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ZIMBABWE ASSISTANCE PROGRAM IN MALARIA

QUARTERLY REPORT

APRIL 1 - JUNE 30, 2018

ZIMBABWE ASSISTANCE PROGRAM IN MALARIA

QUARTERLY REPORT

APRIL 1 - JUNE 30, 2018

Recommended Citation: Year 3, Quarter 3 April–June, 2018 Report. Rockville, MD and Harare, Zimbabwe. Zimbabwe Assistance Program in Malaria, Abt Associates Inc. Contract and Task Order Number: AID-613-A-15-00010 Submitted to: United States Agency for International Development/President’s Malaria Initiative Submitted on: July 30, 2018

Abt Associates Inc. 1 6130 Executive Boulevard 1 1 Rockville, Maryland 20852 1 T. 301.347.5000 1 F. 301.913.9061 1 www.abtassociates.com

CONTENTS

Contents ______i Acronyms ______iii 1. EXECUTIVE SUMMARY ______1 2. BACKGROUND ______1 3. ADMINISTRATIVE ACTIVITIES ______3 3.1 STAFFING AND MANAGEMENT ______3 3.2 CONFERENCES, RETREATS, TRAININGS AND MEETINGS ______3 4. TECHNICAL ACTIVITIES ______5 4.1 MALARIA CM AND MiP ______5 4.1.1 Sending of SMS reminders to health care workers ______5 4.1.2 Malaria Clinical Mentorship ______5 4.1.2.1 Selection of Mentors ______5 4.1.2.2 Training of mentors ______5 4.1.2.3 Commencement of malaria clinical mentorship visits ______9 4.1.3 Mashonaland Central malaria death audit meeting ______11 4.1.4 Community CM ______12 4.1.4.1 Binga VHW training ______12 4.1.4.2 Orientation of Health workers to VHW supportive supervision tools and processes ______13 4.1.4.3 Post training follow up and Supportive supervision ______15 4.2 LLINs ______22 4.2.1 Delivery of LLINs for CD ______22 4.2.1.1 Training on use of rectangular nets ______23 4.2.2 CD of LLINs ______27 4.2.3 Net Durability Study ______28 4.3 SBCC ______28 4.3.1 Assessment of Drivers of Continuing Malaria Transmission in Angwa Ward, Mbire District, Mashonaland Central Province ______28 4.3.2 Chikunda language malaria control Audio book for Chapoto ward in Mbire district, mashonaland central province ______31 4.3.3 SBCC Subcommittee meeting ______35 4.3.4 Community-based Activities ______36 4.3.4.1 CAC Refresher Course Training ______36 4.3.4.2 Matabeleland North CAC ToT ______37 4.3.4.3 Matabeleland North CAC District Sensitization (Binga and Hwange) ______37 4.3.4.4 CAC ACT-TOGETHER TRAINING IN MUTOKO DISTRICT ______37 4.3.4.5 GOROMONZI OUTBREAK SUPPORT______38 4.4 M&E/OR ______41

4.4.1 Assessment of Drivers of Continuing Malaria Transmission in Angwa Ward, Mbire District, Mashonaland Central Province ______41 4.4.2 Finalization of the National Malaria SM&E Plan ______41 4.4.3 Revision of the Epidemic Preparedness and Response Guidelines ______41 4.4.4 Training of Health Workers in M&E ______41 5. Gender ______42 6. Environmental Compliance ______42 7. CHALLENGES and LESSONS LEARNED ______44 7.1 CHALLENGES ______44 7.2 RECOMMENDATIONS AND LESSONS LEARNED______45 ANNEX A: PMP INDICATOR/YEAR 3 MILESTONE MATRIX ______47

ACRONYMS

ACT Artemisinin Combined Treatment ANC Antenatal Care CAC Community Action Cycle CD Continuous Distribution CM Case Management CCM Community Case Management CSBCC Community Social Behavior Change Communication DHE District Health Executive DHIS2 District Health Information System 2 DMO District Medical Officer DNO District National Office DPS Department of Pharmaceutical Services DQA Data Quality Assessment EHT Environmental Health Technician EPI Expanded Program on Immunization EPR Epidemic Preparedness and Response HCC Health Centre Committee HMIS Health Information Management System HW Health Worker IPC Infection Prevention and Control IPTp Intermittent Preventive Treatment in Pregnancy IRB Internal Review Board IRS Indoor Residual Spraying LLIN Long-lasting Insecticide-treated Net M&E Monitoring and Evaluation MIM Multilateral Initiative on Malaria MiP Malaria in Pregnancy MoHCC Ministry of Health and Child Care NDS Net Durability Study

iii

NMCP National Malaria Control Program OR Operational Research PEDCO Provincial Epidemiology and Disease Control Officer PEHO Provincial Environmental Health Officer PHE Provincial Health Executive PMD Province Medical Directorate PMI President’s Malaria Initiative PMP Performance Monitoring Plan PNO Provincial Nursing Officer RDT Rapid Diagnostic Test SBCC Social and Behavioral Change Communication SM&E Surveillance, Monitoring and Evaluation SMS Short Messaging Service SP Sulfadoxine-Pyrimethamine SS Supportive Supervision TBD To Be Determined TOT Train-the-Trainers USAID United States Agency for International Development VHW Village Health Worker ZAPIM Zimbabwe Assistance Program in Malaria ZDHS Zimbabwe Demographic and Health Survey

1. EXECUTIVE SUMMARY

This report presents the third quarter of Year 3 performance of the Zimbabwe Assistance Program in Malaria (ZAPIM). It covers the period April 1-June 30, 2018. ZAPIM accomplished the following planned activities during this quarter:  Sent short message service (SMS) reminder messages to 304 health care workers trained in case management (CM) and malaria in pregnancy (MiP) in Year 3  Trained 22 malaria clinical mentors from five districts (Mbire, Murewa, Mutoko, Hwange, and Binga)  Conducted a malaria death audit meeting in Mashonaland Central Province  Supported malaria clinical mentorship visits to 20 health facilities in four districts  Trained 120 village health workers (VHWs) in CM and MiP in Binga  Distributed registers, stationary, timers, satchel bags and T-shirts to 120 VHWs in Binga  Oriented 48 health workers in VHW supportive supervision tools and processes in Binga and Hwange districts  Held district VHW program review for Binga and Hwange  Conducted post-training follow up of (279) VHWs in three districts (Binga, Hwange, and Mudzi)  Conducted supportive supervision of 27 VHWs in five districts (Bindura, Centenary, Mt. Darwin, Mutoko, and Shamva)  Delivered 35,100 long-lasting insecticide-treated nets (LLINs) to five districts (Bindura, Guruve, Mazowe, Mt. Darwin, and Shamva) for continuous distribution (CD)  Distributed 25,153 LLINs through the CD channels. Will distribute the remaining nets, which are stored at various distribution points, next quarter.  Delivered 4,000 LLINs to three districts (Binga, Beitbridge, and Chipinge) in response to malaria epidemics  Introduced a pull system for ordering LLINs for CD by health facilities  Trained 40 health workers and 268 VHWs on the use of rectangular nets  Conducted an assessment of the forces behind continuous malaria transmission in Angwa Ward of Mbire District  Developed and launched the Chikunda audio book on malaria control  Supported and participated in social and behavior change communication (SBCC) subcommittee meeting held on June 8, 2018

 Held a Community Action Cycle (CAC) refresher course for 35 CAC district facilitators  Trained 10 CAC trainers in Matabeleland North  Held CAC district sensitization meetings in Binga and Hwange  Trained 11 health center committees on the CAC Act Together phase in Mutoko  Provided SBCC support for outbreak response in Goromonzi  Continued work on development of the malaria Surveillance, Monitoring and Evaluation (SM&E) Plan  Review of the Malaria Epidemic Preparedness and Response (EPR) plan is currently ongoing  Trained 51 health care workers on the SM&E plan in Mashonaland East  Sent the senior case management specialist to attend a train the trainers (TOT) session on malaria elimination organized by the National Malaria Control Program (NMCP)  Sent the M&E/operations research (OR) manager to attend a training on evaluation methods of malaria programs held in Ghana

2. BACKGROUND

The President’s Malaria Initiative (PMI) was created in 2005 to reduce malaria-related mortality by 50 percent across 15 high-burden countries in sub-Saharan Africa. The PMI’s commitment to combating malaria was bolstered with the 2008 passage of the Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act (www.pmi.gov/about). In fiscal year 2011, Zimbabwe was chosen to be a PMI country; the United States Agency for International Development (USAID) had provided some limited support prior on indoor residual spraying (IRS) and commodity procurement (Zimbabwe Malaria Operational Plan 2016). The PMI supports an array of malaria prevention and treatment activities in Zimbabwe, including LLIN procurement and distribution, IRS in high-burden areas, rapid diagnostic tests (RDT), artemisinin combined treatment (ACT), sulfadoxine-pyrimethamine procurement and distribution, and the training of health care workers in the diagnosis and treatment of malaria. On September 25, 2015, USAID awarded the ZAPIM project to Abt Associates, Inc. and its partners, Save the Children, Jhpiego, and the Liverpool School of Tropical Medicine. This five-year project’s purpose is to support the NMCP in providing comprehensive malaria prevention and treatment services to Zimbabweans with the goal of reducing malaria morbidity and mortality. The project has five main areas of concentration: 1) CM/MiP, 2) LLINs, 3) SBCC, 4) operational research, and 5) SM&E. The project operates in three provinces and 15 districts within those provinces: Mashonaland Central (Bindura, Centenary/Muzarabani, Guruve, Mazowe, Mbire, Mt. Darwin, Rushinga. and Shamva), Mashonaland East (Goromonzi, Mutoko, Mudzi, Murehwa, and Uzumba Maramba Pfungwe [UMP]), and Matabeleland North (Binga and Hwange). The project continues to scale up support for community work in CM and SBCC.

3. ADMINISTRATIVE ACTIVITIES

3.1 STAFFING AND MANAGEMENT During this quarter, ZAPIM recruited Dr. Anthony Chisada as the new ZAPIM technical director to replace Dr. John Bosco Rwakimari. ZAPIM recruited a new administrative assistant, Mazvita Kanoyangwa, to replace Grace Chivandikwa. ZAPIM and Vector Link continue to share the administrative assistant position.

The project benefited significantly from the in-country support from the Abt Associates Inc. home office staff. First, ZAPIM Technical Project Manager Ms. Nicole de Gier provided short-term technical assistance to the program from April 22-May 4, 2018, when the Chief of Party (COP) was on home leave, and there was no substantive technical director. Second, Ms. Catherine Thompson, Abt Associates’ regional managing director for east and southern Africa and outgoing ZAPIM Portfolio Manager, was in the country from May 28-June 2, 2018, to introduce incoming ZAPIM Portfolio Manager Ms. Rebecca Bronheim. Ms. Bronheim was in the country from May 28-June 13, 2018, and had a period of overlap with the COP when he returned from his leave.

