BACKGROUND: In 2021, PEPFAR released guidance introducing more comprehensive criteria for an adolescent girl or young woman (AGYW) to complete DREAMS, and simultaneously emphasizing a public health approach to saturating the vulnerable population of AGYW. Zimbabwe is nearing DREAMS saturation in 10 districts under the former definition of completion, finishing the primary package plus at least one secondary service. As the country implements new guidelines in 2023, we assessed the impact of the new criteria on our ability to maintain saturation among AGYW going forward.
DESCRIPTION: We examined needs assessment data to estimate the number of services required for AGYW by age and district to complete DREAMS according to new guidance. To see how many AGYW would complete DREAMS in 2023 assuming the same budget level, we applied service delivery data from 2022. We estimated outcomes prioritizing either AGYW with higher needs who require more services, or those with lower needs who require fewer services. We modeled the results forward for 2023 to determine the impact on saturation levels.
LESSONS LEARNED: In 2022, AGYW completing the primary package received an average of 1.4 secondary services; analysis of preliminary quarter 1 data shows that AGYW needed, on average, 2.5 services to complete using the new definition. Modeling demonstrates reductions in the number of AGYW who would complete DREAMS and in overall saturation. We found significant differences in completion and saturation depending on whether the program prioritizes highest need (39,701 would complete with 32 districts at saturation) or lowest need AGYW (84,683 would complete with 39 districts at saturation). Using previous completion guidance, 95,780 AGYW would complete DREAMS with 41 of 48 districts at saturation.
CONCLUSIONS: With current budgets, new completion criteria will reduce the number of AGYW that complete DREAMS in 2023. The new criteria may inadvertently incentivize programs to prioritize low-needs AGYW to achieve saturation. In the Zimbabwean context of high needs among AGYW, the requirement to deliver all services needed by an AGYW in order for her to complete DREAMS is at odds with program objectives to reach the most vulnerable AGYW.

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