USAID/Zambia Systems For Better Health Quarterly Progress Report January-March 2019

May 2019

This publication was produced for review by the United States Agency for International Development. It was prepared by Abt Associates for the USAID Systems for Better Health activity.

Contract No: AID-OAA-I-14-0003 Order No: AID-611-TO-16-00001 GUC Mechanism

Submitted to: William Kanweka Contracting Officer’s Representative USAID Zambia

Prepared by: Abt Associates Inc.

In collaboration with: Akros Inc. Save the Children

DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government.

Contents

Contents ...... i List of Figures ...... ii List of Tables ...... ii Acronyms...... iii 1. Introduction ...... 4 2. Highlights ...... 5 3. Progress by Objective ...... 6 3.1 Objective 1: Performance Management Improved in Six Target Provinces ...... 6 Sub-Objective 1.1 Improved Provincial and District Planning ...... 6 Sub-Objective 1.2 Improved Performance Assessment ...... 8 Sub-Objective 1.3 Improved Performance Review Meetings ...... 10 3.2 Objective 2: Public Financial Management Improved in Six Target Provinces ...... 13 Sub-Objective 2.1 NAV Rolled Out and in Use in All Relevant Institutions ...... 13 Sub-Objective 2.2 Improved Public Financial Management Practices ...... 15 3.3 Objective 3: Increased Data Use for Decision Making ...... 16 Sub-Objective 3.1 Improved Generation and Use of RMNCAH&N Scorecards ...... 16 Sub-Objective 3.2 Improved Data Quality ...... 18 3.4 Central-level Activities ...... 20 Health Care Financing ...... 20 Quality Improvement ...... 21 3.5 Research, Monitoring, and Evaluation ...... 27 Activity Monitoring and Evaluation Plan (AMEP) ...... 27 Data Collection ...... 27 Program M&E Database ...... 27 USAID Reports ...... 28 Conduct Quarterly DQAs of SBH Field Data ...... 28 Kitwe HIV Linkages Activity Documentation ...... 28 4. Project Management ...... 29 4.1 Finance and Administration ...... 29 4.2 Overall Budget and Expenditures ...... 29 4.3 Personnel ...... 29 4.4 Subcontracts ...... 29 5. Success Stories ...... 30 Annex 1. Central Province Scorecard ...... 36 Annex 2. Eastern Province Scorecard ...... 37 Annex 3. Luapula Province Scorecard ...... 38

i Annex 4. Muchinga Province Scorecard ...... 39 Annex 5. Southern Province Scorecard ...... 40 Annex 6. Western Province Scorecard ...... 41 Annex 7. Performance Indicator Tracking Table ...... 42

List of Figures Figure 1. District achievement of planning milestones in Q1 2019 ...... 7 Figure 2. District achievement of performance assessment milestones in Q1 2019 ...... 9 Figure 3. District achievement of performance review milestones in Q1 2019 ...... 12 Figure 4. District and institution achievement of NAV milestones in Q1 2019 ...... 14 Figure 5. District achievement of RMNCAH&N scorecard milestones in Q1 2019 ...... 17 Figure 6. District achievement of data quality assessment milestones in Q1 2019 ...... 19

List of Tables

Table 1. District progress toward completion of the MSI improvement plan for planning ...... 8 Table 2. District progress toward completion of the MSI improvement plan for performance assessment ...... 10

Table 3. Examples of PFM issues identified during self-assessments and planned actions ...... 15 Table 4. District and institution progress toward completion of the improvement plan from the PFM self-assessment ...... 16

Table 5. Example of summary findings from SQA for adolescent health ...... 25

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Acronyms

AMEP Activity Monitoring and Evaluation Plan CBO Community-based Organization CoC Continuum of Care DFID United Kingdom’s Department for International Development DHIO District Health Information Officer DHIS2 District Health Information System Version 2 DHO District Health Office DIM District Integrated Meeting DQA Data Quality Assessment DUO Data Use Officer HCC Health Center Committee HCF Health Care Financing HCFS Health Care Financing Strategy HMIS Health Management Information System M&E Monitoring and Evaluation MOH Ministry of Health MSI Management Systems Inquiry NHC Neighborhood Health Committee NHI National Health Insurance NHSP National Health Strategic Plan PA/ePA Performance Assessment/electronic Performance Assessment PFM Public Financial Management PHO Provincial Health Office PIM Provincial Integrated Meeting PMS Performance Management Specialist QI Quality Improvement RM&E Research, Monitoring and Evaluation RMNCAH&N Reproductive, Maternal, Neonatal, Child and Adolescent Health and Nutrition SBH Systems for Better Health SHIO Senior Health Information Officer Sida Swedish International Development Agency SQA Service Quality Assessment TSS Technical Support Supervision USAID United States Agency for International Development

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1. Introduction

The United States Agency for International Development (USAID) awarded the five-year Systems for Better Health (SBH) activity in Zambia to Abt Associates, Inc. in October 2015. The original goal of SBH was to improve health outcomes for Zambians by strengthening the health systems that underpin the delivery of high-quality health services and increasing the utilization of high-impact health interventions at the district and community levels.

In its original design, SBH had four objectives:

1. More effective national-level health stewardship 2. Improved capacity of provincial and district health teams to perform program management functions 3. Increased quality and availability of priority health services at the community level in targeted districts 4. Increased utilization of key public health interventions In 2018, USAID modified the SBH scope to adapt to the USAID’s changing priorities and strategies. SBH’s contract modification number 11 focuses the project’s efforts on supporting 70 districts in six provinces – Central, Eastern, Luapula, Muchinga, Southern and Western – to implement the Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH&N) Continuum of Care (CoC) program. This government-to-government program provides direct grant funding to District Health Offices (DHOs) to support the implementation of high-impact interventions to improve RMNCAH&N outcomes. The grant funding comes from USAID, the Swedish International Development Agency (Sida) and the United Kingdom’s Department for International Development (DFID). Following this contract modification, SBH’s new objectives are:

1. Performance management improved in six target provinces 2. Public financial management (PFM) improved in six target provinces 3. Increased data use for decision making in six target provinces SBH’s focus is on supporting systems for performance and financial management, as well as health information at the district and provincial levels, while other implementing partners provide technical assistance to DHOs to select and implement RMNCAH&N interventions. In line with the new scope of work and objectives, SBH phased out all of its other activities which did not contribute directly to these three objectives or the RMNCAH&N CoC program in 2018. Year Four will be the final year of the project; SBH will close in mid-October 2019. This document describes the project’s progress from January-March 2019.

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2. Highlights

Improved performance management. Following up on the improvement plans developed in 2018 using the Management System Inquiry (MSI) for planning tool, the SBH team focused technical assistance efforts in Q1 2019 to ensure implementation in targeted districts. Thanks to targeted SBH TA, District Manager leadership capacity notably improved in the 23 districts where monthly in-house meetings were held consistently in the quarter. Performance scorecards are increasingly used, both in DIMs and monthly in-house meetings, as well as in the documented action points of the meeting (Activity 1.3.1).

Improved public financial management. Institutions in Eastern and Southern province received training funded under the CoC grant in January and February. By the end of March, two districts in Eastern province posted their first live transactions. All institutions in Southern province batched and posted their transactions for 2018 before the training began. SBH PFM specialists assisted nine institutions in the Eastern province and five institutions in Southern province to complete the inception steps necessary for live use of NAV and helped the District Accountants to prepare their teams for the live use of NAV.

Improved generation, use, and quality of data. In Q1 2019, the Western Province Data Use Officer trained the Sioma District Health Information Officer (DHIO) in the use of the scorecard for planning and decision making. In March 2019 during the joint support supervision to the District, the MOH and SBH witnessed an excellent presentation of the scorecard by the DHIO. The DHIO builds the capacity of the health facilities to generate quality data and promote its use for decision making.