3.2 CONFERENCES, RETREATS, TRAININGS AND MEETINGS ZAPIM staff participated in the following training sessions and meetings in addition to the routine partner meetings throughout the quarter:  Evaluation Methods of Malaria Programs: The ZAPIM M&E/OR manager attended a five-day training session at the University of Ghana from June 18-22, 2018. The training covered the following modules;  Basic concepts for evaluation  Statistical concepts for evaluation  Process evaluation  Impact evaluation  Designing evaluations for malaria programs Ten participants attended the training. Participants came from Angola, Burundi, Ghana, Kenya, Malawi, Mozambique, Zambia, and Zimbabwe. The training involved plenary sessions, discussions, group work, and hands-on experience.  Elimination TOT: The senior case management specialist attended the training, which the NMCP organized, in Mutare from on June 14-15, 2018. The training laid a good foundation for elimination work ZAPIM intends to start in Year 4. The training covered:

 Implementation of the WHO Global Technical Strategy in African region and Zimbabwe  Progress on malaria elimination in Zimbabwe and the expansion from the current 20 districts to 30 by 2020. The results of capacity assessment for elimination for the additional 10 districts concluded that in Mashonaland East Province, Chikomba, Seke, and Marondera districts are ready for elimination and Wedza District will be treated as a buffer district for now.  Malaria elimination surveillance  Entomological surveillance in elimination  SBCC and community participation in malaria elimination  Overview of the Heath Management Information System (HMIS) for Zimbabwe  Use of District Health Information System 2 (DHIS2) Tracker  Community Health Information System  Case management in malaria elimination  Vector control in elimination  Multilateral Initiative on Malaria (MIM) Conference April 15-18, 2018: ZAPIM presented two abstracts at the MIM conference. The LLIN specialist presented an abstract on the results of the endline survey of mass distribution of nets. The logistics coordinator in the Department of Pharmaceutical Services (DPS) in the Ministry of Health and Child Care (MOHCC) presented the other abstract on a case drug consumption survey.  National Malaria Vector Control Planning and Review Meeting: The ZAPIM LLIN specialist participated in this important meeting in Mutare from April 22-27, 2018. The meeting reviewed vector control in the country, including LLINs.  Review of the LLIN Mass Distribution Campaign Plan for 2018: ZAPIM supported and participated in the review held in Gweru on May 30-31, 2018  Matabeleland Provincial Health Team Meeting: ZAPIM presented project achievements to date and planned upcoming activities for the province.  ZAPIM/NMCP Meetings: The two groups met regularly to share and discuss program achievements and challenges. Following are some of the issues discussed:  Update on the implementation of ZAPIM-supported activities  Progress on finalizing the revision of the EPR Guidelines  Development of the National Malaria SM&E Plan  Assessment of factors behind the continuing transmission of malaria in a rural Zimbabwean community, Angwa Ward, Mbire District  Calendar for Year 4 Work Plan development and proposal to recruit ZAPIM focal persons at the provincial level

4. TECHNICAL ACTIVITIES

4.1 MALARIA CM AND MIP

Case management: Summary of achievements (April to June 2018)  Sent SMS reminder messages to 304 health workers trained in CM and MiP in Year 3  Trained 22 mentors for the malaria clinical mentorship from five selected districts in the three ZAPIM- supported provinces  Conducted a malaria deaths audit meeting in Mashonaland Central Province  Conducted first mentorship visits to 20 selected health facilities in four districts  Audited 8 malaria deaths from 5 districts from Mashonaland Central

4.1.1 SENDING OF SMS REMINDERS TO HEALTH CARE WORKERS During this quarter, ZAPIM sent the 304 health care workers trained in CM and MiP in Year 3 SMS reminders of the key points from the training and to help them care for malaria cases. Examples of reminders: “All suspected malaria cases should be tested with RDTs” and “Only confirmed malaria cases should be treated with ACTs.”

4.1.2 MALARIA CLINICAL MENTORSHIP

4.1.2.1 SELECTION OF MENTORS

Carrying over from the mentorship sensitization meeting held in the second quarter, ZAPIM tasked the six mentorship pilot districts (Mutoko, Murehwa, Mbire, Mt. Darwin, Binga, and Hwange) to select five mentors from each district. Learning from the HIV mentorship program, the districts developed appropriate criteria to guide the mentor selection process. The criteria included expertise in malaria CM and MiP, knowledge of the Zimbabwe health care system, and excellent interpersonal skills. After the initial selection process, the district health executives (DHEs) shared the names of prospective mentors with the Provincial Epidemiological and Disease Control Officers (PEDCOs) and ZAPIM, who reviewed them and advised the districts to make necessary adjustments to suit the selection criteria.

4.1.2.2 TRAINING OF MENTORS

In May 2018, ZAPIM supported training of the selected prospective mentors. The initial plan was to train five mentors from each of the six pilot districts. However due to competing programs, only 22 mentors participated in the training. There were no participants from Mt. Darwin District because the selected mentors were involved in other programs. As a result, this district was excluded from the mentorship pilot . The participants included doctors, nurses, pharmacy and laboratory personnel. Table 1 below shows the breakdown of the mentorship training participants.

Table 1: MALARIA MENTORSHIP TRAINING PARTICIPANTS BY DISTRICT, TARGET AND ACTUAL NUMBERS, ZIMBABWE, MAY 2018

Province District Target Number of participants Matabeleland North Hwange 5 5 Binga 5 5 Mashonaland East Mutoko 5 4 Murehwa 5 4 Mashonaland Central Mbire 5 4 Mt. Darwin 5 0 Total 30 22

Provincial HIV mentorship trainers, Mashonaland East and Matabeleland North PEDCOs, and ZAPIM CM specialists facilitated the training. It covered the following aspects: overview of the Zimbabwe health delivery system, management of severe malaria, approaches to clinical mentorship, adult learning methodology, communication skills, and continuous quality improvement. The National HIV Mentorship Coordinator also shared experiences from the HIV program. The training approaches used included PowerPoint presentations, review of health facility records to identify good practices and gaps, health facility visits, and role plays. ZAPIM assessed knowledge before and after the training. The bar graph below shows marked improvement in malaria mentorship knowledge among participants. The mean score increased from 75% to 87%.

Pretest and Posttest knowledge assessment scores for the mentorship training 100

50 Pretest Post test 40

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Figure 1: IMPROVEMENT IN MALARIA MENTORSHIP KNOWLEDGE AMONG PARTICIPANTS, ZIMBABWE, MAY 2018

On the final day of the training, the district teams came up with action plans. The teams had to prioritize five health facilities for mentoring and justify their selection. The teams then came up with dates and requirements for commencing mentorship activities. The teams forwarded their requests of airtime, fuel and mentorship tools to ZAPIM for procurement. The mentorship training in pictures….

FIGURE 2: ZAPIM SENIOR MALARIA CLINICAL CM SPECIALIST (STANDING) DISCUSSING MENTORSHIP PLANS WITH THE MUTOKO TEAM, MAY 2018

FIGURE 3: PEDCO MATABELELAND NORTH, NATIONAL COORDINATOR HIV MENTORSHIP AND PEDCO MASHONALAND EAST DISCUSSING THE MENTORSHIP PROGRAM, MAY 2018

FIGURE 4: GROUP PHOTO OF THE MALARIA MENTORSHIP TEAM AFTER COMPLETION OF THE TRAINING AT KADOMA HOTEL, MAY 2018

4.1.2.3 COMMENCEMENT OF MALARIA CLINICAL MENTORSHIP VISITS In June 2018, Binga, Hwange, Murehwa, and Mutoko initiated mentorship visits. Mbire did not start mentorship activities because their vehicle was non-functional. The purpose of the first mentorship visit was to introduce the malaria mentorship program to health facility staff. This introductory visit served as a platform to explain the mentorship rationale, agree on the implementation approaches and communication channels, provide sensitization on mentorship tools, and, in instances where there are conflicts, agree on how to solve them. Furthermore, this visit served as a baseline assessment of malaria quality of care at selected sites. This was done through mentee self-assessments, clinical performance assessments of mentees by mentors, and health facility assessments using mentorship tools. The teams used findings of these assessments to identify challenges or gaps for mentors and mentees to address during program implementation.

The mentorship program was well received by the health facility staff. A nurse aide from Siansundu Clinic in Binga had this to say: “Thank you for visiting us. Some people come to disturb us but your team came to help us. You are welcome to come again”. This comment was made in appreciation of the mentors, who helped in seeing patients at the clinic on a busy day. One of the approaches of the mentorship program is for the mentors and mentees to attend to patients together. In instances where there are many patients on site, the mentors also attend to patients, thus reducing workload. Afterward, there was an opportunity to discuss patient visits and any challenges encountered. The mentorship visits identified some gaps at the health facilities. Some gaps were unique to certain health facilities but others were common to most facilities. Table 2 highlights some common gaps, recommendations, and the person responsible for addressing the challenge.

TABLE 2: GAPS AND RECOMMENDATIONS IDENTIFIED DURING MENTORSHIP VISITS IN BINGA, HWANGE, MUTOKO, AND MUREHWA DISTRICTS, ZIMBABWE, JUNE 12-13, 2018 Gaps/Challenges Recommendation Responsible person Unavailability of reliable vehicle for the ZAPIM management to provide transport for ZAPIM Binga and Mbire teams districts with transport challenges in the short management term while the districts solve the problem internally in the long term The districts to share the challenge with provincial District medical medical directorates and come up with a way officer (DMO) forward Some mentees not on site because of Mentees will receive mentoring during subsequent Mentors competing activities visits Involve the health facility staff in coming up with Mentorship Team the mentorship schedule Leader Mentees need to commit to visitation dates Mentees

Inadequate interpersonal skills, history Mentorship on interpersonal skills, history taking, Mentors and taking, physical examination, diagnosis, physical examination, diagnosis, and treatment gaps mentees and treatment gaps Lack of dissemination of the updated Mentorship on new IPTp guidelines Mentors intermittent preventive treatment in pregnancy (IPTp) policy, which specifies starting sulfadoxine-pyrimethamine (SP) Share new guidelines ZAPIM Case at 13 weeks gestation rather than at Management quickening. Comment from one of the Specialist, nurses, “The guidelines are at times not PEDCO, NMCP well disseminated. It is so embarrassing to be told by visitors about change in policies and guidelines. Implementers should be informed about these changes as soon as possible.” Shortage of malaria commodities Problem to be discussed and the magnitude NMCP, documented at higher level meetings, e.g., CM Department of One of the nurses had this to say, “ZAPS subcommittee, PMI meeting, Provincial Health Pharmacy Services, (*) is giving us problems. We always order Team meetings, etc. Department of Pharmacy CM Specialist/ medicines but they do not give us the Services can share Fulfillment Reports quarterly to DMOs quantities we order. This needs to be create awareness of this issue. Stock levels and addressed.” buffer stock needs to be corrected. Health facilities need guidance on what they should do when commodities ordered do not arrive. Redistribution of commodities to health facilities in District Pharmacy need. The mentors can assist in identification of Managers, overstocked and understocked health facilities as Provincial they carry out their mentorship visits Pharmacists, Mentors

(*) ZAPS - Abbreviation for Zimbabwe Assisted Pull System, an ordering system where health facilities with the help of District Pharmacy Managers quantify their medicines and commodity requirements every quarter. The National Pharmaceutical Company then supplies the medicine based on the requirements.

4.1.3 MASHONALAND CENTRAL MALARIA DEATH AUDIT MEETING

A total of 52 health care workers from the eight Mashonaland Central districts attended the meeting. The Mashonaland Central Provincial Medical Director (PMD) also attended the meeting. Mbire, Rushinga, Bindura, Mazowe and Mt. Darwin made presentations on eight malaria deaths that occurred in the first quarter of calendar year 2018. One of the deaths involved suspected congenital malaria. The discussions of the suspected congenital malaria case concluded that it was most likely a case of neonatal sepsis and respiratory distress due to prematurity. This conclusion was reached because the neonate’s malaria slide was negative despite a positive RDT. The positive RDT may have stemmed from antigens circulating in the mother, who had malaria. The assessment of the mother was inadequate. It missed indications of pre- term labor and a urinary tract infection. As a result, health workers took no measures to prevent pre- term delivery or prepare the neonate for pre-term delivery. Teaching emphasis was on understanding the risk for pre-term delivery and miscarriages in patients with MiP. Mentors and mentees discussed measures to mitigate against pre-term delivery and to prepare MiP neonates for such an eventuality. MiP teaching included explanation of the new policy on first IPTp doses at the community level, laboratory diagnosis of malaria, and assessment and classification of malaria cases.

The Provincial Pharmacist presented on the stock status of malaria commodities in the province, which revealed shortages of RDT kits, ACT, SP, rectal artesunate and, quinine. The general consensus from the pharmacist was that ZAPS was short changing health facilities, with almost all health facilities receiving less than 20% of their ordered quantities of malaria commodities at any given time. This low level of order fulfillment indicated low stock levels at the national level. The proposed solutions were for procurement of adequate stocks at the national level and appropriate distribution of the commodities to provinces and districts based on the disease burden. Through various national meetings such as the CM subcommittee meeting and biweekly meetings with PMI, ZAPIM will continue advocating for procurement of adequate commodities.

The key observations were: 1) Lack of blood for transfusion in patients with severe anemia secondary to malaria and active bleeding due to disseminated intravascular coagulation 2) Inadequate supportive care for patients with severe malaria and a reduced level of consciousness 3) Inadequate case assessment and documentation 4) Community practice of “scratching the throat” as part of treatment for patients with malaria symptoms. This has a tendency to create complications and delayed presentation. There is need for tailor made messages to address these issues as harmful. 5) Delays in presentation by patients who first seek treatment from traditional and faith healers 6) Lack of rectal artesunate at the community level, which means there is no pre-referral treatment for the majority of severe cases

Table 3 shows proposed recommendations from the death audit meeting, the location, proposed date, and responsible person or institution.

