical, psychological, social and spiritual well-being of the community members. Second, this model provided a platform for beneficiaries to interact, support each other in managing the chronic needs associated with HIV and AIDS, and increase adherence to treatment. As MSF staff and ART beneficiaries explained:

CAG helps the consciousness and autonomy of people in a rural society that was historically disadvantaged, through this model you would realise that patients develop self-management skills which are important as far as their treatment is concerned. (MSF staff)

CAG has enabled us [ART patients] to save a lot of time which we used to waste every month in going to collect our medicines. But now we can afford to do productive work because we take turns to go to clinic to collect pills. (ART beneficiary)

Decentralisation of services

Through the MSF Art programme, the services were decentralised from the district hospitals to local clinics, which increased access to services. As a result, they managed to broaden the scope of delivery of ART outside district hospitals by involving the clinics and communities. This was defined by one doctor as taking the treatment to the people:

Treatment was taken to the people and at clinic levels, patients can get these services free of charge, so they also benefit, there was also support with drugs for opportunistic infections and these drugs are normally made available free of charge to the patients and even at clinic level. (Medical doctor, Buhera)

When the programme started, it was centralised; all clients had to go to the district hospital to get ART services, but through decentralisation it moved to all treatment centres in the districts, which are closer to the clients. For example, in Buhera district, services and beneficiaries were decentralised from Murambinda mission hospital to 25 referral centres (2 rural hospitals and 23 clinics) and in Tsholotsho they were decentralised from the district hospital to 18 referral centres. The community was capacitated in the sense that it could now access and afford the available services, such as therapy, counselling and scanning, at their nearest centres. In the in-depth interviews, participants reported that decentralisation became handy for the resource-strained people in the rural areas who did not have money to visit faraway health centres. It also reduced cases of people defaulting, because the services were brought closer to the clients and more people were reached:

They said they discovered that people were defaulting saying we do not have bus fare, so I think the problem has been at district hospitals that is when the drugs were being decentralised and everything. (Nurse, Tsholotsho)

Some participants acknowledged that decentralisation enhanced task shifting of treatment initiation to lower-level health workers such as nurses and nurse aides because initially ART was administered by medical doctors only. Through decentralisation, the nurses were empowered to do HIV testing and enrol HIV patients on the ART programme. Consequently, decentralisation became instrumental in enabling lower-level healthcare providers to deliver care.

Support groups

Support groups were identified as part of the models of care that enhanced the capacity building of healthcare workers and ART beneficiaries. The MSF ART programme promoted support groups, which allowed peer interaction and education among the beneficiaries. The support groups were formed by old and newly diagnosed HIV-positive patients who were living within the same community. The support groups facilitated regular home visits, the exchange of health information and building the health knowledge base among peers who were living with HIV and AIDS. Other participants had the view that the support groups that were initiated by the MSF ART programme resuscitated the Mbuya Utsanana model (Village Health Workers), which was once operational and focused on community healthcare at the primary level, linking it to the formal health system. These support group healthcare workers supported the delivery and monitoring of HIV and AIDS treatment by making follow-up visits to patients who did not honour their scheduled appointments. One key informant explains:

. . . but we simply benefit information, information is power, when you are given information about HIV and AIDS you become aware. Those support groups we benefit because we were taught how to protect ourselves from HIV and AIDS. (Community key informant, Buhera)

. . . people were coming saying, ndarohwa nemvura yepasi (I was beaten by underground water) meaning herpes zoster so they were not knowing that was it and there were many people suffering from TB and other things without even suspecting they thought it was witchcraft. (Nurse, Tsholotsho)

Key informants explained that support groups improved the beneficiaries’ knowledge about HIV and AIDS management, home-based care skills, nutritional advice and HIV prevention knowledge by sharing information among the group members or peers. As explained by most participants, the peer group members met to share experiences, counsel and encourage each other with regard to the management of their chronic conditions and adherence to ART. Through support groups, the community and patients were accorded the autonomous power to manage HIV and AIDS, which helped to reduce the associated stigma. This was articulated by a key informant from Tsholotsho to illustrate the importance of support groups:

There were some support groups to educate other people. Those who are already HIV positive would form support groups to educate other patients who are newly diagnosed with HIV so that they will manage to accept and control the situation. (Key informant, Tsholotsho)