Improved Health Care Financing. In January 2019 the two consultants hired by SBH to develop the HCFS implementation framework addressed all the stakeholders’ comments in the document and finalized it. SBH HCF specialist reviewed and verified that the Health Care Financing Strategy Implementation Plan met the expectations of the Ministry of Health (MOH) and all relevant stakeholders. The MOH thereafter started using the plan to engage stakeholders on possible financial and technical support for the identified and prioritized activities in the implementation plan.

Improved capacity for Quality Improvement. In Q1 2019, SBH QI Specialist worked with QI Technical Working Group members to train newly hired senior managers at the national level, which addressed recent leadership turn-over. SBH contributions will include continuing to help plan for, prepare, and deliver orientations. (Activity 4.2.8)

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3. Progress by Objective

3.1 Objective 1: Performance Management Improved in Six Target Provinces Performance management is a continuous process involving interconnected systems and processes across different levels of the health system. In support of the CoC program, SBH works with the MOH to strengthen key pillars of the MOH’s performance management system: planning and resource allocation; PA; and Performance Review Meetings. Data is an essential element of performance management that cuts across these three pillars, however, due to the structure of SBH’s new objectives, the report presents progress on HMIS activities under Objective 3.

Sub-Objective 1.1 Improved Provincial and District Planning

Measurable improvements in performance begin with effective, data-driven planning. If districts do not include the right interventions in their annual plan, they are less likely to improve RMNCAH&N indicators, no matter how well PA or performance review meetings are conducted. The CoC cooperating partners provide funding to provinces and districts based upon the PHO and DHO CoC annual plans. The SBH team targets the DHO and PHO planning processes as a critical opportunity to strengthen performance indicators and service delivery. SBH TA seeks to strengthen the culture of data use and to assist institutions to use data to inform action planning. The DHOs need technical support to effectively identify and prioritize high-impact interventions based on data and analysis of bottlenecks or root-causes, as well as successes in other districts or facilities.

Our 2019 technical assistance focuses on the achievement of the following planning milestones:

1. PHOs and DHOs complete implementation of the improvement plan developed based on Management Systems Inquiry (MSI) before the next planning cycle. 2. PHOs and DHOs review the RMNCAH&N program performance using scorecards. 3. PHOs and DHOs identify priority program areas using scorecards and other information. 4. Based on priorities, PHOs and DHOs identify suspected root causes of poor performance. 5. PHOs and DHOs select high-impact interventions to address poorly performing areas and suspected root causes. Activity 1.1.1 Support development of annual Action Plans In Q1 2019, SBH provided technical assistance to 8 DHOs to build scorecard review skills to better understand trends and where to target support. The exercise will help them develop their 2020 plans in the second or third quarter. In 2019, the SBH PMS will work closely with the PHO and DHO planners to develop a timeline for the annual planning cycle which begins in May with data review and analysis. The SBH DUO will assist PHO and DHO teams to prepare and interpret the RMNCAH&N scorecards as part of the planning process and will assist the PHOs and DHOs to review their HMIS and other data to identify areas of weakness in the RMNCAH&N continuum of care.

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Since the planning process for 2020 begins in May, the PMS did not expect to focus much attention on planning from January to March. Because SBH TA will end in mid-July 2019, SBH expects to achieve five planning milestones in 42 of the 71 districts.

In Q1 2019, SBH teams or individual specialists visited 55 districts where they provided TA in SBH mentorship resulting in increased RMNCAH&N scorecard use by the MOH various technical areas. As shown in Figure 1, in eight of the districts visited SBH PMSs assessed the “When we were introducing the district and some provincial health staff into this use of the progress on planning had initiated activities related scorecard…we realized this is a MOH tool for to planning. Those eight districts reviewed their quick tracking of our indicators, particularly those RMNCAH&N scorecard and four of the eight under RMNCAH&N…it helped ensure that we now embrace and run with the fact that the districts made the preliminary selection of priority scorecard is a MOH tool…We’ve benefitted from areas based on performance. In the second quarter, the team we’ve worked with and I think that the PMS will increase the focus on planning with the integrating the team within the ministry structure goal of assisting a total of 42 DHOs to attain the and functions helped us to achieve more.” first three milestones. Dr. Chungu, PHS, Muchinga

Figure 1. District achievement of planning milestones in Q1 2019

DHO team assessed RMNCAH&N program 1 7 performance using scorecard

DHO identified priorities based on evidence 4 2

SBH assisted DHO to document use of evidence and 4 2 analysis causes of poor performance

0 1 2 3 4 5 6 7 8 9

Completed Partially Completed

Activity 1.1.2 Support quarterly review of annual Action Plans The SBH program promotes a culture of data use and approaches the review of RMNCAH&N scorecards and Action Plans as an opportunity to apply data-driven decisions on where to target support. In Year Four, SBH will provide technical assistance to the PHO and DHO teams to hold quarterly Action Plan and budget reviews (either during the PIM/DIM or in-house) for their MOH and their CoC grants. SBH did not assist with Action Plan reviews during the first quarter because most districts had not received funding from the MOH or the CoC grants to implement their action plans.

Activity 1.1.3 Follow up on findings and actions from planning Management System Inquiry SBH has an MSI tool for Planning and Resource Allocation which it developed in collaboration with the MOH. The Planning MSI tool asks PHO or DHO teams to review how they are completing their Annual Action Plans in comparison to standards drawn from MOH guidelines. Through discussion, team members identify areas where individual and group performance affects the quality of the results which the Planning system yields. The goal of the MSI for Planning is to facilitate reflection by PHO and DHO teams and highlight areas needing improvement. Based on reflection, teams develop improvement plans to address identified areas of weakness. The SBH PMS assists the teams to monitor the implementation of their improvement plan

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This quarter, the SBH team advocated with 26 districts visited to implement the action points in the improvement plan developed in 2018 based upon the Management Systems Inquiry for Planning. Eight districts had completed their MSI improvement plans and three districts made some progress toward implementation while the majority of districts (15) had not started the implementation of the plan. The districts that did not begin implementing their action plan had either set aside the plan and forgotten about it or faced challenges with the capacity of staff. For example, Nkeyema is a new district with a small staff that has not yet been oriented for planning. Other districts have experienced staff but their personnel still express doubt on how to use the planning tools.

Table 1. District progress toward completion of the MSI improvement plan for planning Improvement plan Less than 50% of planned No progress actions completed action complete Chitambo Mpika Chadiza Nkeyema Kapiri Mposhi Kawambwa Chembe Nyimba Luano Samfya Chipata Petauke Mkushi Isoka Senanga Nchelenge Lundazi Sikongo Kalabo Mambwe Sinda Sioma Mwansabombwe Vubwi Sesheke Nakonde Based on experience with the MSI for Planning, SBH is revising the tool to simplify it and make it faster to implement. Revisions will include simplification of the scoring method, re-design of the tool format to permit easy use of the printed or the projected tool, development of probes for key questions, and clarification of imprecise terms in the original standards. SBH will recruit an estimated 10 new PHOs or DHOs to conduct the MSI for Planning using the revised MSI tool. The project will gather suggestions for additional improvements to the tool and process from the DHOs, will refine the tools, and will document key changes in the end-of-project report.

Sub-Objective 1.2 Improved Performance Assessment

PA is a management tool that the central MOH, PHOs, and DHOs use to conduct self-assessments, followed by an external assessment performed by the supervising level. The PA enables PHOs to monitor the performance of their hospitals and districts. It also allows the districts to monitor their hospitals and health centers. The PHOs and DHOs conduct PA twice a year using a standard Excel or a newer e-PA application that posts data to a cloud database.

SBH will help the MOH improve PA implementation in target districts and provinces. To guide technical assistance, SBH monitors the following PA milestones:

1. PHO/DHO completes the implementation of PA MSI improvement plans before the next PA. 2. PHO/DHO conducts a pre-PA meeting to review the previous PA report action plan implementation status and review previous performance using RMNCAH&N scorecards to plan for the current PA. 3. PA report and action points distributed (either electronic or hard copy) to all officers at PHO/DHO and to all assessed districts/facilities.