TABLE 3: RECOMMENDATIONS OF THE MALARIA DEATH AUDIT MEETING IN MASHONALAND CENTRAL PROVINCE, JUNE 12-13, 2018 Recommended activities Location Proposed Responsible date person/institution

Improve assessment and documentation of All districts ongoing Doctors and nurses malaria cases through mentorship, supportive supervision, and post-training follow ups Involve health center committees and community All districts ongoing Health Promotion leaders to address delayed health seeking and Officers at harmful behavior provincial and district level Districts to review and audit all their malaria All districts ongoing District Medical deaths and take corrective measures to prevent Officers (DMOs) further similar deaths Health facilities to consider setting aside funds All districts ongoing Facilities from results-based financing for malaria-specific administration supportive supplies such as glucometer strips and blood for severely anemic patients Provincial and District Pharmacists to set up a Province As soon as Provincial dashboard to enable commodity tracking in All districts possible Pharmacist and facilities. The dashboard should also consider the District Pharmacists shelf life of commodities and enable movement of stock between facilities as appropriate. Pharmacy to improve use of available data for decision making. Improved liaison and ordering of commodities Province As soon as NMCP, Provincial from Nat. Pharm to improve order fulfillment All districts possible and district rates. pharmacists

4.1.4 COMMUNITY CM ZAPIM carried out a number of community CM activities during the quarter. These include VHW community case management (CCM) training, post-training follow up, and supportive supervision.

4.1.4.1 BINGA VHW TRAINING Binga District is one of the districts ZAPIM is supporting in Matabeleland North Province. The clinics ZAPIM selected for the refresher trainings are along the Zambezi River, where there is a high malaria burden. A total of 120 VHWs received training using the current (2015) Malaria Community Case Management (MCCM) guidelines. Improved scores for most participants during the theory assessment showed learning took place across the three groups, as Table 4 shows.1 Some participants remained below 50% in scoring due to their inability to understand the English language, although they are able to read and write in their local language. Plans are for them to continue reading the modules they received to become more familiar with the English language and terminology. They will get support from their supervisors during their clinical attachment which takes place soon after training. ZAPIM will use the same questionnaire to reassess participants every six months.

1 NB The scores are for the theoretical knowledge only.

TABLE 4: PRE- AND POST-TEST RESULTS OF VHW TRAINING IN BINGA, MATABELELAND NORTH PROVINCE, ZIMBABWE, APRIL 2018 SCORE RANGE % of participants achieving mark % of participants achieving mark in pre-test in post-test 0-49% 77 % (92) 27% (32) 50%-100% 23% (28) 73% (88)

ZAPIM trained all the VHWs reporting to a selected clinic. This enables the VHWs to have a standardized approach for documentation and reporting. During the training, VHWs received job aids to help them document and report their work. The items were well received by the District trainers and VHWs as they will ease the challenges of reporting. The training allocated time to enable the VHWs to practice documenting with the job aids so that they are familiar with the tools. Items distributed during the training are listed in Table 5.

TABLE 5: LIST OF ITEMS DISTRIBUTED TO VHWS AFTER THE TRAINING IN BINGA DISTRICT, APRIL 2018 Item distributed Total number RDT/malaria medicines register 120 Satchel bags 120 T-shirts 120 Red pens, blue pens, pencils 360 (120 of each) Referral booklet 120 Participant manuals 120 Timers 120 Sick child recording booklet 120 Hard cover books to use as adult consultation register 120 Monthly reporting form booklet 120

4.1.4.2 ORIENTATION OF HEALTH WORKERS TO VHW SUPPORTIVE SUPERVISION TOOLS AND PROCESSES In Binga and Hwange Districts, ZAPIM oriented health workers to familiarize them with the tools VHWs will use to collect data as they perform their work in the community. Of those invited, a total of 48 out of 50 (96%) participants attended the meeting from the two districts. Each district had 24 participants each. The participants included all Nurses-in-Charge from the health facilities in the district, District Pharmacist, District Health Information Officers, and Environmental Health Technicians (EHTs) from selected clinics. Key issues that came out during discussion are listed in Table 6.

TABLE 6: ISSUES AND RECOMMENDATIONS FROM THE DISTRICT ORIENTATION FOR HEALTH WORKERS TO VHW SUPPORTIVE SUPERVISION (SS) TOOLS AND PROCESSES IN BINGA AND HWANGE DISTRICTS, MATABELELAND NORTH, ZIMBABWE, APRIL & MAY 2018 Issues Recommendation/action taken A number of partners support the district, This presents an opportunity for ZAPIM in Year 4 namely: Anglican Diocese, Isdell Flowers, Save to advocate for a district/provincial partners the Children, Red Cross, World Vision, and meeting, where partners can share the activities ZAPIM. The Community Nurse who was they are doing, discuss areas of coordination, coordinating the training was not sure what share resources where feasible, and standardize partners are doing with the VHWs. tools VHWs are using. Some VHWs are not reporting weekly data due The province has agreed to have the VHWs to long distances to travel to health facilities. report monthly but will disaggregate the data by week while considering other reporting options like giving one peer mentor air time to send the statistics from other VHWs. Some VHWs do not have proper registers for ZAPIM has handed over 120 registers to the RDTs, hence they were using improvised tools. districts to distribute to the VHWs. This is in addition to the 120 VHWs trained with ZAPIM support already received. VHWs have inadequate medicines and This is a nationwide problem being addressed by commodities for CM. The District Pharmacy relevant offices in the MoHCC which hopes to Manager reported that there has been a shortage improve the situation later in the year. of RDT kits and ACTs in the district since December as facilities received less quantities than they ordered. A lack of VHW SS tools meant there was no During the meeting, ZAPIM shared the tools with standardized guidance during SS, if it was all participants. The participants practiced using conducted. the tools, and felt they were easy to use. Health workers at facility and the community are ZAPIM encouraged health workers at facilities to not following the criteria and guidelines for give guidance to the community during the selecting VHWs. As a result, some selected selection of the VHWs for training so that the VHWs are not well qualified and not performing community follows MoHCC guidelines. well. VHWs are not using hard cover books to order Practice on calculating VHW commodity their commodities from the facilities instead of requirements was done during the meeting so the the malaria medicines and RDT register. nurses could be familiar with the tool. Staff were urged to use the malaria medicines and RDT register to supply VHW commodities but first to verify the data. Health workers are not tracking commodities VHW commodity register/tracker was distributed allocated to each VHW to all nurses in charge during the orientation meeting for them to use for documenting commodities resupplied to VHWs. VHWs from Binga highlighted that IRS teams did It was suggested that VHWs be involved in not spray all the areas they were supposed to, showing the spray teams the households in each which may be contributing to malaria outbreaks village. experienced in the district this year. This omission was attributed to long distances

traveled by the spray operators and their lack of knowledge of the catchment area.

4.1.4.3 POST TRAINING FOLLOW UP AND SUPPORTIVE SUPERVISION ZAPIM conducted post-training follow up visits for Mudzi, Hwange and Binga VHWs this quarter and conducted SS for five districts: Bindura, Shamva, Mt. Darwin, Centenary, and Mutoko.

4.1.4.3.1 POST-TRAINING FOLLOW UP After the CM training, trainers followed up with VHWs after 4-6 weeks (Table 7). To ensure each VHW trained received post-training follow up, District trainers assembled all the VHWs at the facilities, reviewed their records, and assessed competencies in RDT testing and assessments of sick clients while at the health facility. Most VHWs followed up had done their five-day attachment at the clinic. However at some clinics, VHWs had not completed the attachment due to competing priorities within their families. One of the challenges highlighted was that the VHWs were busy with other important commitments, especially harvesting their crops from the fields, and could not complete their attachment. The VHW Trainers conducting the post-training follow up encouraged nurses to provide continuous support for the success of the program.

TABLE 7: POST TRAINING FOLLOW UPS CONDUCTED IN MUDZI, HWANGE, AND BINGA DISTRICTS, ZIMBABWE, MAY-JUNE 2018 District Dates of Dates of post- No. of VHWs % of VHWs reached / training training follow trained total VHWs in up district Mudzi 22-24 February April 30-05 May 80 74% ( 59) Hwange 11-16 March 07-11 May 80 51% (41) Binga 08-17 April 11-15 June 120 83% (99)

Post-training follow up exercise During the post-training follow up, ZAPIM assessed 19 of 199 VHWs on their knowledge of malaria prevention and control, using the same questionnaire as for their group training (see graph below). There is indication of a decrease in knowledge for some VHWs. Nine of 19 VHWs, or 47%, had scores lower than their training post-test scores. This suggests the need for continuous knowledge checks and support from both trainers and local supervisors at the facilities. On the brighter side, during the assessment, all the VHWs had scores above 50%, which is the minimum pass mark.

Continuous knowledge assessment of VHWs 100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Pre test % Post test % Follow up %

FIGURE 5: CONTINUOUS KNOWLEDGE ASSESSMENT OF VHWS DURING POST-TRAINING FOLLOW UP

4.1.4.3.2 SUPPORTIVE SUPERVISION Supportive supervision is a regular, ongoing process in Zimbabwe to ensure and improve quality malaria case management. ZAPIM carried out supportive supervision at least one year after training while VHWs were at their homes, where they treat patients. In Mashonaland Central, ZAPIM visited four districts. ZAPIM visited only one district, Mutoko District, in Mashonaland East. In total, ZAPIM reached 19 VHWs through SS. For Mashonaland Central, ZAPIM allocated one day per district, which meant ZAPIM visited one clinic per day. These visits were the first for the ZAPIM CCM Coordinator, who spent time getting familiar with the Mashonaland Central and Mashonaland East (Mutoko) DHEs. The SS assessed use of the job aids ZAPIM provided, in particular the sick child register, RDT/medicines register, and the commodity tracker. ZAPIM used the same checklist during the post-training and SS visits. The gaps ZAPIM identified were similar. Most of the VHWs reached had selected suitable settings within their homestead where they test and treat patients. Supervisors had the opportunity to conduct a retrospective review of the VHW registers, discuss gaps identified, and discuss how to correct them.

FIGURE 6: VHW ASSEMBLING A SHARPS BOX RECEIVED FROM A CLINIC

The VHW above faced challenges in assembling the sharps box and received assistance on the steps to follow. This was a learning opportunity for both the VHW and the nurse from the clinic. The nurse learned that nurses should demonstrate to VHWs how to assemble the sharps box for it to serve its purpose. The SS team reviewed registers to enable proper documentation by the VHW.

FIGURE 7: FACILITATORS REVIEWING THE REGISTERS AT VHW HOMESTEAD

During the SS visits, facilitators learned that the bracketed totals section (total for the page, total for the month and closing stock) is incompletely documented in the RDT/medicines register. The missing information is critical for calculating the commodity needs of the VHWs. Facilitators discussed this

gap with the health workers. FIGURE 8: INCOMPLETELY DOCUMENTED RDT/MEDICINES REGISTER

Completeness of recording during assessment of sick children. The SS team assessed how the VHWs conducted assessments of a sick child. Generally, VHWs provide incomplete documentation in the sick child register. This is mainly because it is a new tool they need intensive support from the clinic to practice using it. Clinic staff have received orientation on the tools. With continuous support, there will be improvement in the documentation by the VHWs

Areas with gaps in the sick child register: -Case number -Date of visit -Name of child -Complaints presented

Gaps identified were discussed and the VHW appreciated the support.

FIGURE 9: GAPS IN SICK CHILD REGISTER

This VHW’s performance was quite satisfactory; and the VHW was praised for good performance. However, the danger sign of ‘vomiting everything’ was not asked during the assessment. This omission was corrected. The facilitators took time to discuss danger signs in sick children and the importance of screening for them. FIGURE 10: SATISFACTORY VHW PERFORMANCE

During the SS visit for Mashonaland Central, the SS team used a checklist to assess the performance of seven VHWs during a sick child assessment simulation. Generally the performance of the seven VHWs observed assessing a sick child (simulation) was not good. There was only a fair attempt by the VHWs to assess for general danger signs in a sick child as shown in the graph below.

