Zimbabwe: 'I Have the knowledge and skills to help'.

In Zimbabwe, Hebron Gotora's workday officially ends at 4:30 p.m., but it is often later than 6:00 p.m. when he navigates his bicycle down the bumpy dirt road to his home in the community of Chihota. His dedication and pride as a community-based distributor (CBD) of contraceptives for the Zimbabwe National Family Planning Council (ZNFPC) is evident. Seemingly everywhere, people seek him out for advice.

Gotora has been a CBD worker for nearly a decade, taking family health services beyond clinic walls to the doorsteps of people in the community. But his job was recently expanded to include the more holistic approach of providing information about HIV/AIDS, sexually transmitted infections (STIs), HIV voluntary counseling and testing (VCT), referrals to VCT services, access to prevention of mother-to-child transmission services, and much more.

"With my new role, I feel renewed," Gotora, 39, and a father of three, said in a recent interview with the Advance Africa project, supported by the U.S. Agency for International Development (USAID). "Now I can assist many people."

Advance Africa, a consortium of six organizations that includes FHI and seeks to increase family planning and reproductive health services in sub-Saharan Africa, began working with the ZNFPC in 2001 to integrate HIV/AIDS services into the jobs of CBD workers. The initiative followed an extensive ZNFPC review of the existing CBD program that considered ways of expanding CBD workers' roles to address the AIDS crisis in the country. Such expansion was natural since CBD workers were already reaching people of reproductive age. The expanded CBD program, which targeted adolescents, men, and low-parity women, was piloted in eight districts and has since been expanded to 16 districts. USAID and Advance Africa continue to provide financial and technical support.

Initial districts were chosen based on proximity to VCT centers (so clients could make the trip within a day), availability of CBD workers, and proximity to ZNFPC provincial offices for support and supervision. VCT services in Zimbabwe are still largely urban based. CBD workers serve in rural areas, but few have problems making referrals because "clients are already asking them about HIV," says Premila Bartlett of FHI, who is country director for Advance Africa in Zimbabwe. The main challenges are the scarcity of VCT centers and travel difficulties that many clients face due to the country's economic decline.

Before CBD workers were trained for their expanded role, ZNFPC reviewed, streamlined, and revised CBD responsibilities and guidelines. Advance Africa provided technical assistance to ZNFPC to develop a curriculum. Subsequent training at headquarters and the provincial level targeted leaders of CBD groups, CBD workers, and volunteer depot holders (who work from home to provide information and resupply clients). To date, 19 CBD supervisors, 141 CBD workers, and 379 depot holders have been trained.

Although the project has not been evaluated, Advance Africa is working with ZNFPC to develop improved monitoring and evaluation systems and to assess the cost and cost-effectiveness of expanded service delivery, among other things.

Anecdotal evidence suggests that trained CBD workers and depot holders have embraced the provision of information beyond family planning. And initial analyses of the expanded program have been encouraging. Between 2001 and 2003, CBD referrals for VCT rose from 121 to 840, and referrals for STI and HIV/AIDS care rose from 202 to 499. The number of people receiving HIV/AIDS information and behavior change messages through group meetings rose 10-fold, from some 3,000 to more than 30,000. The impact of HIV/AIDS activities has also been measured in terms of the distribution of condoms: some 725,000 male and female condoms in 2003, compared to about 175,000 in 2001. Meanwhile, access to family planning has increased and quality has improved, as providers have been retrained about contraceptive methods and now spend more time with clients. Distribution of oral contraceptives increased from about 53,000 in 2001 to more than 360,000 in 2003.

However, lack of funding has prohibited growth of the expanded program to a proposed 58 districts in Zimbabwe, says Bartlett. Similarly, economic factors have compromised the strength of Zimbabwe's well-respected CBD program as a whole. Since the 1980s, Zimbabwe's network of about 800 salaried male and female CBD workers has shrunk to an estimated 550. Another concern is that CBD workers as a group are aging. Some find it difficult to ride a bike long distances and may not be "the most appropriate" people to reach youth, a goal of the expanded program, says Bartlett.

Nevertheless, "the CBDs are generally happy with their roles and find that they are now more relevant to the needs of their communities," she says.

Gotora continues to reach out with his expanded message anywhere he can--churches, businesses, agricultural shows, clubs, and even roadside meetings in villages or at his own home. He says he considers his job nothing short of an honor.

"Now I can communicate and discuss with everyone, whereas in the past, we talked only about family planning and to women alone," Gotora said recently. "Women, men, and youth, many of them school-leavers, seek my services and advice on their different health and reproductive concerns. And I have the knowledge and skills to help."