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4. PHO/DHO plans (prepares a schedule and budget) and conducts TSS and monitors the PA action plan. 5. PHO/DHO monitors and updates the status of the PA action plan implementation quarterly. Activity 1.2.1 Support effective pre-PA meetings and PA SBH provided technical assistance to assist PHOs and DHOs to strengthen the quality of PA, HMIS use, and other information before, during, and after the PA. To prepare for and support more effective PA activities, SBH specialists supported PHOs and DHOs to:

• Plan or conduct effective pre-PA meetings to review the RMNCAH&N scorecards, the previous PA report and action plan, and other relevant data during pre-PA meetings. During these meetings, PHOs/DHOs also design the PA schedule and form teams for each route based on the pre-PA data review. • Analyze reports and develop the PA action plan and a TSS plan to address the gaps. • Monitor the implementation of the PA action plan and the TSS plan. This year, SBH aims to assist 48 DHOs to achieve the first three milestones while it will assist 44 DHOs to prepare for PA and 20 districts with tasks related to conducting PA. The project will provide advocacy and assistance which supports 24 districts to implement the full TSS plan from the previous PA.

Figure 2 demonstrates progress made to strengthen PA via SBH technical assistance. SBH provided TA to assist 33 districts to prepare for PA by reviewing prior reports (24 DHOs), HMIS information (21 DHOs), monitoring completion of the previous TSS plan (23 DHOs) or by organizing to prepare for the pre-PA meeting. SBH teams found that 24 of the districts where they provided TA were monitoring the implementation of their TSS plan and 26 districts had completed the TSS plan from the round of PA.

Figure 2. District achievement of performance assessment milestones in Q1 2019

P/DHO conducted a pre-PA meeting. 21 3

P/DHO reviewed HMIS data in the pre-PA meeting 17 4 P/DHO team assess whether they completed the 19 4 TSS plan from last PA SBH provided TA to assist the P/DHO to prepare 33 0 for PA Did the SBH team provide TA to assist the PHO or 27 0 DHO to conduct the PA

P/ DHO monitors implementation of the TSS Plan 15 9 P/DHO implemented the TSS plan from the last PA 16 10 in full 0 5 10 15 20 25 30 35

Completed Partially Completed

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Activity 1.2.2 Conduct MSI for PA and follow up on improvement plans SBH has an MSI tool for PA which it developed in collaboration with the MOH. The PA MSI tool asks PHO or DHO teams to review how they are implementing PA in comparison to standards drawn from MOH guidelines. Through discussion, team members identify areas where individual and group performance affects the quality of the results which the PA system yields. The goal of the MSI for PA is to facilitate reflection by PHO and DHO teams and highlight areas needing improvement. Based on reflection, teams develop improvement plans to address identified areas of weakness. The SBH PMS assists the teams to monitor the implementation of their improvement plan.

At the end of 2018, 61 districts had completed MSI for PA. These assessments revealed specific issues on PA implementation that DHOs and PHOs are now aware of and able to address. In Q1 2019, SBH provided technical assistance to 30 DHOs to follow up on the implementation of their MSI PA improvement plans. Table 2 shows that 14 DHOs completed their full improvement plan and three additional districts completed more than half of their plan by the time of SBH’s visit. Six districts had started to implement their plan but had not completed half of the required actions, while seven districts made no progress at all. The PMS’s worked to encourage the 16 districts with incomplete improvement plans to review their plans and tackle the remaining items.

Table 2. District progress toward completion of the MSI improvement plan for performance assessment Less than 100% Less than 50% Action plan fully implemented but above 50% complete No progress Chadiza Mambwe Petauke Isoka Chipili Chipata Mkushi Lavushimanda Nchelenge Livingstone Chisamba Mpika Sinazongwe Luampa Milenge Chitambo Nkeyema Shangombo Mumbwa Kapiri Mposhi Nyimba Chikankata Mwansabombwe Katete Senanga Siavonga Mwense Lundazi Vubwi Nakonde TOTAL: 14 3 6 7

Based on experience with the MSI for PA, SBH revised the tool to simplify it and make it faster to implement. SBH will recruit an estimated 10 new PHOs or DHOs to conduct their first MSI using the revised MSI tool. Revisions will include simplification of the scoring method, re-design of the tool format to permit easy use of the printed or the projected tool, development of probes for key questions, and clarification of imprecise terms in the original standards. SBH will gather PHO and DHO input on the effectiveness of the revised tool and document them in the final project report.

Sub-Objective 1.3 Improved Performance Review Meetings

Regular and consistent Performance Review Meetings organized and led by PHO and DHO teams are an essential platform where technical assistance partners can support the RMNCAH&N CoC program and health system areas. These performance reviews generally take place during Ministry PIMs and DIMs. The performance reviews could also occur within PHO or DHO offices to enable teams to monitor performance between semi-annual or annual PIMs and DIMs.

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The SBH team recognizes performance reviews as being key opportunities to promote improved data use. The SBH team builds the foundation for this by reinforcing the opportunities and how to do this, however, the SBH program also recognizes that the culture of institutionalized data use in performance meetings is still in its early stages. This is primarily due to organizational and financial factors, many of which the SBH program has been and is currently addressing. For example, of the six SBH CoC target provinces, only Luapula PHO held their monthly in-house review data review meetings regularly in quarter 1, 2019. Most PHOs and DHOs hold fewer than four quarterly PIMs/DIMs per year due to a lack of funding or competing priorities. When they do hold review meetings, there are opportunities to strengthen efficiency and management. For example, the meeting agenda is generally broad and presentations of program data tend to focus on one district at a time but describe all health programs and other priority areas. By doing this, it is challenging for participants to compare district and program performance over time. In Year Four, SBH continues to provide technical assistance to PHOs and DHOs to improve their Performance Review Meetings, with a view towards achieving the following milestones:

1. Conduct integrated program Performance Review Meetings (or PIM/DIMs) with districts/facilities and review performance using RMNCAH&N program scorecards at least twice per year.

2. Review RMNCAH&N program performance using RMNCAH&N scorecards in routine management meetings on a monthly basis.

3. Develop an action plan from PIM/DIM to address performance gaps and establish a system to follow up on the implementation of the action points.

Activity 1.3.1 Support planning and facilitation of district and provincial Performance Review Meetings To improve the efficiency and effectiveness of Performance Review Meetings, the SBH PMS and DUO provided technical assistance to PHO and DHO counterparts to: develop the schedule and program agenda for quarterly Performance Review Meetings; produce and share RMNCAH&N scorecards with all Program Officers; and ensure that during meetings, they review scorecards and other data, interpret information, and identify key areas for improvement with practical recommendations. The scorecard analysis helps program officers to understand how to use data to inform responses or decisions.

Additionally, the SBH specialists mentored PHO and DHO teams to plan for and hold internal monthly meetings where they review scorecard data to monitor performance and develop recommendations for improvements. The use of performance scorecards helps the MOH and the subnational levels to systematize routine use of standard indicators. SBH will continue advocating for these meetings to happen routinely within each PHO/DHO office and encourage teams to leverage existing meeting forums to do so to maximize time and reduce financial barriers.

In Q1 2019, of the 55 DHOs visited, 11 held DIM meetings, while none of the six target provincial health offices held PIMs. All 11 DHOs that held DIMS used the scorecard to guide discussion regarding program performance. It is encouraging to note 10 out of the 11 DIMS documented action points from the meeting. The small number of DIMs this quarter was likely due to a lack of funding from the government and CoC funding sources. Figure 3 reflects the progress made in the first quarter. Each of the activities in Figure 3 has a target of 37 districts.