Mentoring

The MSF ART programme also capacitated the Ministry of Health staff at district level through mentoring on ART management. The responses this study got from participants suggest that MSF invested substantial human resources who were responsible for mentoring the ministry of health staff on how to handle HIV cases and administer ART. The MoHCC was capacitated through skills transfer by the highly qualified experts, who came from within and outside Zimbabwe. These took place mainly through on-the-job trainings. The skills (e.g. routine HIV care, M & E, testing and screening) were transferred through trainings that included theoretical and practical trainings, which were referred to as on-the-job trainings in the interviews with key informants. One MSF staffer said:

. . . came the next phase which was the capacity building. So, you had to now transfer the competencies from the high experienced MSF staff to the MoHCC staff and that of course that needed a lot of trainings, theoretical trainings and then also on the job trainings. (MSF staff, Tsholotsho)

MSF also had teams which offered clinical mentoring, which focused mainly on routine HIV care, and administration of ARV drugs to patients. This was explained by MSF staff as follows:

Then MSF on the other side commits itself to provide this mentoring teams and to have this mentoring teams to visit the clinics on periodic basis whereby MoH again commits itself to have a mentoring team available to be mentored by our team so you have mentoring of mentors approach by which the mentors are the MoH staff on one side and the mentors of these mentors are MSF staff, so the commitments are on one side to transfer these competences and on the other side to receive these competencies. (MSF staff, Tsholotsho)

The mentorship element of the programme was done in such a manner that the nurses who were mentored by the MSF mentors also had their own teams that they were mentoring. As a result, more people became familiar with the administration of HIV and AIDS-related medicines, which contributed more patients being treated in various parts of the districts. Mentoring was not only done at the staff level, it was also done at the community level, where mothers who had received Prevention of Mother-to-Child Transmission (PMTCT) also mentored their peers who were newly introduced to the programme:

Based on volunteer work, HIV positive women who have already gone through the PMTCT program act as mentor mothers to provide peer support and first-hand experience to women newly enrolled in the program. (Nurse, Tsholotsho)

The training focused on giving ART to those who needed it. The in-depth interviews with MoHCC staff revealed that the training also included, among other issues, skills transfer on how to use specialised machines like the CD4 count machines and other innovative and cost-effective tools such as the GeneXpert, which were supplied by MSF to diagnose TB in HIV-infected people:

They were trained, nine courses they were trained under MSF which pertains the HIV programme because they were trained even for CD4 machines, they were trained even to test the people, they were trained all the things which we are doing here for those mothers they were trained the staff members were trained. (Senior Nurse, Buhera)

The participants said that the trainings were truly relevant because before MSF, there were no people trained to initiate patients on ART except for maternal PMTCT. As was pointed out in some interviews that were conducted:

Aaaum, before MSF there wasn’t much about the initiation of HIV, it was more on PMTCT where there was a programme being offered to the pregnant mothers by Miss Tsungai (not her real name) and group I can’t remember the name. It was more to do with maternity than to all other patients. (Nurse, Tsholotsho)

Furthermore, most of the participants reiterated that the training was done in a way that encouraged learning. The trainers allowed knowledge exchange among the facilitators and the participants. Those who were exposed to these trainings appreciated the fact that it was a two-way learning process that encouraged knowledge exchange:

Most of us gained a lot from MSF, their doctors used to train us a lot of things regarding OI (Opportunistic Infections) ART. We were intact, working together so beautifully and being taught how to manage ART patients. So, we appreciated in terms of knowledge and good teamwork, we learned a lot from them though they also learned a lot from us, we had a good teamwork. (Nurse, Tsholotsho)

Employment opportunities

The MSF ART programme created employment opportunities through which people got income that they used for their basic needs. In a country where most of the economically active people who had qualifications were out of employment, any acceptable form of employment helps them build the capacity that they would not if they were unemployed. MSF employed medical doctors, nurses, counsellors and support staff such as logistics personnel, guards and general handmen. About 108 of these were stationed at Buhera, while 73 workers were in Tsholotsho. A key informant explains:

At one-time MSF had to employ a lot of people and I am sure at one-time MSF was a big employer in the district in as much as health is concerned. (Key informant, Buhera)

Another key informant added that the salaries were standard and could afford those who were employed a decent life as they were able to take care of families, pay school fees for their children and provide for their day-to-day needs:

Their salaries were good they gave us a standard life. The salaries helped us to keep our children and providing food for them. (Nurse, Tsholotsho)