VHWs Correctly Assessing for Danger Signs in a Sick Child Simulation, Mashonaland Central, Zimbabwe, June 2018 80 70 60 50 40 30 20 10 0 Vomits Everything Convulsions Very Chest in drawing Unable to eat or weak/unconscious drink

FIGURE 11: VHWS WHO CORRECTLY ASSESSED FOR GENERAL DANGER SIGNS MASHONALAND CENTRAL, BINDURA, SHAMVA, MT DARWIN AND CENTENARY DISTRICTS JUNE 2018

From the seven VHWs visited in Mashonaland Central, some of them were not following the job aid sequence during the assessment of a sick child. As a result, they missed screening for all the five danger signs. The SS team provided immediate coaching.

During the SS visit in Mashonaland Central, ZAPIM also checked RDT performance. The table below shows the performance by seven VHWs during the simulation. Generally the performance was satisfactory. During RDT testing, the VHWs are expected to demonstrate that they check the kit for expiry dates. Those who had commodities in stock at their home said they checked for expiry when they opened the RDT box so they were confident their kit was still potent. Labeling of the cassette with patient name is not commonly practiced by most VHWs, and the SS team corrected that. Most of the VHWs were not waiting for the total recommended time for test results because they did not refer to the standard operating procedure. The SS team corrected this, but it is an area that needs strengthening at both the community and health-facility level. Below is a summary of VHW performance during RDT testing simulations at the VHW’s home. TABLE 8: VHWS PERFORMANCE DURING RDT TESTING SIMULATIONS, MASHONALND CENTRAL, BINDURA, SHAMVA, MT DARWIN AND CENTENARY DISTRICTS, JUNE 2018 Procedure %VHWs who correctly performed procedure Was the expiry date checked? 57 Did the worker label the cassette completely? 29 Buffer applied correctly to the RDT device well 89 Appropriate number of drops of buffer dispensed into well 100 Did CBHW/VHW wait for correct amount of time (15-30 43 minutes or according to manufacturer’s instruction) Reads test result correctly (supervisor verifies results) 89 Records results correctly in register 89 Used tests, transfer devices, and other blood- 71 contaminated material disposed of correctly Used lancet disposed of correctly 100

4.1.4.3.3 AVAILABILITY OF COMMODITIES During the SS visits, the team assessed availability of RDTs and anti-malaria medicines. The districts have limited stocks of both RDTs and ACTs. Thus at some of the health facilities, the VHWs could not get supplies of commodities and referred patients to the clinic for most of the year. However, during the support visit to Mutoko District, toward the end of the quarter, the clinics were receiving improved quantities of malaria commodities, including rectal artesunate. The clinics then were able to distribute the commodities to VHWs.

Storage of medicines and other commodities at the community level

The SS teams assessed storage of commodities during the SS/follow up. VHWs do not have proper storage boxes, and individual VHWs have improvised storage boxes to ensure proper storage of medicines. Some use empty cardboard boxes, and some use empty trunks in their homes. ZAPIM is in the process of acquiring the proper compartmentalized kits for the VHWs.

FIGURE 12: OLD TRUNK USED TO STORE MALARIA COMMODITIES

VHW commodity tracker ZAPIM designed this tool to address the gaps in proper tracking of commodities supplied to VHWs. It was encouraging to find that health facilities valued the tool as essential to track movement of commodities between a health facility and the community. ZAPIM commended the health facilities for tracking the commodities as this will strengthen VHW accountability. During the SS visits, the team learned that the tool was very helpful in tracking what is given to individual VHWs and the state of the commodities. The tool is also useful during the support visits to health workers by National Pharmaceuticals.

The tool may need improvement to track commodities VHWs return to the facility and the state of returned products. Some VHWs return the commodities after they have expired while others bring them before expiration.

FIGURE 13: VHW COMMODITY TRACKER IN USE

4.2 LLINS

4.2.1 DELIVERY OF LLINS FOR CONTINUOUS DISTRIBUTION This quarter ZAPIM delivered 35,100 rectangular nets for CD to Bindura, Guruve, Mazowe, Mt. Darwin, and Shamva Districts. ZAPIM delivered 4,000 LLINs to Binga, Beitbridge, and Chipinge Districts for epidemic response. ZAPIM delivered all the LLINs from the national warehouse to distribution facilities with a top up or resupply left at district holding points. ZAPIM adopted this distribution approach to overcome transport challenges districts faced in delivering nets to health facilities. During this quarter, the CD moved from the push to pull approach. Districts are now ordering LLINs according to their six-month minimum stock levels, while health facilities order according to their three-month levels. The deliveries conducted during this quarter are indicated below (Table 9).

TABLE 9: NUMBER OF LLINS DELIVERED FOR CONTINUOUS DISTRIBUTION AND OUTBREAK RESPONSE BY DISTRICT, ZIMBABWE, QUARTER 3 2018

District Number of bales delivered Number of LLINs delivered Bindura 12 600 Guruve 118 5,900 Mazowe 247 12,350 Mt. Darwin 216 10,800 Shamva 109 5,450 Binga 44 2,200 Beitbridge 30 1,500 Chipinge 6 300 Total 782 39,100

Nine ZAPIM-supported districts have received their second supply since the launch of the CD program in October 2017. The only challenge is the availability of storage at health facilities. In some cases, health facilities receive only monthly stocks because of lack of storage. This poses transport problems as some districts do not have transport to supply health facilities monthly. Currently, health facilities have been advised to reorganize their storerooms to create space for LLINs storage for a three-month stock.

4.2.1.1 TRAINING ON USE OF RECTANGULAR NETS Training of personnel involved in LLINs distribution is central to the successful implementation of the program. The main focus of CD training is to equip health workers (HWs) and VHWs with knowledge and skills for CD and on multiple strategies for hanging rectangular nets. The training adopted a total/full coverage approach. All those (HWs and VHWs) involved in LLIN distribution are to receive the training on CD of LLINs. ZAPIM conducted the training under the “My Net My Life” campaign slogan. ZAPIM continued to use the gospel-led approach for motivating personnel. ZAPIM uses language to describe the LLIN deployment as a crusade and uses relevant biblical verses to reach people on a spiritual level. ZAPIM deployed the gospel-led approach in recognition of the importance of the church and church leadership in community weekly activities and lifestyle in general in Zimbabwe. The reception of the use of gospel language has been good and led to a successful roll out of the CD program. The rectangular nets have a high acceptance rate. Demand is increasing with orders rising for re-supply of nets after distribution of the entire six-month supply within 3-4 months. ZAPIM taught participants various ways to hang a rectangular net. These included the manufacturer’s method, ring methods, droppers, and cross methods. ZAPIM has provided further modifications and innovation to the methods of hanging the rectangular nets. All the methods use familiar, locally available materials and were topics of innovative discussion during the training events. During training under the My Net My Life campaign, ZAPIM shared key messages on promoting high net usage. The training emphasized messages with the acronym SEFUS. The acronym promotes the messages that:  Nets are safe  Nets are effective in preventing malaria  Nets are free  Nets should be used every night, all the time  Nets are strong and flexible  Nets should cover all sleeping spaces – indoors and outdoors Encompassing the key messages in the SEFUS memory aid made the LLIN attributes accessible and easy for the HWs and VHWs to remember. In addition to emphasizing SEFUS, ZAPIM-trained participants on how to conduct household/community net follow-up visits and use of the assessment form to record findings. During the training, ZAPIM conducted assessments on net ownership and use among participants. ZAPIM used participatory approaches and explored successes, challenges, and solutions as indicated below. TABLE 10: ASSESSMENT OF NET OWNERSHIP AND UTILIZATION AMONG HEALTH WORKERS AND VHWS IN MAZOWE DISTRICT, ZIMBABWE, JUNE 2018 Net ownership Net Utilization Slept under Did not sleep Site Yes No Total net previous under net Total night previous night Tsungubvi Clinic 17 1 18 5 12 17 Concession Hospital 29 5 34 15 14 29 Henderson Research 40 0 40 24 16 40 HQ Holme Eden Farm 25 1 26 16 9 25 Health Donje Clinic 29 1 30 16 13 29

Total 140 8 148 140 76 (54.3%) 64 (45.7%) (94.6%) (5.4%) (100%) (100%) TABLE 11: ASSESSMENT OF NET OWNERSHIP AND UTILIZATION AMONG HEALTH WORKERS AND VHWS IN MT. DARWIN DISTRICT, ZIMBABWE, JUNE 2018 Net ownership Net Utilization Site Slept under net Did not sleep under Yes No Total Total previous night net previous night Mutwa 30 2 32 20 10 30 Tsakare 22 1 23 12 10 22 Matope 41 2 43 38 3 41 Mt. Darwin- Kandeya 11 0 11 9 2 11 Mt. Darwin 28 6 34 23 5 28 Total 132 11 143 132 102 (77.3%) 30 (22.7%) (92.3%) (7.7%) (100%) (100%)

The tables above show the results of the assessment on net ownership and use among the CD training participants. The participants indicated through secret ballot their net ownership and use. In the Mazowe District, 94.6% of the participants had at least one net, and in the Mt. Darwin District, the figure was 92.3%. Those without nets were mostly new in the area. In the Mazowe District, 76 (54.3%) of those with nets said they slept under an LLIN the night before the meeting, while 102 (77.3%) of participants in the Mt. Darwin District said they had done so. Because the Mazowe District is a low transmission area, people ignore the need to sleep under a net at all times throughout the year. Hence, there are low net utilization rates. The outcome of this assessment mirrors data at the community level. ZAPIM and MoHCC will be intensifying health education efforts on the importance of using a net at all times year-round for every sleeping space. The utilization rate is well below the national target of 85%. ZAPIM asked respondents why they slept or did not sleep under a net the night before. The table below shows the reasons for use and non-use of a net.

TABLE 12: REASONS FOR USE OR NON-USE OF LLINS BY PARTICIPANTS ATTENDING CD TRAINING, JUNE 2018

Motivation for use of LLINs Reasons given for non-use of LLINs - Slept under net to prevent mosquito biting to - No mosquitoes in my house avoid getting malaria - Never been bitten by mosquitoes - Mosquito nets also prevent other insects from - Feel restricted when under the net disturbing my sleep - Feel too hot when under the net - My child was infected with malaria so I have - Just complacency made it a habit of using the net all the time - No mosquitoes because of low temperatures - Reside close to the Mazowe River, where there - Did not sleep at home are lots of mosquitoes - Have difficulty breathing if I sleep under mosquito - Mosquitoes are still present and biting people net - The area has disused sewage ponds, which act as - Was on night duty so did not sleep breeding sites for mosquitoes (culicines) - Religious objectors - Uncovered sewerage/drains provide ideal - Old nets no longer usable breeding sites - Slept at a funeral - The net is treated and kills mosquitoes - Did not know how to hang the rectangular net - Feel responsible enough to protect myself and - Not malaria season my family from getting malaria - Just do not want to sleep under the net - Spent the night at church - Itchiness ZAPIM and participants discussed the reasons for non-use. ZAPIM advised non-users to learn from the net users and urged non-users to use the net year-round to avoid getting malaria. ZAPIM taught the participants how to address these issues when they engage communities during LLIN visits and at meetings. The training included discussions on the successes and positive issues, challenges observed or encountered in LLIN promotion at the community, VHW, and HW levels, and solutions.