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Figure 3. District achievement of performance review milestones in Q1 2019

PHO/DHO held an in-house performance review 23 meeting P/DHO uses RMNCAH&N scorecard during its 23 performance review meeting P/DHO records action points during the in-house 23 meeting

PHO/DHO held a PIM/DIM since the last visit 11 P/DHO used RMNCAH&N scorecard during the 11 PIM/DIM

SBH team provided TA for before the PIM/DIM 22

SBH provide TA during the PIM or DIM 5 Did the PHO or DHO record action points for the 10 PIM/DIM 0 5 10 15 20 25

Despite district-level funding challenges, SBH’s PMS’ provided TA to 22 districts to prepare SBH: Strengthening MOH capacity to improve the effectiveness of DIMs for DIMs, although only half of the districts that received TA held DIMs within the quarter. “The last DIM we held…was very effective because we were guided to even come up with action points that Even though provinces and districts lacked helped us to follow up health facilities on identified gaps and we have seen improvements in some indicators.” sufficient funds to hold DIMs, SBH advocates for teams to hold in-house meetings without Rebecca Mukumbuta, District Planner, Western Province additional financial resources. In Q1 23 of 37 targeted districts held monthly in-house data review meetings. Eighteen 8 of the 23 districts which held meetings were in Central, Eastern and Luapula Provinces. Muchinga and Southern reported three and two meetings respectively. Western Province did not report in-house monthly data review meetings in its districts. SBH seeks progress through the strong leadership of district managers in the 23 districts which held consistent monthly in-house meetings, the increasingly widespread use of performance scorecards in DIMs and monthly in-house meetings, and the documentation of action points.

Activity 1.3.3 Help MOH establish national Performance Review Meetings In Q1 2019, SBH in collaboration with MOH scheduled the first-ever a National Integrated Meeting (NIM) for quarter two which will be supported by SBH. The main objective of the meeting is to review national and provincial performance. One of the key agenda items is to review the provincial and district integrated meeting structure and content and to provide standard guidance for these meetings. SBH successfully advocated with the central MOH to hold a NIM as a way to strengthen district and provincial accountability to the central MOH for performance and to increase demand for data and for the use of the scorecard.

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3.2 Objective 2: Public Financial Management Improved in Six Target Provinces Effective and compliant financial management is essential for minimizing the risk of donor investment in the CoC program and ensuring all resources are efficiently used towards the achievement of the program’s RMNCAH&N goals. To improve public financial management (PFM), SBH focuses on two areas: implementation of the enterprise resource planning software Microsoft Dynamics NAV, and supporting improved PFM practices.

Sub-Objective 2.1 NAV Rolled Out and in Use in All Relevant Institutions

Activity 2.1.1 Build capacity of DHOs and PHOs on NAV use In Q1, the SBH PFM Specialists (PFMS) continued providing targeted technical assistance to the provinces, districts, hospitals, and training institutions to overcome challenges and use NAV in live mode. This year, Eastern and Southern Provinces received NAV training in January and February and began to work on going live. These two new provinces join Central, Luapula, Muchinga and Western provinces which began to use NAV last year in June.

The figure below shows NAV milestones completion progress for the 40 institutions supported in Q1. Support occurred through both physical and remote means. The institutions reported in milestones 1 to 7 (creation of imprest holder master files) are in Eastern and Southern provinces where the newly trained personnel need to complete the inception steps to use the 2017 NAV version. Milestone 8 (vendor master files created) includes districts in the four provinces which began to use NAV in 2018 as well as the new provinces. Only 8 institutions report complete vendor files because the central MOH initiated a clean-up of the vendor file data after observing duplications in the vendor files created independently in the four original provinces. Institutions say that their progress toward live use suffers because the central MOH has not yet completed the maintenance of the vendor files.

Notably, live-mode activities increased across the institutions that were supported in Q1 2019. There are more institutions have completed or partially completed live-mode milestones than those that have not started. To address challenges that prevent NAV implementation, particularly those related to change management, SBH continued to advocate with the central MOH and the Director of Finance to provide clear leadership to increase the motivation of provinces, districts, and other institutions to begin live use.

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Figure 4. District and institution achievement of NAV milestones in Q1 2019

Key personnel trained 36 0

Annual budget uploaded 31 0

Personnel have log-in credentials 20 2

NAV client installed on all computers 19 4

Computers configured 20 3

Bank account master files created in NAV 14 1

Imprest holder master files created in NAV 12 1

Vendor master files created in NAV 2 25 NAV batches created for all of 2018 before going 8 20 live.

NAV batches posted for 2018 up to live use period. 13 18

Program personnel post activity requests in NAV 12 10

PSOs able to prepare purchase orders in NAV 13 5 Accountants able to prepare NAV payment 12 5 vouchers

Accountants generate financial reports using NAV 2 19 Accountants prepare monthly budget variance 1 1 reports PHO accountants review NAV reports from their 1 4 institutions Accountants receive NAV technical support from 13 11 PHO 0 5 10 15 20 25 30 35 40

Completed Partially Completed

Activity 2.1.2 Help central MOH establish clear and stronger leadership to sub-national levels on NAV To maintain and scale up the gains in NAV roll out and use, it is essential that the MOH provides clear and strong leadership to provinces and districts. SBH collaborated with the central MOH to promote several change management interventions to increase the attention at the PHO level to NAV implementation and increase the oversight role from the MOH level.

In Q1 2019, the Director Finance appointed several central MOH personnel to a newly-formed NAV implementation unit. SBH advocated for the creation of this unit to strengthen NAV implementation and sustainability. The unit is responsible to direct the delegation of responsibilities at sub-national levels, adjust system configuration, manage workflows and user rights, resolve issues experienced by users, and monitor the quality and timeliness of transactions and reports from all institutions.

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Further, the Director Finance applied SBH’s recommendations and is organizing a national forum for NAV leadership in the provinces to better explain the Ministry’s policy regarding NAV. Among other technical issues to be addressed during that national level forum are:

• To clearly define the individuals or teams within the PHO responsible for ensuring that PHOs, DHOs, training institutions, and hospitals generate reports in NAV and post real- time data. The responsible PHO officer should provide technical support to lower level institutions to solve problems and assure the quality and timeliness of their work. • To develop an operational guideline or standard operating procedures for NAV specifying the roles and responsibilities for NAV operation at each level, the business process flows for all NAV transactions or system administration tasks, and the supervision and reporting responsibilities of each level.

Sub-Objective 2.2 Improved Public Financial Management Practices

The successful rollout of NAV should contribute to improved PFM practices in CoC districts. However, it is not sufficient: The MOH must ensure all relevant institutions have sound, compliant, PFM practices beyond the use of NAV. To support this achievement SBH uses a self-assessment approach that applies a standardized tool to help institution teams identify key gaps in financial management systems and develop concrete, time-bound plans to address gaps. The table below shows examples of the findings and planned actions from previously conducted assessments.

Table 3. Examples of PFM issues identified during self-assessments and planned actions

Sample findings Planned action Responsible person(s) Not conducting financial management Begin reviewing financial District Accountant (with reviews performance support from Planner) The district lacks files of supporting Create a file for all purchase District Purchasing Officer documents for some purchase transactions in the purchasing transactions from the purchasing office office DHO personnel do not receive an Conduct staff orientation Human Resource Management orientation on the Code of Ethics, job meeting(s) and particularly Officer (with support from the roles, planning, purchasing, and accounting orient staff as they join the District Health Director) procedures DHO The Accounting and Stores team do not Conduct asset inspections District Accountant (with consistently conduct asset inspections to support from Planner and verify the existence and determine Stores Officer) conditions Lack of a procurement plan Prepare the Annual District Purchasing Officer Procurement Plan

The primary focus for SBH PFM Specialists during Q1 2019 was to assist all institutions to attain live use of NAV. Once a district attains live use of NAV, the PFM Specialists works with them on the PFM self-assessment. To monitor progress in districts and guide technical assistance, PFM Specialists tracked the following milestones:

1. PHO and DHO complete a self-assessment on PFM using the PFM tool. 2. PHO and DHO teams develop an improvement plan based upon identified priorities. 3. PHO and DHO team review the progress toward implementation of the improvement plan.