The observation by the professional nurse, regarding employment of the local people, aligns with what MSF staff expressed. MSF was one of the programmes that employed many local people. However, in some areas where they needed specialised skills and technical knowledge on drug-resistant TB in HIV and knowledge that could not be found locally, they outsourced. Below is what he said:

The whole district benefited from employment except for those professions which were not found here those are the ones we had to take people from outside. (MSF staff, Buhera)

Monitoring and evaluation

The success of every programme is evaluated through its data that are collected on a continual basis. The patients, MSF local staff and the Ministry of health workers were tasked with collection of data regarding patients’ adherence to treatment. This assisted with continuous observation of the performance of the programme through progress of the patients and determining how to continue with the treatment. With such information, they were able to make decisions about the success of the programme. This was facilitated through the Follow-up and Care of HIV Infection and AIDS (FUCHIA) monitoring and evaluation tool. They therefore considered monitoring and evaluation as fundamental in controlling the health of patients as well as the HIV epidemic, as explained below by one of the medical doctors who participated in this study:

Monitoring HIV patients is fundamental for controlling their health, as well as the epidemic itself. It is important to know if the medication is working or not, how effective it is for the patient and against the virus. (Medical Doctor MoHCC)

Most of the participants reported that the MSF ART programme shared unique skills of monitoring and evaluation with Ministry of Health personnel, doctors and nurses through on-the-job trainings and workshops. The monitoring and evaluation skills did not only benefit the nurses and medical practitioners but also the community. As indicated by the participants, the community benefitted from basic information on how to monitor one another’s administration of medication as well as counting pills for each member in a group. Through monitoring and evaluation, the community members were trained to identify, discuss and document any new symptoms, adherence problems or unintended interruptions. The excerpt from a community informant below explains how the community members benefitted from monitoring and evaluation skills that they shared with MSF:

Each one of us in the group plays a role, we monitor how to take the medicines, we count the pills of each member every month and we encourage each other to keep on taking the medicines, as we were taught by our donors [MSF] (Community informant, Buhera).

To improve the health of the patients, the MSF ART programme invested in technology for accurate monitoring of the patients. To this effect, they brought some of the world recommended technologies like the viral load test machines and the GeneXpert.

Though viral load monitoring has been used for years in Western countries and is recommended by the World Health Organization as the model of care for HIV patients we only got it now through MSF. This technology accurately calculates the amount of virus in the patient’s body, unlike the usual test – known as the CD4 test – that is used in most countries without resources. (Medical staff, Buhera)

Participants indicated that MSF made sure that the patients’ conditions were monitored and evaluated regularly. To achieve this, MSF used a paper-based system with several registers plus an electronic database system (FUCHIA), where patients in the decentralised ART sites were monitored on a regular basis with regard to adherence, recurrence of opportunistic infection diseases and weight improvement. Participants mentioned that the monitoring and evaluation of patients included physical follow-ups for defaulters. The participants indicated that a monitoring system has been maintained over the past years, from the first ART initiation in 2004 to the time of transition in 2013.

Discussion

This study aimed to explore the role of MSF in capacitating communities and healthcare workers for HIV and AIDS treatment, care and support in Zimbabwe’s Buhera and Tsholotsho districts. Grounded in Garlick’s capacity-building framework, the theoretical approach effectively explains the multilayered capacity development fostered by the MSF ART programme. The findings show that MSF’s interventions were pivotal in capacitating individuals on ART, district hospitals and clinics, and broader societal structures through community-based ART groups.

A key innovation introduced by MSF was the CAG) model, which addressed the challenges faced by vulnerable populations in accessing HIV treatment. Barriers such as transportation costs, distance to referral centres, and long waiting times – identified in studies across sub-Saharan Africa (Addo-atuah et al., 2012; Azia et al., 2016) were effectively mitigated by this model. This is consistent with findings from Malawi and Mozambique, where decentralised ART services reduced both patient and health worker burdens (Decroo et al., 2017; Pellecchia et al., 2017; Rasschaert et al., 2012, 2014). By decentralising services, MSF not only reduced transport and occupational costs for patients but also improved ART adherence rates. The capacity of healthcare staff was enhanced as they dealt with manageable patient loads, significantly reducing defaulters and improving the quality of care. The focus on decentralisation underscores the potential for pro-poor development in healthcare, challenging assertions that such decentralisation is inadequate for improving service provision to marginalised populations (Wolf, 2007).