TABLE 13: SUCCESSES, CHALLENGES AND SOLUTIONS IN CD OF LLINS IN MAZOWE DISTRICT, ZIMBABWE, JUNE 2018 Category/Level Successes Challenges Solutions - Community - Reduced malaria - Long distances to - EHTs to conduct LLIN cases health facilities outreach programs - Short queues at - Rash among children - Proper aeration of nets health facilities - Lack of concern - Continue educating the people - People are now about getting malaria on the importance of using the knowledgeable - Cultural practices net all year round about malaria - Itchiness of nets - Continuous education on - Free nets (we used - Lack of knowledge of importance of having adequate to buy nets) how to hang the net rooms - No more mosquito - Inadequate space to - VHWs to use the assessment bites hang all the nets tool as trained. - Collection of more nets than needed

- Happy and very grateful about getting nets

VHWs/CHWs  Malaria has declined  Few or a shortage of  Give more coupons to health  Pregnant women coupons facilities booking early  Some people not  Continuous education  People are using using nets  Community policing nets  Misuse of nets  VHWs should be provided  Program has been  Itchiness bicycles and spares highly accepted  Long distances to health facilities

HWs  Malaria trend on the  Misuse of nets  Community policing decline  Non-use of nets  Continuous education  Antenatal care  VHWs do not write  VHWs to be trained on how to (ANC) and coupons well write the coupons properly Expanded Program  Some community  People should get nets on Immunization beneficiaries have no regardless of whether they (EPI) coverages have identification cards have identification cards improved  VHWs have no  ZAPIM should distribute nets  People are getting means of transport to companies and retrieved if nets  Company staff on an employee is redeployed  Early ANC bookings rotation within six months.  Under one aged  Some VHWs refuse  Orient all health workers on children immunized coupons to some net distribution processes on time affluent people  Provide extra coupons at  People are now  Some VHWs and health facilities knowledgeable HWs are not yet  Train all VHWs on LLIN about the benefits of trained distribution using a net

ZAPIM spent time addressing the challenges and ways to implement suggested solutions. At the end, there was a general agreement that all parties involved in LLIN distribution should play their part for the smooth implementation of the CD activity. The parties also agreed that regular interaction with the communities and continuous engagement is key to increasing net utilization.

TABLE 14: TRAINING OF HEALTH WORKERS IN USE OF RECTANGULAR NETS BY DISTRICT, ZIMBABWE JUNE 2018

Date District M F Total 4-8/06/2018 Mazowe 6 9 15 6-11/06/2018 Mt. Darwin 13 12 25 Total 19 21 40

TABLE 15: CD TRAINING OF VHWS FOR MAZOWE AND MT. DARWIN DISTRICTS ZIMBABWE BY HEALTH FACILITY JUNE 2018 Date Cluster Target M F Total MAZOWE DISTRICT 6/4/2018 Tsungubvi 15 1 13 14 6/5/18 Concession 40 1 31 32 6/6/18 Henderson 36 5 30 35 6/7/18 Home Eden 24 2 21 23 6/8/18 Donje 30 5 24 29 Sub Total 145 14 119 133 MT. DARWIN DISTRICT 6/11/2018 Mutwa 29 7 20 27 6/12/18 Tsakari 22 8 12 20 6/13/18 Matope 45 11 30 41 6/14/18 Mt. Darwin-Kandeya 18 4 12 16 6/15/18 Mt. Darwin 33 6 25 31 Sub-Total 147 36 99 135 Grand Total 292 50 218 268

The training for this quarter focused on the Mazowe and Mt. Darwin Districts. These two districts piloted the CD program in Zimbabwe and were the last targets for training as they were already involved in CD implementation. The training used a cluster approach to reduce the travel distance for VHWs and to implement total/full coverage. This approach also enabled the sharing of experiences among neighboring health facilities. A total 268 VHWs and 40 HWs (Tables 12 and 13) received training on CD distribution and on the various methods of hanging the rectangular net. Workers will organize on-the-job training for the VHWs who failed to attend the health facility meeting or use monthly meetings to orient them.

4.2.2 CONTINUOUS DISTRIBUTION OF LLINS Currently ZAPIM is supporting 11 districts with CD implementation. The table below (Table 16) shows the number of LLINs distributed by channel and by quarter for the 11 districts. The districts are Bindura, Centenary, Guruve, Mazowe, Mt Darwin, Mbire, Rushinga, Shamva, Murewa, Goromonzi and Hwedza TABLE 16: DISTRIBUTION OF LLINS IN 11 DISTRICTS BY CHANNEL BY QUARTER ZIMBABWE, OCT 2017-JUNE 2018

Channel of Total Distributed Total Distributed Distribution Oct-Dec 2017 Jan-Mar 2018 Apr-Jun 2018 Total LLINs % Distributed Distributed ANC 2,753 6934 3,476 13,163 14%

EPI 1,852 5434 3,096 10,382 11%

Community 5,621 40773 22,966 69,390 75%

Total 10,226 53,141 29,568 92,935 100%

ZAPIM distributed 29,568 rectangular nets in the Quarter 3 to beneficiaries from the 11 districts. This is 31.8% of the total nets distributed since the start of CD implementation in October 2017. Quarter 2 had the highest number of nets distributed at 53,141 (60%) nets distributed since October 2017. Of the 92,935 nets distributed since October 2017, ZAPIM distributed 69,390 (75%) through the community channel, followed by ANC with 13,163 (14%) and EPI with 10,382 (11%) The 92,935 nets distributed were against a target of 71,000 for the period October 2017 to June 2018. These results are a clear indication that the CD program has been successfully rolled out and the demand for rectangular nets is very high. The main challenges are the lack of adequate storage capacity at the health facility level and transport by districts for supportive supervision and for supplying health facilities with additional nets.

4.2.3 NET DURABILITY STUDY PMI has approved the 18-month Net Durability Study (NDS) report. ZAPIM is editing the report for final submission. ZAPIM received the 24-month NDS results for both the bioassays and chemical analysis during the quarter under review. We will include the results in the 24-month NDS report, which we currently are writing.

4.3 SBCC

During the period under review, the SBCC thematic area focused on four broad areas of action:

1. Evidence gathering to inform improved programming

2. Developing and rolling out an innovative local language and culturally sensitive audio product for a hard-to-reach community

3. Supporting the NMCP in reviewing and planning for actions to improve the NMCP‘s SBCC program direction and effectiveness

4. Community mobilization for malaria prevention and treatment through the community action cycle

4.3.1 ASSESSMENT OF DRIVERS OF CONTINUING MALARIA TRANSMISSION IN ANGWA WARD, MBIRE DISTRICT, MASHONALAND CENTRAL PROVINCE, ZIMBABWE

The Zimbabwe NMCP prioritizes achieving universal coverage of malaria vector control interventions for at-risk populations. According to programmatic data, NMCP has attained high levels of IRS and/or LLIN coverage for most targeted populations. With complementary efforts to promote uptake of these services and healthy behavior changes, malaria incidence is expected to decline. However, malaria incidence remains high in many areas perceived to be adequately covered by these interventions. One possible explanation is that lifestyle patterns some communities adopted in attainment of livelihoods are

inadvertently leading to continued malaria transmission. The Mbire District in Mashonaland Central Province typifies this trend. During the period under review, ZAPIM designed an assessment of the drivers of continuing malaria transmission in the Angwa Ward in Mbire District and submitted a protocol to the Medical Research Council of Zimbabwe for approval. Key stages of the assessment ZAPIM conducted during this quarter included:

1. Submission and approval of the protocol by the Medical Research Council of Zimbabwe

2. Pre-testing of the data collection tools in Chidodo Ward, Mbire District

3. Training of data collectors and supervisors in preparation for data collection

4. Conducting the field data collection in Angwa Ward

5. Cleaning of quantitative data and transcribing qualitative data in preparation for analysis

ZAPIM completed the data collection fieldwork. ZAPIM administered 329 questionnaires at the household level and conducted 11 focus group discussions in the supervisory areas. ZAPIM completed a desk review. ZAPIM interviewed two district and one Angwa clinic personnel as key informants. ZAPIM completed data collection despite challenges of access to some of the harder-to-reach areas in the ward. Key investigations made during the fieldwork were gathering data and information on:

 Malaria trends in Angwa Ward for the period 2012-2017  The socio-economic and geographic context and activities in Angwa Ward  The health care system in Angwa Ward  Current coverage, quality, access, and use of malaria prevention interventions in Angwa Ward, including personal protection outdoors  Malaria vectors and description of vector bionomics and insecticide resistance patterns in Angwa Ward  Knowledge, attitudes, practices, and perceptions of malaria and malaria risk  Type, quantity, and timing of outdoor activities in Angwa Ward

Preparatory work for data analysis such as data cleaning and qualitative information transcription also commenced during this quarter. Finalization of data analysis, compilation of findings, report writing, and dissemination of results will be completed in the Quarter 4.

FIGURE 14: A SESSION OF PRE-TESTING THE FOCUS GROUP DISCUSSION GUIDE WITH A GROUP OF MEN IN CHIDODO WARD, MBIRE DISTRICT, MASHONALAND CENTRAL, ZIMBABWE, MAY 2018

FIGURE 15: A TRAINEE DATA COLLECTOR PRESENTS GROUP WORK ON A MAP DEVELOPMENT EXERCISE AS PARTICIPANTS PREPARE FOR FIELDWORK DURING THE TRAINING, CHIDODO WARD, MBIRE DISTRICT, MASHONALAND CENTRAL, ZIMBABWE, MAY 2018

FIGURE 16: A MORNING BRIEFING SESSION AS DATA COLLECTORS PREPARE TO RIDE OUT TO THE ENUMERATION AREAS DURING THE DATA COLLECTION PHASE , CHIDODO WARD, MBIRE DISTRICT, MASHONALAND CENTRAL, ZIMBABWE, MAY 2018

FIGURE 17: COLLECTING AND LABELING OF MOSQUITOES (SPECIMENS) BY THE ENTOMOLOGICAL INVESTIGATION TEAM DURING THE DATA COLLECTION PHASE, CHIDODO WARD, MBIRE DISTRICT, MASHONALAND CENTRAL, ZIMBABWE, MAY 2018

FIGURE 18: INSPECTION OF MOSQUITO BREEDING SITES CAUSED BY HUMAN LIVELIHOOD ACTIVITY ALONG THE ANGWA RIVER BANK AND RIVER BED DURING THE DATA COLLECTION, CHIDODO WARD, MBIRE DISTRICT, MASHONALAND CENTRAL, ZIMBABWE, MAY 2018

4.3.2 CHIKUNDA LANGUAGE MALARIA CONTROL AUDIO BOOK FOR CHAPOTO WARD IN MBIRE DISTRICT, MASHONALAND CENTRAL PROVINCE

ZAPIM finalized the Chikunda language malaria control audio book (named Dipa la malaria) in this quarter and produced 50 copies. Dipa la malaria is Chikunda meaning “spear for fighting malaria.” ZAPIM also developed and produced promotional and advocacy materials. ZAPIM distributed banners and 400 T- shirts to promote the Dipa la malaria concept in the community. ZAPIM officially handed over the audio book for dissemination to Chapoto Ward - Mbire District, Mashonaland Central Province during a launch event held on the June 27, 2018. The province adopted the district-level launch event to mark the commemoration of World Malaria Day. The following categories of people attended: provincial health

executive (PHE) members from Mashonaland Central Province; district health executive members from Mbire, Mazowe, and Guruve Districts; DMO of Luangwa District, Zambia came with a delegation, district administrator of Mbire District, who was the Guest of Honor; Chapoto ward councilor and council personnel, the Chief’s representative and Village Heads from Chapoto Ward; Chapoto health facility staff, representatives of development agencies operating in Chapoto; health clubs and VHW groups from Chapoto; and members of the public and school children from Chapoto primary schools.

When providing future SBCC to the province, ZAPIM will consider the following key advocacy messages that were highlighted by various speakers:

1. Recognition and acknowledgement of the role of VHWs in the malaria control program through preventive efforts and CCM

2. Need to improve community standards for building houses and ensuring that houses have walls that can be sprayed during IRS

3. Calling for more pregnant women to book early and get all their IPTp doses that country guidelines require

4. The district was congratulated for achieving 93% IRS coverage last season and for not having an outbreak in 2018. The provincial medical director highly appreciated these achievements and encouraged them as a standard for the province to maintain. The District Health Team put up exhibitions that showcased and explained to the traditional leaders and community members IRS, LLINs, and personal protection against malaria.

5. Community members were encouraged to source and use mosquito repellants for additional protection during outdoor activities.

6. The guest of honor appealed for continued use of local languages for most health programs to ensure the community understands the messages fully. He also highlighted the need to be creative and innovative in delivering malaria behavior change communications to reach people with malaria information.

7. The Luangwa District Health Administrator highlighted the similar malaria situation in Luangwa District of Zambia and noted the need for Zambia to emulate the Dipa la Malaria initiative.

8. ZAPIM underscored the objectives of the Dipa la Malaria slogan and initiative to all present stakeholders and community members. The community was encouraged to make of use of Dipa la Malaria fully and take ownership of malaria prevention, treatment, and positive health-related behavior change.