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Activity 2.2.1 Help districts conduct or follow up on PFM self-assessment During Q1 2019, SBH PFM Specialists worked with accountants and District Health Directors to support the completion of PFM improvement plans for districts that previously completed PFM self- assessments. For districts who attained live use of NAV but had not yet completed a PFM self- assessment, SBH helped them complete the self-assessment tool, develop the improvement plan, and followed up to ensure implementation. The table below represents the extent of completion for action points under the PFM Improvement Plans per district visited.

During Q1 2019, Chitambo, Kapiri Mposhi, Kawambwa, Mwansabombwe, and Samfya completed their PFM self-assessment and the improvement plan, so they could not report yet on implementation of action items. While no institution had completed all improvement action items Chilonga Mission Hospital, Luampa, Mwense, and Kabwe implemented 50% or more of the action points in their plans. The other four institutions which completed the assessment in 2018 had begun to work on their plans.

Table 4. District and institution progress toward completion of the improvement plan from the PFM self-assessment More than 50% of the 50% or less of the action action points implemented points implemented New assessments Kabwe Mwense Samfya Chilonga Mission Chitambo Luampa Kapiri Mposhi Mpika Kawambwa Nakonde Mwansabombwe Isoka Lukulu Chembe Total: 1 8 5 3.3 Objective 3: Increased Data Use for Decision Making Data enables provinces and districts to understand how they are performing, make informed decisions, and provide better supervision. Without effective and regular use of quality data, districts and provinces cannot monitor and manage their programmatic and financial performance. SBH focuses its data support on two critical areas: assisting districts and provinces to generate and use their RMNCAH&N scorecards, and building capacity to improve the quality of scorecard and other data.

Sub-Objective 3.1 Improved Generation and Use of RMNCAH&N Scorecards

In Year Four, the project will use the following milestones to guide and monitor progress toward the use of scorecards (milestones 1-3) and data quality (milestones 4-6):

1. DHOs enter revised 2019-2020 population projections in DHIS and allocate to facilities.

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2. Senior Health Information Officers (SHIOs) or District Health Information Officer (DHIOs) generate the RMNCAH&N scorecards and share with Program Officers for monthly data review at PHO and DHO level. Figures 5 and 6 below show cumulative progress districts made towards the achievement of the seven HMIS milestones among the 39 districts supported in Q1 2019. Based on experience, SBH converted the milestones for a SBH performance review to a binary format so that the milestones are rated either as complete or incomplete.

Activity 3.1.1 Build DHO capacity to generate and use RMNCAH&N scorecards The RMNCAH&N scorecard is a program tool that allows all stakeholders to measure progress and make decisions. DHOs use results from the scorecards to define actions to improve performance such as planning technical support visits to health facilities and to identify areas where data needs verification. Without effective implementation and use of the scorecard, provinces and districts have greater difficulty identifying and targeting areas of poor performance.

The SBH target for accurate population data is 70 districts, while the project expects 58 districts to run and share the scorecard. In Q1 2019, SBH helped DHOs make significant progress to create and use the scorecard. As the figure below shows, 31 districts supported this quarter revised their population data in DHIS2 and 31 DHOs are generating RMNCAH&N scorecards and sharing with Program Officers. In 2018, 65 of 70 districts completed the first milestone by updating their population data. However, many districts are reporting new activity on this milestone in Q1 2019 because DUOs have helped the DHIO update health facility population projections, thereby making changes to figures entered last year.

Figure 5. District achievement of RMNCAH&N scorecard milestones in Q1 2019

DHIO entered revised 2019-2020 population projections in DHIS and allocated to the district 31 71 facilities

S/DHIO generates RMNCAH&N scorecards for 31 their office 58

S/HIO shares the scorecard with program officers 31 58

0 10 20 30 40 50 60 70 80

Completed Target

By end of the Q2 2019, SBH expects to support all districts to ensure that they have updated population figures in DHIS2 and at least 58 districts will generate and share the scorecard. Kapiri Mposhi is the only district among the ones supported this quarter that did not complete the population data entry because they are making corrections to health facility level population data projections. The SBH DUO is supporting the DHIO to complete this exercise.

In districts such as Chikankata and Shang’ombo where Program Officers were trained on DHIS2 last year, DHIOs are not generating and sharing scorecards with the program officers because SBH expects that trained program officers now have access to the system will generate the scorecards

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themselves. Other DHIOs such as Sioma and Chibombo needed additional support and the SBH team delivered targeted mentorship on how to generate, interpret, and share the RMNCAH&N scorecard. DUOs now print the scorecards for PHOs and DHOs and deliver them during visits, encouraging provinces and districts to display printed scorecards on their bulletin boards.

In Q2 2019, SBH will provide technical support to the MOH M&E team by engaging a DHIS2 system developer to help the MOH execute DHIS2 back-end development, system upgrades, and maintenance. The system developer will work closely with the MOH M&E team to build capacity to re-program data elements to make retrieval more efficient, align data elements to the correct data sets, archive old data elements and associated data sets, and format data entry screens and the scorecard to make them more user-friendly.

Activity 3.1.2 Demand for scorecard use in MOH supervising levels SBH noted in 2018 that is that some provinces and districts are reluctant to use the scorecard because the central MOH has not directed them to use it. This applies particularly to the use of the scorecard in Provincial Integrated Meetings and District Integrated Meetings. To address this problem, the project approached the Directorate of Performance Improvement, Quality Assurance, and Monitoring and Evaluation. The project asked whether the Directorate would hold a National Integrated Meeting and use the scorecard. The Directors expressed a strong interest in holding such a meeting and in revising the scorecard to align with the new Monitoring and Evaluation Framework for the National Health Strategic Plan. (The Permanent Secretary of the MOH for Health Services is currently reviewing the Framework and the Director for M&E expects to receive approval soon.) The Ministry tentatively plans to hold its first NIM with a focus on RMNCAH&N indicators in June. The NIM will be an opportunity for the MOH to gather comments from the Provincial Health Directors to contribute to a draft guideline for PIMs and DIMs which encourages the use of scorecards.

Sub-Objective 3.2 Improved Data Quality

Activity 3.2.1 Build DHO capacity to produce quality data In Year Four, the project will use the following milestones to guide and monitor progress toward improved data quality (milestones 4-6):

1. PHO/DHO team conducts data quality assessments (DQA) and monitors progress on data quality at least once in six months. 2. SHIO/DHIO creates a database to track identified data quality issues and solutions and updates it at least once per quarter. 3. PHO/DHO follows up with facilities on data quality issues and documents corrective actions. While generating and using RMNCAH&N scorecard data is essential for effective programming, it is not sufficient; PHOs and DHOs must ensure the quality and accuracy of the reported data. To ensure data accuracy, DUOs support SHIOs and DHIOs to perform data validation and cleaning. SBH DUOs helped DHIOs run data quality and validation checks in DHIS2 to identify gaps in data quality and plan efficient DQAs. DQA usually involves data verification at health facilities and comparing data reported to the DHO versus health facility registers and tally sheets. Figure 6 (below) shows 24 of the targeted districts conducted DQA during Q1 2019 and about 50% of those targeted for implementation of the Excel-based tool have started using it.