Moreover, the study highlights the role of CAGs in promoting holistic well-being within the community. These groups provided a structured environment for patients to support each other, enhancing physical, psychological and social well-being, while fostering stronger adherence to ART. This aligns with findings from Lusikisiki (Bedelu et al., 2007), where peer support groups similarly enabled patients to manage chronic HIV needs and combat stigma. The emphasis on peer interaction facilitated emotional and logistical support, particularly regarding drug refills and treatment management, as observed by Pellecchia et al. (2017) and Harrison et al. (2023). Such community engagement speaks of the broader implications of capacity-building models that empower beneficiaries to take ownership of their health, thereby reinforcing the sustainability of HIV and AIDS programmes.

The study also highlighted that access to treatment service such as therapy, counselling, screening and scanning were increased through the decentralisation process. In addition, decentralisation was instrumental in reducing cases of defaulters because services were brought closer to the clients and more people were reached. Decentralisation also promoted task shifting of treatment initiation to lower-level health workers, such as nurses and nurse aides, who could now do HIV testing and enrol HIV patients on ART programmes, which was a preserve of the doctors only. Studies done elsewhere concur with the findings of this study that decentralisation brings services closer to clients and improves patient access and retention in care (Kredo et al., 2013; Mukora et al., 2011; Otiso et al., 2017). However, in South Africa it was found that patients favour centralised services because of many reasons, among which were less stigma, patients established relationships at centralised clinics and availability of ancillary services (Mukora et al., 2011).

Contrary to critiques of foreign aid’s limited long-term impact on employment and poverty reduction (Page and Shimeles, 2015), this study presents a nuanced view. While MSF’s interventions indeed created temporary employment opportunities, particularly for health workers and community leaders, there is a need for sustained efforts to ensure the longevity of such employment beyond the lifespan of donor-driven programmes. The short-term nature of these jobs, although instrumental during the project, raises questions about the long-term sustainability of donor-funded employment in capacity-building efforts. This suggests that future interventions should consider more robust strategies for local job retention and capacity transfer post-programme.

According to the result of the study, the MSF ART programme developed the appropriate training, mentoring and supervision, which made it possible to delegate the running of the ART programme to primary healthcare nurses and community health workers. Mentoring allowed ancillary workers to support and engage in key processes of ART management such as service-user support, treatment preparedness, facilitation of support groups and health education (Bedelu et al., 2007).

Conclusion

While donor aid is often seen as an opportunity for creating dependency syndrome, this article demonstrates that MSF support influenced the development of capacities of local staff and the community. Based on Garlick’s capacity framework, MSF managed to build the capacity of the local staff and community through knowledge building, which enhanced the skills and fostered learning on ART management. Local staff were employed and received mentoring, and skills transfer on specialised areas such as routine HIV care, dispensing of ARV drugs, HIV testing, monitoring and evaluation, to lead the programme to enhance its sustainability. The capacity was also created by network building mostly at community level through decentralisation of services, community ART groups and support groups, which linked the community health systems with the formal health systems. In the process of capacity building, MSF involved the community to participate in leadership, where those mentored by MSF mentored others and encouraged peer interaction and education in the community. All these efforts resulted in empowerment of healthcare workers in local clinics as they could now manage the HIV and AIDS care, support and treatment better. The capacities resulted in increased access to ART, reduced congestion at ART centres, reduced travelling costs by patients and increased participation by community in provision of support for drug adherence and educational support.

Therefore, decentralising health services, as seen with MSF’s CAG model, should be scaled to improve access to treatment in rural areas. In fact, decentralisation should be viewed as a pro-poor development strategy to improve healthcare access for the most vulnerable populations. Institutionalising a comprehensive capacity-building strategy within national health systems is essential for long-term sustainability beyond donor intervention. Finally, policies should ensure that donor-funded employment transitions into permanent roles through local investment, addressing the temporary nature of jobs created by donor programmes. Peer-led support structures should also be integrated into national health strategies to promote ART adherence and reduce stigma and discrimination.

The sustainability of these positive accolades could not be investigated in this case study, it is therefore important to consider these in future. This may assist in determining whether donor intervention could be sustained by the community beyond the lifespan of the project. It is also imperative to undertake a comparative study to compare MSF programme with other similar programmes so that the results may be applied to the generality of Zimbabwe.