ZAPIM discussed a dissemination plan for the audio book with the provincial and health facility staff, who committed to implementing the plan to reach all five villages that comprise Chapoto Ward through specially organized listening groups that health personnel and VHWs would facilitate. They would conduct independent listening sessions at the family level, as families could borrow the audio books for specified periods. ZAPIM will track and monitor the dissemination plan and evaluate the initiative’s reach and impact. The following were the recommendations for future actions:  Distribute audio gadgets to serve five villages in Chapoto Ward

 Organize listening and infection control and prevention (IPC) sessions with groups of people in all villages  Devise a data capturing tool to track use and coverage of the audio players, including patterns of use for evaluation purposes

FIGURE 19: ZAPIM UNDERSCORES THE IMPORTANCE OF THE DIPA LA MALARIA INITIATIVE

FIGURE 20: EMBRACING THE DIPA LA MALARIA WAY OF LIFE. SCHOOL CHILDREN FROM CHAPOTO PRIMARY SCHOOL PERFORM TRADITIONAL AND MODERN DANCES TO MALARIA PREVENTION MESSAGING SONG

FIGURE 21: ZAPIM OFFICIALLY HANDS OVER THE DIPA LA MALARIA GAGDETS TO THE GUEST OF HONOR, WITH THE PMD AND COUNCILLOR IN ATTENDANCE

FIGURE 22: COMMITMENT TO USE DIPA LA MALARIA AT ALL LEVELS – MEMBERS OF THE DHE LED BY THE DMO (LEFT), WHO WILL LEAD THE DISSEMINATION OF THE AUDIO BOOK

FIGURE 23: COMMITMENT TO USE DIPA LA MALARIA AT ALL LEVELS – THE TRADITIONAL LEADERSHIP OF CHAPOTO WARD SUPPORTIVE OF THE INITIATIVE AT THE LAUNCH

4.3.3 SBCC SUBCOMMITTEE MEETING

The social and behavior change subcommittee meeting for the quarter took place on June 8, 2018, at the Holiday Inn Hotel, Harare. This was the first subcommittee meeting in 2018. Key achievements of the meeting were:

 The revision of the subcommittee terms of reference, the first update since 2014.

 Appointment of new officers. ZAPIM is the new Chair, and United Methodist Church Health Program is Vice Chair. NMCP remains the Secretariat.

 Discussing and mapping the way forward on the branding of the NMCP. The meeting unanimously supported the need to rebrand the Zimbabwe malaria program and reflect the drive toward malaria elimination in all communications.

 Reviews and updates by provinces and partners of SBCC activities during 2017–2018. Shortage of adequate funds and operational challenges for disbursing SBCC activity funds using the Global Fund Public Financial Management System were issues in all provinces

The NMCP Director gave a keynote address and highlighted that the subcommittee should live up to its mandate of discussing technical issues and to advise the NMCP accordingly. Heavy rains that characterized 2017 were noted as contributing to an increase in malaria cases. The rains showed the need for enhanced SBCC to enable communities to use malaria control interventions more consistently and conscientiously. The Director urged the subcommittee to take stock of the 2017 SBCC activities, identify gaps, and adjust accordingly. A shortage of malaria behavior change communication materials was reported in some institutions that ZAPIM visited during supportive supervision exercises this quarter. The director informed the meeting that branding of the NMCP was a priority issue on which the NMCP expected the subcommittee’s guidance. That comment led to discussions on how to go about the branding process.

The Director also announced and congratulated the team for getting the African Leaders Malaria Alliance award in recognition of Zimbabwe achieving the highest reduction of malaria burden from 2010 – 2015.

4.3.4 COMMUNITY-BASED ACTIVITIES

4.3.4.1 CAC REFRESHER COURSE TRAINING ZAPIM conducted a two-day CAC refresher course for Mashonaland East and Central, targeting district CAC-trained facilitators. The objectives were to:  Share experiences in implementation of CAC process  Share knowledge and skills for implementation of CAC act-together, evaluate-together, and scaling- up phases  Make recommendations to address gaps identified  Develop methods and skills for effective facilitation of the CAC process to help participating communities achieve positive malaria outcomes  Learn how to assess and strengthen community capacity to identify and prioritize malaria issues

TABLE 17: CAC REFRESHER TRAINING IN MASHONALAND EAST AND MASHONALAND CENTRAL, ZIMBABWE, APRIL-MAY 2018 Province Male Female Total Mashonaland East 11 7 18 Mashonaland Central 8 9 17 Total 19 16 35

After the refresher course, facilitators expressed confidence with implementation of the CAC process, acknowledging that at first they were not sure how CAC could make a difference. The following issues were discussed during the training:

TABLE 18: ISSUES AND RECOMMENDATIONS DURING THE CAC REFRESHER TRAINING IN MASHONALAND CENTRAL AND MASHONALAND EAST, ZIMBABWE, APRIL-MAY 2018 Issue Recommendation Out of eight targeted districts, HCCs in Bindura, These plans should be finalized before the act- Mt. Darwin, and Goromonzi Districts had not together CAC phase training finalized their CAC plans None of the CAC district facilitators had followed District facilitators were encouraged to support up on the trained HCCs, citing fuel, transport HCCs consistently and provide necessary logistical challenges, and competing programs and technical support Documentation of community-based malaria HCCs were encouraged to document their activities activities was not consistent as this evidence will be needed during evaluation of their activities Health staff are not sharing malaria information Health staff are encouraged to share information, with HCCs to enable them to make informed inform HCCs, and provide them necessary guidance decisions

4.3.4.2 MATABELELAND NORTH CAC TOT ZAPIM trained 10 provincial and district facilitators. Participants were from the Provincial Office, and Binga and Hwange District. The participation of the PEDCO, Provincial Environmental Health Officer (PEHO), Provincial Health Promotion Officer (PHPO) and Provincial Nursing Officer (PNO) representatives was positive:

 The provincial team acknowledged that it was not paying much attention to how it conducted SBCC nor was it following any framework.

 The participants recognized that by applying the CAC process, the province can improve on key malaria outcomes.

 The PEDCO, PEHO, PHPO and PNO representatives agreed to incorporate Community Social Behavior Change Communication (CSBCC) variables in the provincial malaria support and supervision tool. Previously they were not on the supportive supervision checklist.

 Matabeleland North strongly recommended working with ward health teams.

The training was well-received. Individual and group participation was noted and manageable. Facilitators explained in detail other conceptual tools such as fishbone, problem tree, community mapping, and ranking matrix. The application of the problem tree concept during the Simatelele malaria outbreak was instructive as the participants noted that the investigations had not been exhaustive enough, leading the PEDCO to redeploy another team to do further investigation.

4.3.4.3 MATABELELAND NORTH CAC DISTRICT SENSITIZATION (BINGA AND HWANGE) ZAPIM supported the Binga and Hwange Districts’ two-day CAC sensitization targeting DHEs (Binga-7 and Hwange-5) and health facility staff (Binga-21 and Hwange-17). Trainees came from wards with high malaria burdens. Both districts reported that the majority of health facilities have annual malaria plans though they do not follow the CAC process in generating the plans. Some clinics reported success in reducing home deliveries through working with Ward Health Teams. The CAC process can ride on these successes. Another positive was that the Hwange District conducted an assessment of late ANC bookings, which can serve as a baseline. The two districts assigned one EHT a specific role for entomology. That resulted in other EHTs relying on assumptions when identifying mosquito breeding sites. This was exemplified by the EHT for Simatelele, who received larvicides but did not use them because he did not have the knowledge and skills to identify mosquito breeding sites. Therefore, the team has learned that all EHTs should be trained in entomological surveillance and basic information on identification of mosquito larvae within communities.

4.3.4.4 CAC ACT-TOGETHER TRAINING IN MUTOKO DISTRICT The CAC act-together phase uses a matrix to assess a community’s capacity to implement its CAC plans. The matrix covers aspects such as:  Proposed activity  Knowledge skills and resources needed  Capacity available in the community  Capacity not available in the community  How the community will develop this capacity  Responsibility

 Timeframe  Resource mobilization skills  Proposal development skills  Financial and resource management skills  Group maintenance skills

ZAPIM trained 11 HCCs on the act-together phase from June 17-23 in Mutoko. Sixty-nine representatives from the 11 HCCs participated in the half-day training and are now expected to provide the training to other members.

TABLE 19: KEY FINDINGS FROM THE ACT-TOGETHER TRAINING, MUTOKO, ZIMBABWE JUNE 2018 Capacity Area Findings Knowledge skills and resources HCCs members do not have comprehensive knowledge of malaria. needed In particular, there is lack of knowledge on vector breeding habits, identification of breeding sites, vector feeding habits, effects of malaria on community, preparation of rooms before and after being sprayed, and insecticides used. Resource mobilization skills HCCs are mobilizing local resources such as bricks, building sand, and labor, although with no formal training. Proposal development skills All the HCCs lacked training in proposal development. Financial and resource All HCCs have been trained in financial management by MoHCC. management skills The majority of HCCs are engaged in income-generating projects with some having raised more than $3,000 in the last year. Group maintenance skills All HCCs reported having clear roles for every member of the group.

The Kapondoro HCC showed remarkable improvement in documentation of its activities compared with other HCCs. This was attributed to the SS it received during the last MoHCC/ZAPIM visit. The District Health Promotion Officer (DHPO) and the EHT for Kawere also testified that HCCs trained in the CAC process performed better in terms of participation, analysis of issues, and contributions compared with HCCs that had not yet introduced CAC.

4.3.4.5 GOROMONZI OUTBREAK SUPPORT Goromonzi District experienced an outbreak beginning in January 2018 in wards13, 14, and 16. These wards had received LLINs distributed through ZAPIM support. The wards are serviced by Kubatsirana Clinic (Ward 13), Arcturus Mine Clinic (Ward 14) and Chinyika Clinic (Ward 16). The District requested support for SBCC activities from ZAPIM. ZAPIM confirmed the outbreak and conducted the following activities:  Consulted on the results of entomological activities by VectorLink staff in the affected area. Results showed a high density of A. funestus, which has a high preference for indoor resting.

 Conducted a number of interviews with people who were recently treated for malaria in areas that experienced high malaria cases. ZAPIM sought to elicit information on knowledge of malaria, travel history, ownership of nets and utilization patterns, risk perception, and social and economic activities.

 Based on the analysis of the above data, ZAPIM developed communication messages focusing on:

 Existence of an outbreak  Transmission  Risk factors specific to Goromonzi documented outbreak areas  Signs and symptoms  Effects of malaria at the individual, family, community, and national levels  Prevention options  Identifying breeding sites  Demonstration of aeration  Hanging nets

The possible drivers of the outbreak included an influx of alluvial gold panners, who did not have nets. This influx took place during a change of ownership of the Arcturus Gold Mine. Some gold panners were reported to be sleeping in the open and in vacant houses. A significant number of farms (Goromonzi Rural District Council Compound, Alderly Farm, Pleasant Valley, and Warrendale) had not yet been issued nets, although nets were available at Kubatsirana Clinic. Another possible factor was the period when families are entertaining before going to bed. A total number of 28 community education sessions were conducted, reaching an audience of 821 individuals.

Below find the pictures from Goromonzi District during community education sessions.

FIGURE 24: MR. MANGANZO [EHT] HELPING COMMUNITY TO IDENTIFY A BREEDING SITE

FIGURE 25: ONE OF THE PERSONAL INTERVENTIONS TO FIGHT MALARIA (REPELLENTS)

FIGURE 26: A TYPICAL BREEDING SITE: THE BLUE BUCKET AT KUBATSIRANA CLINIC HAD LARVAE

FIGURE 27: MR. MANGANZO [EHT] LEADING A COMMUNITY SESSION

4.4 M&E/OR

4.4.1 ASSESSMENT OF DRIVERS OF CONTINUING MALARIA TRANSMISSION IN ANGWA WARD, MBIRE DISTRICT, MASHONALAND CENTRAL PROVINCE

ZAPIM developed the assessment protocol, which the Medical Research Council of Zimbabwe and Abt Associates Institutional Research Board approved. In addition, the Centers for Disease Control and Prevention Center for Global Health reviewed the protocol and provided clearance as it was classified as a program evaluation. Soon after the approval, ZAPIM undertook the following activities:  Pre-testing of the data collection tools  Training of data collectors and supervisors  Data collection, cleaning, and analysis Report writing is expected to commence the first week of July 2018.