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Figure 6. District achievement of data quality assessment milestones in Q1 2019

P/DHO team has conducted DQA since the last 24 visit 27

S/DHIO uses an electronic or paper based tool to 23 note data quality issues and the solutions 43

DHIO identifies data quality issues during data 22 entry and scorecard review since the last visit 37

DHO followed up on identified data quality issues 19 by DHIO 21

0 5 10 15 20 25 30 35 40 45 50

Completed Target

In Muchinga province, Isoka, Shiwang’andu, and Nakonde DHOs conducted DQAs to review health facility data for Q4 2018 and audited all RMNCAH&N data elements. The major issue identified was that facilities were either over-reporting or under-reporting some RMNCAH data elements. The DQA team responded by meeting with the health facility staff to resolve data quality issues and provide mentorship on the correct use of registers and reporting forms. Other data quality audit findings included: • Facilities are still using old and improvised registers • Data discrepancy in a facility arising from double counting of clients between OPD and IPD • Facilities and DHO are not harmonizing data (recompiling) after conducting DQAs, thus the DQA is not achieving the desired result of better quality data • Facilities are not analyzing their data before submitting; as a result, some reports reflect discrepancies between source registers and aggregated forms

Efforts by the SBH team to help DHIOs resolve problems include: • The DUO helped DHIOs and Planners to develop action plans and follow-up with facilities • The DUO shared lessons learned from Lavushimanda DHO on how to promote facility-level data analysis where facility staff attach narratives to HIA reports on indicator trends

DUOs mentor DHIOs on the need to perform monthly data quality checks after data entry and before running scorecards. During this mentorship, DUOs explain how to clearly document all identified data quality issues and actions taken to resolve them. While some DHIOs report they are not able to complete DQAs due to funding constraints and/or conflicting priorities, others resolved to use alternative methods, including WhatsApp groups and phone calls, to contact health facilities to verify data. DHOs also verify data during routine technical support visits to health facilities. The SBH team will continue following up with the DHO team in Q2 2019 to assess if these practices are leading to better quality data.

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3.4 Central-level Activities As described in the SBH Annual Work Plan, in Year Four SBH will continue to provide limited central-level assistance to the MOH on HCF and QI until June 2019. (The Work Plan initially indicated that SBH would cease its support for QI in March, but the MOH requested that USAID reconsider this deadline. SBH and USAID then agreed to extend the QI support to June.)

Health Care Financing

Since its first year, SBH has been a key partner providing technical assistance to the MOH’s Health Care Financing (HCF) portfolio under the Policy and Planning Department and Health Care Financing and Resource Mobilization Department. Through its HCF Specialist, SBH’s assistance focused on supporting developing key documents and strategies to help the MOH plan for and secure resources for health. The project helped the MOH achieve significant milestones, including:

• Developing the 2017-2027 HCFS • Conducting annual NHAs • Developing the NHI scheme In its fourth and final year, SBH will support critical HCF efforts at the central MOH level to ensure success and sustainability. Support will continue until June 2019, when the SBH HCF Specialist will be phased out. The activities listed below are included in the MOH’s 2019 plan and the national budget.

Activity 4.1.1 Support the finalization of the HCFS implementation framework In Year Three, the MOH began developing an HCFS implementation framework to guide implementation of the strategy. In Year Four, the SBH HCF Specialist continued providing technical assistance to the MOH to finalize and implement the framework.

In January 2019, the SBH team hired two consultants to develop the HCFS implementation framework, address all stakeholder comments, and finalized it. The SBH HCF Specialist reviewed and verified that the document met MOH expectations, as well as those of all relevant stakeholders. The MOH thereafter started using the plan to engage stakeholders on possible financial and technical support for identified and prioritized activities in the implementation plan.

Activity 4.1.2 Support 2017 NHA and institutionalization of NHA In Year Three, the SBH HCF Specialist and Abt Associates Home Office NHA experts helped the MOH lead preparations for the 2017 NHA. In Year Four, SBH will help the MOH finalize the 2017 NHA. To support the MOH’s institutionalization of resource tracking and diminish the need for external support for the NHA, SBH helped the MOH to introduce a Resource Mapping Tool to track resources from source to end users in the health care system. The MOH intends to implement a second round of the Zambia Household Health Expenditure Utilization Survey.

The aim of NHA and resource tracking is to help the government identify the sources and levels of health care funding in the health system, as well as the allocation and utilization of the funds. Higher levels of out-of-pocket expenditure and low private health insurance have been two arguments for the introduction of NHI. In addition, NHA shows the distribution of the uses of finances for health

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in the health system by level and disease type. This information is key to deciding the priority interventions that the NHI should include in its benefits package. Furthermore, NHA provides an invaluable tool to identify progress toward universal health coverage through its disaggregation of the levels and sources of funding for health, from which financial risk protection can be gauged.

In Q1 2019, the SBH HCF Specialist, in collaboration with University of Zambia, provided technical assistance to the MOH Directorate of Policy and Planning to finalize the 2017 National Health Accounts (NHA) data collection tools, mapped target agencies and firms to provide the data, and finalized contracts with NHA data collectors trained by SBH in December 2018 with technical assistance from Abt Associates’ Home Office NHA experts. In March 2019, data collection for the 2017 NHA began, and the HCF Specialist, in collaboration with the University of Zambia, provided remote technical assistance to supervise data collectors in the field.

Activity 4.1.3 Support the launch of NHI In Year Three, SBH provided essential technical support to the MOH on the development of the NHI scheme and as a result, was recognized as a “trusted partner” on NHI by the MOH.

In Q1 2019, the SBH HCF Specialist continued to support the development and costing of the National Health Insurance benefits package, in collaboration with experts from the University of Zambia and MOH counterparts. SBH support included presenting the draft NHI benefits Package and holding discussions with stakeholders such as the Public Service Management Division and the National Health Insurance Implementation Team. The SBH HCF Specialist also worked with the MOH to develop and cost a proposal for financial support towards the implementation of National Health Insurance from the Chandler Institute of Governance, a Singapore-based grant-making institution that supports governments in Africa on governance for economic development. The proposal is awaiting consideration by the Institute. The SBH HCF Specialist also traveled with the Continuum of Care team to Eastern Province on a technical assistance visit to learn about the application of the NAV system and assess the preparedness of facilities for the introduction of NHI. Observations in the field were that:

• DHOs have not been thoroughly oriented to the NHI Act and its proposed implementation.

• Health facility staff have not been oriented on the impending implementation of the NHI Act, which would require changes in the facility management practices regarding patient record and billing systems. This relates to the application of NAV systems for NHI billing purposes.

In view of the above observations, SBH recommended that the MOH conduct a thorough orientation of its staff on National Health Insurance.

In March the SBH HCF Specialist was appointed Secretary to the newly-created National Health Insurance Implementation Team by the MOH. Following his appointment, he led the team in drafting the National Health Insurance Management Authority (NHIMA) Inception Strategy, for presentation to the first NHIMA Board Meeting. This marked the achievement of a major milestone in the HCF Strategy Implementation Plan that SBH supported the MOH to develop in January 2019.

Quality Improvement

In addition to supporting planning, PA, and Performance Review Meetings at the sub-national levels, in its final and fourth year SBH continued to provide technical assistance to the central MOH

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through a seconded QI Specialist to the central MOH in quarter 1 to enable a smooth transition to new MOH personnel in the newly created Directorate for QA/PI and M&E. The QI Specialist continued to assist the MOH to strengthen structures, systems, and tools to support effective QI of health services at sub-national levels. These structures, systems, and tools are essential for successful performance management of provinces, districts, and health facilities. The SBH QI Specialist led this support, worked closely with the Department of QI, Performance Improvement, and M&E.

Activity 4.2.1 Review and improve PA tool and guidelines The MSI for PA revealed several gaps in the implementation of PA. Many of these gaps are related to the difficulty that some PHO and DHO teams have in properly following the PA guidelines and understanding and using the PA tool. The MOH recognized the need to improve the PA tool and guidelines. In Year Four, quarter 1, the SBH QI Specialist provided technical assistance to the MOH to review the PA tool and guidelines to make them more user-friendly. This should contribute toward improving the implementation of PA and achieving PA objectives.

In Q1 2019, the SBH QI Specialist seconded to the MOH helped the Ministry pilot the electronic Performance Assessment (PA) tool in selected facilities in Lusaka District. The pilot was preceded by a one-day orientation for Program Officers. The electronic PA tool desktop application has been in use since November 2016 and deployed to eight provinces, with the exception of Lusaka and Southern Provinces.

The general consensus from Program Officers participating in the pilot was that the tool was user- friendly and overall improvement from the paper-based system. Observed challenges included system access, connectivity, delays in system startup, loading pages, and auto-saving when offline. A number of data elements were inactive in the system during the pilot, including Human Resource Standards, Number of available health workers/Total establishment for health workers (denominator), Number of patients managed according to nursing protocols/Number of patients files sampled, etc. These were resolved immediately after the exercise.

Activity 4.2.2 Help central MOH develop tools and templates for PIM/DIM Currently, there are no standardized guidelines for conducting PIMs/DIMs and consequently, these meetings are often unfocused and ineffective. In Year Three, the SBH QI Specialist began working with the Department of QI, Performance Improvement, and M&E to develop PIM/DIM guidance. In Q1 2019, SBH successfully advocated with the central MOH to hold a National Integrated Meeting to strengthen district and provincial accountability to the central MOH for performance and increase demand for data and data use. The first-ever National Integrated Meeting will be held in Q2 2019 and will be supported by SBH. The meeting objective is to review the National and Provincial performance. A meeting agenda item is to review provincial and district integrated meeting processes and provide standard guidance for these meetings. Draft PIM and DIM implementation templates will be finalized in this meeting.

Activity 4.2.3 Standardize TSS tools and processes There are currently no standardized guidelines for conducting post-PA TSS, and as such, the MOH technical teams and leaders at all levels have been conducting uncoordinated TSS to lower levels. As a result, TSS is often ineffective. In Year Four, the SBH QI Specialist provided technical assistance to the central MOH to develop standardized TSS tools and guidelines. The TSS guidelines will describe

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how supervising MOH teams should prepare for TSS which can be in the form of mentorship, conduct visits, and document their work.

The QI Specialist worked with the Directorate of Monitoring and Evaluation, Quality Assurance and Performance Improvement to facilitate a meeting to draft guidelines for Technical Support and Supervision. There was broad consultation with districts and health facilities. The guidelines will be shared for comments in Q2 2019 and will be consolidated, ratified, and disseminated by the MOH.

Activity 4.2.4 Support the finalization and dissemination of a QI Strategic Plan In Year Three, the SBH QI Specialist supported the Department of QI, Performance Improvement, and M&E to develop Zambia’s first QI Strategic Plan, which was finalized in Q1 2019. SBH provided technical input into each stage of the document’s development. The Strategic Plan will provide direction on QI activities at all MOH levels.

Working with the Directorate of Quality Assurance and Performance Improvement, the SBH QI Specialist facilitated collaborative meetings that included the SBH Director of Technical Support to draft the QI Strategic Plan. The MOH Directorate of Quality Assurance and Performance Improvement shared the draft with QI TWG members and other stakeholders for input. A meeting to finalize the document has been planned for Q2 2019.

Activity 4.2.5 Support the finalization of client service charters The MOH is prioritizing its patient-centered approach to health services for better outcomes and client satisfaction. As part of good governance and social accountability, communities must be informed of what standards apply to the health services being provided to them. To support this, the MOH is developing client service charters for hospitals at different levels. In Year Four, the SBH QI Specialist provided technical assistance to the MOH to refine the charters. Service charters will be useful tools for patients, their relatives, and anyone wishing to learn about the health facility and the services it provides.

Working with the Directorate of Quality Assurance and Performance Improvement, the SBH QI Specialist facilitated meetings to draft the Client Service Charters with some health facilities in Western and Central Provinces. These included Lewanika General Hospital, Kabwe Central Hospital, Mushukula Rural Health. Other provinces will be supported when resources are available.

Activity 4.2.6 Support effective QI fora In Q1 2019, the SBH QI Specialist continued working with the MOH to strengthen existing QI fora such as QI Technical Working Group (TWG) meetings and Teaching and Central Hospital QI Committee meetings. SBH technical assistance included helping plan and facilitate the meeting agenda, prepare materials and presentations, and document meeting outcomes and action items. These meetings are important fora for supporting QI activities at all MOH levels; strengthening these fora should strengthen implementation, monitoring, and the sustainability of QI efforts.

The SBH QI Specialist supported the MOH to convene two central level QI TWG meetings in Q1 2019. The SBH QI Specialist developed the agenda, invited participants to the February and March QI TWG meetings, and helped the MOH to prepare presentations for the meeting, and recorded meeting minutes. Two QI projects from the tertiary level, University Teaching Hospital (UTH) which have received a lot of technical input from SBH’s QI Specialist, were also presented at the first

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meeting. The projects were entitled: (1) Improving theatre efficiency; and (2) To improve the supply, accessibility, and storage of anesthetic drugs in theatres.

The second meeting’s objective was to update members on the Annual National QI Conference on June 4-6 2019. The conference theme is “Excellence and Innovation towards Universal Health Coverage”. SBH provided input to the National QAQI Strategic document that will guide the enhancement of quality in Zambian Health Services. The activity was supported by the World Bank.

Activity 4.2.7 Support health facility assessments using the SQA tool In Year Three, SBH helped the MOH develop, field test and implement the SQA tool. The tool’s use has helped hospitals facilitate gap identification, analyze and solve problems in different health service areas. In Q1 2019, the SBH QI Specialist continued working with QI TWG members to provide technical assistance on the utilization of the SQA tools. Technical assistance included participating in SQAs with QI committee members and service providers in health facilities and in the process, guiding them on the proper use of the tool, making on-the-spot corrections, answering questions, and facilitating post-SQA reflections to identify and address difficulties and issues.

In Q1 2019, the SBH QI Specialist seconded to the MOH joined a MOH team to conduct SQA in selected facilities in Northern Province. Although Northern Province is not included in SBH’s geographic coverage, the central MOH team relies heavily on SBH’s QI Specialist and sought her assistance for this exercise. SBH’s support for this activity helps build central MOH capacity for leadership in QI. Functional areas assessed using the SQA tool included: infection prevention and control, monitoring and evaluation (M&E), labor and delivery, pharmacy, pediatric antiretroviral therapy (ART), and adolescent health.

Summarized SQA results demonstrate that:

• Functional areas that performed well in comparison to others were pediatric ART and Human Resources for Health. This was attributed to support from cooperating partners for HIV services and recruitment and deployment of health workers in 2018.

• The worst performing functional areas in all the hospitals assessed were adolescent health and infection prevention and control.

• The worst performing domains across functional areas were non-availability and broken down equipment and the use of national guidelines and treatment protocols.

The QI Specialist facilitated discussions and orientations before, during and after assessments. The MOH team and SBH QI Specialist oriented facility management and teams on the process of assessing facilities. The MOH-SBH team discussed identified gaps with hospital teams using an in- depth analysis of root causes. Teams discussed interventions to address gaps, identify action points and time frames for completion. Below are examples of gaps identified with action points discussed with facility teams during the post-assessment discussions for adolescent health.

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Table 5. Example of summary findings from SQA for adolescent health

Problem Identified Analysis of Agreed Action Time-Frame Responsible Identified (Recommendation) Officer Problem

ADOLESCENT HEALTH

Infrastructure Adolescent Identify room to counsel End of March Casualty in-charge Health Program and refer adolescents to 2019 No dedicated room to not available access various services attend to adolescents within the hospital (adolescents used to meet in pediatric ART room in the past)

Equipment Lack of an Establish an Adolescent End of March Casualty in-charge Adolescent Health Program and 2019 No information, Health Program order/ make available the education, to warrant the required communication availability of equipment/materials materials, signage and the said entertainment materials equipment/materials for adolescents

Human Resources Hospitals not Provincial Health Office End of March PNO-MCH considered for to train at least two staff 2019 No staff trained in trainings in the in adolescent health adolescent health past during the next training

Practices Non-availability Establish an Adolescent End of March Casualty in-charge of Adolescent Health Program and 2019 No protocols Health Program provide the necessary protocols and guidelines

Records/ data Non-availability Establish an Adolescent End of March Casualty in-charge management of Adolescent Health Program and 2019 Health Program provide the necessary No registers and data management tools reporting tools available

Activity 4.2.8 Build capacity of senior managers at national level on QI methodologies Recent restructuring processes in the MOH led to leadership changes, especially at the national level; many senior managers are new and do not have the knowledge and skills on QI methodologies and are not positioned to deliver effective leadership on QI. To address this, the MOH Department of QI, Performance Improvement, and M&E planned capacity building activities on QI methodologies at national and provincial levels. In Q1 2019, the SBH QI Specialist worked with QI Technical Working Group members to train some senior managers at the national level. SBH contributions will include continuing to help plan for, prepare, and deliver orientations.