4.4.2 FINALIZATION OF THE NATIONAL MALARIA SM&E PLAN ZAPIM continued to encourage NMCP to facilitate the finalization of the malaria SM&E Plan. The project also helped update the document. The Chief of Party engaged the NMCP Director and agreed that the document be finalized before end of July 2018.

4.4.3 REVISION OF THE EPIDEMIC PREPAREDNESS AND RESPONSE GUIDELINES Similar to the SM&E Plan status, there was a delay in finalizing the document because NMCP had other competing activities. ZAPIM helped NMCP update the document, which should be final before the end of July 2018. NMCP has made a commitment to mobilize resources for TOT in all the provinces on the content of the EPR guidelines document. ZAPIM intends to support printing, dissemination, and training of health workers in its three supported provinces.

4.4.4 TRAINING OF HEALTH WORKERS IN M&E ZAPIM supported the training of health workers in M&E in Mashonaland East Province. ZAPIM trained 51 (98%) out of a target of 52 HWs. The training focused on M&E fundamentals: data management, data quality issues, detection, notification, response to malaria outbreaks, and DHIS2. Trainers placed special emphasis on the need to verify data from the community (VHWs) and facility levels before submitting the data to the district office. Table 20 shows the distribution of health workers trained in Matabeleland North Province by gender. TABLE 20: DISTRIBUTION OF HEALTH WORKERS TRAINED IN M&E BY PROFESSION AND GENDER IN MASHONALAND EAST PROVINCE, ZIMBABWE, APRIL 2018

District Profession Male Female Total Mashonaland East Nurse (district and health facility) 5 22 27 Laboratory Staff 2 1 3 Pharmacy Staff 0 1 1 Environmental Health Staff 9 3 12 Health Information Staff 2 1 3 Other 2 3 5 Total 20 31 51

5. GENDER

ZAPIM training materials and SBCC materials the project developed are gender sensitive. Services provided in ZAPIM-supported districts are accessible to both men and women equally. ZAPIM provided pregnant women LLINs and SP during antenatal visits in ZAPIM- supported districts because women are more vulnerable to malaria. ZAPIM recognizes the role women play in the care of children, particularly those under 5 years of age. The activities were aimed at empowering women with knowledge and skills to protect themselves and their families better against malaria and to seek early treatment in case of illness.

6. ENVIRONMENTAL COMPLIANCE

ZAPIM ensures our activities do not harm the environment. Three areas the project focuses on are:  Generation of medical waste at both the health-facility and community level  Disposal of LLIN solid and liquid waste

 Management of public health medicines and commodities 6.1 Medical Waste If ZAPIM does not properly handle, store, dispose of medical waste health facilities and CCM generate, there is risk of disease transmission. In this quarter, ZAPIM technical staff supported health facilities and community health workers in infection prevention. During CM training, ZAPIM trained HWs on infection-prevention measures such as wearing gloves when handling medical waste, avoiding recapping of sharps, proper disposal of sharps into puncture proof sharps containers, and disaggregation of medical waste in color-coded bins. At the community level, the program trained VHWs on proper handling of medical waste and the need to take medical waste monthly to health facilities for proper disposal. Apart from training, the program uses SS visits to mitigate identified gaps in handling and disposing of medical waste and to ensure implementation of suggested measures. In the future, ZAPIM will integrate environmental compliance into quarterly data quality assessments.

6.2 Liquid and Solid LLIN Waste The distribution of LLINs generates solid waste from LLIN packages. Considering the high volume of nets the program distributes, there is potential harm to the environment from failing to follow proper disposal procedures. Washing of nets at the household level also may lead to contamination of water sources if communities don’t know techniques for proper disposal of water from LLIN washing. To mitigate the negative environmental effects of liquid and solid waste, ZAPIM trains VHWs and HWs on the proper disposal of waste from LLINs. This requires cutting of LLIN packaging into small pieces and burying them in a pit 50-100 cm deep, away from water bodies. Households should not wash nets in rivers or dams but rather in a dish with water, which the households should dispose of in a pit. ZAPIM provided this information to all community members during LLIN distributions and CD training this quarter.

6.3 Management of Public Health Medicines and Commodities ZAPIM supports activities at both the health facility and community level at places that distribute medicines and commodities such as malaria medicines, testing kits, syringes, gloves, etc. There is a risk of children ingesting improperly secured medicines. Medicines may also expire, and using expired medicines may result in poor treatment outcomes. It is therefore necessary to have good medicine and commodity management practices in place. Through malaria training and SS, ZAPIM teaches HWs proper storage of medicines and ways to avoid drug expiration (e.g., quantification of stocks and proper handling of expired drugs). To ensure correct communication of information on management of medicines and commodities, pharmacists/pharmacy technicians are part of the malaria CM training team. Plans are underway to procure lockable medicine boxes for VHWs in the next work plan year.

7. CHALLENGES AND LESSONS LEARNED

7.1 CHALLENGES The following were key challenges experienced during Quarter 3 of ZAPIM Year 3:  Shortage of malaria commodities at both health facility and community levels. As a result, health facilities are not distributing these limited commodities to VHWs and diagnosis and treatment are not as available to community members. During the period of RDT stock outs at some HFs, staff were diagnosing malaria cases clinically. To address the shortage of ACTs, District Pharmacy managers were redistributing these commodities to ensure equitable distribution of the medicines.  Transport challenges for district mentors that affected mentorship visits and delivery of LLINs  Delay in the finalization of EPR guidelines and the malaria SM&E plan 2016-2020. This delay was partly due to ineffective facilitation of the stakeholders’ workshop for the EPR guidelines. The workshop failed to produce a comprehensive draft. A lot of the work on the EPR guidelines that should have been accomplished by the workshop was left to a smaller writing team with a lot of other competing activities.

On the SM&E plan, there has not been a sense of urgency/prioritization from the NMCP.  Lack of accurate data on training gaps which makes it difficult to measure progress in closing the gap.  Lack of SS for VHWs due to unavailability of funding for transport for health workers to visit the VHWs at their homesteads.  Lack of lockable medicine boxes for VHWs to secure all medicines under the custody of each respective VHW.  Unavailability of gloves, aprons, and methylated spirit at community level since clinics report receiving limited quantities  No airtime for VHWs to send weekly data to health facilities  Some VHWs running out of coupons for LLINs to give to those in need of nets in their villages.  Limited storage space for LLINs at health facilities  Long distance to LLIN redemption centers  Delays by districts in submitting monthly CD reports to the national level

7.2 RECOMMENDATIONS AND LESSONS LEARNED From these challenges, ZAPIM learned some lessons, which the team will consider for future programming. In light of the challenges, the following are possible recommendations:  Shortage of malaria commodities: The causes of this problem are multi-level. At the health facility level, the staff need to order adequate commodities and keep track of stock levels. The district and provincial pharmacists need to assist health facilities in ordering adequate commodities and redistribute them depending on need. At the national level, the Department of Pharmacy Services and its partners need to procure enough commodities and do so on time. This issue needs further discussion at various meetings.  Transport challenges: Some districts delayed implementation of malaria mentorship activities because of unavailability of reliable vehicles. In the short term, this challenge was addressed by using ZAPIM vehicles. However in the long term, the districts need to share the challenge with the Provincial Medical Directorate and come up with sustainable solutions. The program will be more sustainable if districts use their own vehicles rather than relying on partner vehicles.  The community channel is the most preferred for LLINs acquisition hence there is need to ensure continuous reliable supply of LLIN coupons to VHWs by District Environmental Health Officers.

 Long distance to LLINs redemption centers: EHTs to conduct mobile outreach points for hard-to-reach areas.  Limited storage space for LLINs: Health facilities to reorganize the storage space at health facilities and create space for a three-month supply of nets.  Reporting challenges: Districts are having challenges in the compilation of monthly LLIN reports. Districts, especially District Environmental Health Officers, should designate an Environmental Health Officer/Environmental Health Technician at the district level as the focal point for LLIN activities, including compilation of reports.

ANNEX A: PMP INDICATOR/YEAR 3 MILESTONE MATRIX

Key: PMP Impact-level Indicator PMP Life-of-project-level Indicator Year 3 Milestone/Indicator

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps CM Number of PMP 392 To be 136 270 Not Number of national There is need to scale malaria deaths (HMIS determi applicable malaria deaths up malaria 2016) ned (N/A) increased from 75 in Q2 interventions and also (TBD) to 136 in Q3. Of the 136 continue to support deaths, 31 were malaria death reported in 15 ZAPIM investigations in the supported districts, with affected provinces Mutoko (7), Mudzi (5), Mt Darwin (5) and Mbire (4) having more deaths compared to other districts

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps CM Incidence of PMP 17/1,00 TBD 9.3/1,00 9.3/1,000 N/A Outbreaks were All the health facilties malaria 0 0 (HMIS/ experienced in need to have (HMIS DHIS2) Mashonaland East, Threshold Limited 2016) Mashonaland Central Values calculated at and Matabeleland the beginning of the North year so that outbreaks are detected early CM Proportion of PMP 35% TBD 37% 37% N/A The figure comes from MCHIP carried out an women who (MIS the 2016 Malaria assessment in received two 2012) Indicator Survey Manicaland to or more doses of determine the causes IPTp during ANC for the low uptake of IPTp. ZAPIM will rely on the findings and recommendations of the assessment to improve the program CM Proportion of PMP 68.8% TBD 50% 50% N/A The figure comes from The indicator is not under-five (MIS the 2015 Zimbabwe well reported in the children who 2012) Demogrpahic and 2016 MIS preliminary sought treatment Health Survey (ZDHS) report and therefore within 24 hours of the 2015 ZDHS report onset of fever has been used as the reliable source document CM Percentage of PMP 99.8% 100% 99.8% 99.8% 99.8% Same health facilities Health facilities are suspected (HMIS experienced shortages encouraged to order malaria cases 2016) of RDT kits commodities before that receive a they run out of stocks

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps parasitological test CM Percentage PMP 93% 100% 91.6% 91.6% 100% The baseline is national There is need to have of confirmed (HMIS a revision of the data malaria cases 2016) capturing tool to that receive first- record other anti line antimalarial malaria given for treatment severe case according to national policy CM Number of health PMP 896 785 142 757 97.7% Poor network problems Avail internet dongles workers, including (Year 1 hinder realtime entering for use during training VHWs, trained in ZAPIM of data into TranSmart and establish training malaria CM Annual database and health gaps on a regular (ACTs, MiP/IPTp, Report) worker training gaps not basis RDTs, microscopy, established medicines management) CM Number of PMP 0 4 0 1 25% One supportive Planning to do planned malaria- supervision visit was supportive supervision related SS of done in Mat North in Q2 in the next quarter health facility workers conducted CM Number of PMP 0 15 15 15 100% All the district plans feed As part of the districts with into the provincial plans outbreak response outbreak initiative, ZAPIM will response plans continue to support all the districts during the

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps year to ensure they have robust plans to respond quickly to any outbreaks. ZAPIM supported the revision of the EPR guidelines, and these are near finalization. The project will also support the training of provincial and district staff in revised EPR guidelines. It is anticipated that this will go a long way in improving the quality of the outbreak response plans CM Functional Year 3 0 1 1 1 N/A Poor network problems Avail internet dongles training database mileston hinder realtime entering for use during training (TrainSMART) for e of data into TranSmart and establish training the current database and health gaps on a regular training and workers training gaps basis future training not established CM Number of Year 3 0 30 0 0 0% Planned for Quarter 4 Need to standardize laboratory mileston and onwards the tools and training personnel trained e with the Director of in malaria Laboratory services diagnostics

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps CM Number of Year 3 0 30 22 22 73.3% Mentors trained from 5 Malaria clinical mentors trained mileston districts, Binga, Hwange, mentorship visits to for the pilot e Mutoko, Murehwa and health facilities to be mentorship Mbire. Mt Darwin district scaled up in Q4 program did not participate because of competing activities CM Number of on- Year 3 0 3 1 1 N/A Districts such as Binga Other visits to be done the-job mileston and Mbire experienced in Q4 mentorship visits e transport challenges to three districts conducted CM Number of onsite Year 3 0 4 0 0 N/A Availability of specialists To commence in mentoring visits to mileston remains a challenge Quarter 4 after provincial e mobilizing support hospitals by from the specialists specialists CM Number of Year 3 0 25 0 0 0% Rescheduled for Training will be provincial mileston Quarter 4 conducted in Quarter supervisory teams e 4. However, there is trained on revised need to develop malaria SS tools revised SS tools CM NMCP CM/MiP Year 3 1 2 1 1 N/A Another meeting is ZAPIM will continue to subcommittee mileston scheduled for Quarter 4 engage NMCP so that quarterly e subcommittee meetings meetings are held on supported a regular basis

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps CM Assessment of Year 3 0 1 1 1 N/A Report not yet finalized Report will be finalized malaria case and mileston due to data sharing as soon as the data consumption e issues. An abstract on sharing issues have data conducted the study was been resolved. PMI is accepted and will be engaging NMCP on presented at the MIM this matter conference CM Number of staff Year 3 0 300 304 304 101% These will be sent out SMS be sent out again trained in CM/MiP mileston again in the next in the next quarter reached with SMS e quarter information reminders and quizzes CM SS tools and job Year 3 0 500 0 500 100% These were reviewed Already used for the aids reviewed mileston together with the mentorship training and and updated e mentorship guides also being used for with NCMP mentorship visits CM Number of Year 3 2 (Year 6 1 2 33% One two-day meeting Planning to conduct malaria death mileston 1 ZAPIM held in Mashonaland malaria deaths audits in investigation/ e Annual Central Province Mash East and Mat malaria death Report) North in Q4 audit meetings with NMCP, hospitals and PMDs, DMOs, and matrons in attendance

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps CM Number of Year 3 0 50 24 48 96% A total of 48 health Health workers to use facility- based mileston workers from Hwange the tools for SS HWs oriented on e wereoriented. SS process and tools CM Number of Year 3 0 120 0 15 0% Pushed to Q4 because Follow up visits will be potential VHW mileston of competing activities done in Q4 peer supervisors e followed up (post-training follow-up) CM Number of Year 3 0 1800 1800 1800 100% All training manuals and Support and supervision training manuals mileston job aids were printed, on the use of the tools and job aids e resulting in smooth will be intensified in the (facilitators and running of the training next quarters participant manuals, medicine supply and accountability register, RDT job aid and monthly reporting book) printed CM Number of district Year 3 0 1 0 0 N/A Focus was on CCM Scheduled for Quarter VHW review mileston trainings 4 meetings e conducted

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps CM Number of items Year 3 0 2280 960 2280 100% All trained VHWs Need to procure procured for the mileston received the items storage kits that are VHWs (T-shirts, e lockable timers, rain coats, bags, and salter scales) CM Number of EHTs Year 3 0 60 0 0 0% The activity will no Scheduled for Year 4 and nurses mileston longer be conducted supported to e this year. There is need conduct VHW SS to come up with systems to account for fuel and allowances given to the health workers before supporting the initiative LLIN Proportion of PMP 49% TBD 54% 54% N/A The figure is from the MIS The indicator is not population that (MIS 2016 reported every slept under an 2012) quarter or year LLIN the previous night LLIN Proportion of PMP 8% TBD 17.5% 17.5% (ZDHS N/A It is important to note There is need to scale children under- (ZDHS (ZDHS 2015) the different up the interventions five who slept 2010- 2015) methologies used for that promote net under an LLIN the 11) MIS and ZDHS usage among previous night 49.6% 33% 33% (MIS N/A children. The new (MIS (MIS 2016) National Malaria 2012) 2016) Strategic Plan is still being costed and will inform the targets

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps LLIN Proportion of PMP 49.1% TBD 36% 36% (MIS N/A Only 36% of women There is need to scale women of child- (MIS (MIS 2016) slept under an LLIN the up the interventions bearing age who 2012) 2016) previous night, which that promote net slept under an was a substantial usage among women LLIN the previous decrease compared aged 15-49 years. The night with the 49% in the 2012 new National Malaria MIS Strategic Plan is still being costed and will inform the targets LLIN Proportion of PMP 46.4% TBD 58% 58% (MIS N/A The baseline and results The new National households in (MIS (MIS 2016) are national Malaria Strategic Plan ZAPIM target 2012) 2016) is still being costed districts with one and will inform the or more LLINs targets LLIN LLIN routine PMP 10 (Year 10 11 11 110% NMCP requsted ZAPIM Hwedza now a ZAPIM distribution system 1 ZAPIM to add Hwedza District supported district, rolled out in Annual bringing to 11 the ZAPIM target Report) number of LLIN- districts supported districts LLIN Net Durability PMP 0 1 1 1 N/A The 6-, 18- and 24- 36-month assessment Study findings month accessments to be done in produced and were done and now the Sept./Oct. 2018 after recommendation 36-month assessment which we will produce s adopted for remains a final report. The 18- future distribution and 24-month planning preliminary results will be shared internally with PMI partners

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps LLIN Number of PMP 1,358 770 308 860 111.7% A total of 268 VHWs and The training was part people (LLIN (Year 1 40 HWs were trained in of the preparation for distributors/ ZAPIM use of rectangular nets LLIN routine VHWs) trained in Annual distribution LLIN Report) routine/continuou s distribution LLIN Number of LLINs PMP 573,950 889,950 29,568 92,935 10.4% 10.PMI procured a total Additional LLINs to be distributed (Year 1 of 889,950 LLINs. These distributed in Quarter ZAPIM were given to ZAPIM Quarter 4 Annual and Plan for distribution. Report) Information on the number of LLINs delivered and distributed to Plan is still be gathered. LLINs were distributed through the community, EPI, and ANC channels LLINs Number of Year 3 6 0 6 100% Meetings were Scale up LLIN distribution community mileston conducted to sensitize Leaders’ e community leaders on meetings on LLINs LLIN distribution conducted LLIN Number of vector Year 3 1 (Year 2 0 0 N/A Scheduled for Quarter 4 To be held in August control mileston 1 ZAPIM 2018 subcommittee e Annual meetings Report) supported

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps LLIN Support Year 2 0 1 1 1 100% This is being supported Support is on-going establishment of mileston by Vectorlink and ZAPIM entomology e jointly training at Africa University SBCC SBCC repository PMP 0 1 0 0 N/A NMCP to confirm To follow up with NMCP (on-line MoHCC policy on online database) of resources and give go malaria messages ahead for repository and delivery methods established SBCC Number of PMP 1066 696 104 104 15% 35 district facilitators Additional trainings persons trained in (Year 1 attended CAC refresher will be conducted in SBCC ZAPIM training in Mashonaland Quarter 4 Annual Central and Report) Mashonaland East. An additional 69 HCC members from Mutoko District were trained on CAC Act together SBCC Lifestyle and PMP 0 1 0 0 N/A Data collectors and Data analysis and livelihoods style supervisors were trained, report writing Survey of the followed by data Mbire community collection and data completed cleaning SBCC Commemoration Year 3 0 1 0 0 N/A Commemoration Distribute material of the SADC mileston cancelled that was developed Community e

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps Malaria Day during World Malaria supported Day SBCC World Malaria Year 3 3 3 1 1 N/A This was conducted in Day campaign mileston Mashonaland Central supported in e three provinces SBCC SBCC materials Year 3 248,300 450 450 450 100% This include 350 Tonga These were printed and tools, malaria mileston copies tool kit and 50 Chikunda and distributed calendar, and e Talking Book talking book for hard-to-reach communities printed and disseminated SBCC Health staff and Year 3 0 2000 0 0 0% Rescheduled for To be printed in VHW SBCC mileston copies Quarter 4and onward. Quarter 4 facilitator tools e reviewed and printed SBCC National level Year 3 0 1 0 0 0% Branding workshop Branding workshop malaria branding mileston rescheduled for Q4 rescheduled for Q4 initiative to e operationalize strategy 7 of Malaria Communication Strategy

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps SBCC Number of Year 3 0 3 0 0 N/A Scheduled for Quarter 4 Scheduled for Quarter provincial cross- mileston 4 border e collaboration meetings on SBCC community change SBCC Number of Year 3 0 5,000 0 0 0% Scheduled for Quarter 4 To be procured in promotional mileston Quarter 4 materials e procured for HCC members SBCC Number of HCCs Year 3 0 86 0 86 100% 20 HCCS were followed Follow-up visits for the followed up mileston up in Quarter 3 newly trained HCCs (post- training e were done in Q3 follow-up visits) conducted SBCC Number of radio Year 3 0 2 0 0 N/A LLIN campaign spots to Radio spots to be spots produced mileston be produced in Quarter produced in Quarter 4 for sensitization on e 4 LLINS campaign SBCC Number of radio Year 3 0 2 0 0 N/A IRS campaign spots to Radio spots to be spots produced mileston be produced in Quarter produced toward the for sensitization on e 4 IRS campaign period IRS campaign in Quarter 4 SBCC Number of Year 3 0 86 0 9 10.5% Scheduled for Quarter 4 Scheduled for Quarter advocacy mileston 4 meetings with e community

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps stakeholders on LLIN use conducted SBCC Number of SBCC Year 2 1 2 0 0 N/A Moved to Quarter 4 Scheduled for Quarter subcommittee mileston 4 meetings e conducted SBCC ZAPIM website Year 3 0 1 0 0 0 On hold; home office On hold until further developed and mileston considering budget notice from home populated e office M&E Number of PMP 10 (Year 144 51 101 70% 51 health workers were Additional training for districts and 1 ZAPIM trained in Mashonaland Mashonaland Central health facility Annual East province in Q3 to be conducted in staff trained in Report) Quarter 4 M&E, SS, epidemic alert protocols (EPR/Integrated Disease Surveillance and Response) M&E ZAPIM M&E Year 3 0 1 1 1 N/A The database was Regular updating of database and mileston updated monthly the database and dashboard e give back to the updated technical staff on the performance of the project

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps M&E Number of Year 3 0 6 0 0 N/A Moved to Quarter 4 To target districts with national, mileston because of competing data quality issues provincial, and e activities district data quality assessments (DQAs) conducted M&E Number of Year 3 0 6 0 3 50% A total of 143 The planning and provincial and mileston participants (119% of review meetings are district planning e target) attended conducted bi- and review meetings in Q3 annually. The next meetings meetings will be conducted supported in Quarter 4 M&E Number of Year 3 0 1 0 1 100% ZAPIM supported NMCP Need to finalize the national mileston in revising the EPR revision of the consultative e guidelines through a guidelines and ensure meetings to revise national stakeholders’ that all provinces are the EPR guidelines meeting in Q2 using the new conducted guidelines M&E Number of Year 3 0 1,150 0 0 0% Awaiting the finalization To be printed and revised EPR mileston of the revised guidelines distributed as soon as guidelines printed e the guidelines are and distributed finalized M&E Number of district Year 3 0 75 0 0 0% Awaiting the finalization Training to go ahead staff trained in the mileston of the revised guidelines once the revised revised EPR e guidelines are in guidelines place

Targets/ Benchmarks Results

Baseline* Year 3 YR 3 Q3 Year 3 Percentage Indicator/ Oct 2017 Results Cumulative of Annual Milestone for – Sept Results Target Comments/ # Year 2 Activity Type 2018 Achieved Problems Encountered Next Steps M&E Number of VHW Year 3 0 1,000 1,000 1,000 100% Distributed to ZAPIM- Need to identify gaps RDT registers mileston supported districts and bridge them in printed and e Year 4 distributed M&E Number of T12/ Year 3 0 10,000 0 0 0% Consultation meetings Printing and OPD Registers mileston are being held with distribution on hold printed and e NMCP and other pending the distributed MoHCC structures to finalization and ensure that a standard approval of the register is developed register by the Ministry before printing and of Health and Child distribution Care M&E SM&E plan for the Year 3 0 1 1 1 100% Stakeholders’ meeting Work with NCMP to National Malaria mileston was held to develop the speed up the Strategy e National Malaria SM&E finalization of the developed plan. The draft SM&E SM&E plan plan is available and will be finalized in Quarter 4 M&E Number of Year 2 0 2 0 0 N/A Moved to Quarter 4 Scheduled for Quarter surveillance, M&E mileston 4 and OR e subcommittee meetings supported