Central MOH QI Project Initiation

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In Q1 2019, the SBH QI Specialist helped the MOH initiate a QI Project at the Central Ministry of Health’s main Registry and the Directorate of Policy and Planning’s registry departments to improve the quality of record keeping, which had been noted to affect service delivery to MOH personnel across the country whose employment records were frequently misplaced. The SBH QI Specialist was assigned to lead a team of selected MOH staff to improve filing and record management after numerous complaints from different program staff and directors on delays and missing files when processing personnel or policy files. This led to poor central MOH performance.

The SBH QI Specialist met with a MOH team assigned to improve filing and record management and presented the “5S” quality improvement approach and discussed possible causes and interventions with the team (see box below).

The 5S approach

Sort – Classify items around 3 categories: 1. Needed; 2. May be needed; 3. Not needed.

Set in order – Create an orderly and visually instructive workplace by using visual controls to communicate where things are. Designate locations, placing identifiers such as tapes and labels, arranging so that everything is where it is needed (at the point of use).

Shine – Keeping the working environment, equipment, and machines clean through cleaning, shining, and inspection by involving everyone.

Standardize – Standardizing all works by having implementation schedule, work instructions, standard operating procedures where these are required, labels, color-coding to identify danger zones, waste types, disposal bins, and signboards for easy understanding.

Sustain – Sustaining improvements gained during implementation and enhancing momentum through self- discipline, training/coaching/on-the-job training, effective communication among the team, clearly-defined roles among others.

Some brainstormed possible solutions: • Create more space by rearranging files and eliminating unnecessary items • Improve the filing system by sorting files according to staffing categories and numbering in the main registry and according to programs in the policy registry • Members of staff should be allocated tasks and sections to work on and teams should have 10- minute daily updates on previous and current days’ work • Departmental supervision should be strengthened and departments should be supported in critical areas to improve efficiency

The team noted and visually observed improvements in records filing in the participating departments. According to their QI plan, teams adhered and had put in place implementation schedules, individual roles, and were meeting daily for 10 minutes to review the previous day’s work and plan for the current day.

QI training for health workers at Adult and Pediatric HIV Centers of Excellence at UTH

In Q1 2019, the SBH QI Specialist provided technical input to the QI training for 27 health workers at the Adult and Pediatric HIV Centers of Excellence at UTH. Participants trained included Medical Officers, Nurse Counselors, Pharmacists, Laboratory Technologists, and M&E Officers. The training was funded by the US Center for Disease Control and Prevention.

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Women and Newborn Hospital QI Committee Mentorship

The SBH QI Specialist supported one of the University Teaching Hospital Women and Newborn QI Committee meetings in the quarter, where she mentored on how to improve monitoring and tracking of progress on a QI project titled “Reduce long waiting time on both emergency and non- emergency cases”. The project started in July 2018 and there was progress in the reduction of time spent waiting for services. The creation of a triage desk and team, and having a consultant available at all times to respond to emergencies were strategies used to reduce waiting times. However, the team had poor documentation on the QI process and was not measuring how much time was reduced. The QI Specialist provided guidance on documenting and monitoring the project. 3.5 Research, Monitoring, and Evaluation The SBH approach to M&E is designed to be cost-effective, accurate, reliable, and timely. The SBH Research and M&E (RM&E) team leads the performance reporting and support for final documentation efforts to assess and capture significant SBH results. The SBH AMEP is a key project management tool that serves internal and external audiences over the life of the project. The RM&E team works closely with the SBH Senior Management Team and program staff to ensure the AMEP guides technical assistance to PHOs and DHOs and the program continues to use evidence to inform decisions and modify approaches. The project AMEP includes both output and outcome indicators.

Activity Monitoring and Evaluation Plan (AMEP)

During Q1 2019, the RM&E team started reviewing AMEP, which was initially revised in August 2018 and submitted to USAID based on the first contract modification and project re-focus. The SBH team is currently finalizing the AMEP based on the modified contract and work plan approved in February 2018. The final revised AMEP was expected to be submitted to USAID in Q1 2019. However, because of the delay in the work plan approval, SBH will submit the revised AMEP taking into consideration all the changes by May 30, 2019. The purpose of the revision is to ensure that indicators tracked are aligned with the new project scope of work.

Data Collection

In Q1 2019, the RM&E team revised and finalized the data collection tool to ensure all indicators are captured and aligned with the modified contract. SBH transitioned to using an online web-based system using Google Sheets, which has already notably improved data efficiency.

Program M&E Database

The modification of contract and project re-focus for SBH expanded the scope of work in terms of geographical coverage from the initial 5 provinces and 20 districts to 6 provinces and over 70 districts. As a result of the contract modification and the project re-focus, new indicators were introduced and some indicators became obsolete. This change inevitably required a revision of the database. A more efficient and effective data management system was also required to capture data. As a start-up to this process of capturing data, the RM&E team worked closely with the program staff and developed a simple centralized Excel database system that was used until December 2018.

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In Q1 2019, the RM&E team revised and upgraded the M&E database from a simple Excel to Google Sheets, which is a decentralized online system offering improved version control and controlled access. The system has been finalized and implemented. The team trained provincial staff on how to use and manage the new system. The new system offers improved, real-time collaboration with provincial staff in terms of providing technical support, work with them at the same time wherever they are. Users benefit from its simple, intuitive interface. Google Sheets automatically saves work and is free to use. The RM&E team continues to provide close technical support to provincial teams to implement the new database to ensure efficient and proficient data system management.

USAID Reports

During the quarter, the RM&E team gathered all necessary data in preparation for FY19 Semi-Annual Performance Report (SAPR) through the Data for Accountability Transparency Impact Monitoring (DATIM) system. The data will be submitted in April. In FY19, because of the contract modification, SBH will only report 2 indicators under PEPFAR which will include:

1. Number of beneficiaries served by PEPFAR orphans and vulnerable children programs for children and families affected by HIV (OVC_SERV); 2. Percentage of orphans and vulnerable children (<18 years old) with HIV status reported to implementing partner (OVC_HIVSTAT); Conduct Quarterly DQAs of SBH Field Data

During Q1 2019, the RM&E team did not conduct any DQAs; due to the U.S. government shutdown, most of the activity implementation by field staff started in mid-February. The RM&E team plans to implement DQA in Q2 2019.

Kitwe HIV Linkages Activity Documentation

In Q1 2019, the RM&E team reviewed and provided technical support to the consultant leading the development of the HIV Linkages Activity documentation report. The draft documentation report was submitted to USAID in early March. Feedback was provided by USAID and the consultant is revising the report. The report is expected to be submitted to USAID in Q2 2019.

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4. Project Management

4.1 Finance and Administration During Q1 2019, the SBH finance and administration team provided logistical support to the all-staff Planning, Review and Documentation Meeting held in Lusaka in March 2019. In Q2 2019, the team will commence arrangements for the termination of field office leases, including relocating staff in the Western province to the PHO office in Mongu. This follows the termination of the Lease Agreement by the Landlord in June 2019. 4.2 Overall Budget and Expenditures As of March 31st, 2019, SBH spent a cumulative total of $37,178,935 against the total obligations of $38,508,647. Cumulatively, SBH spent 96.55% of the obligated funding and 89.88% of the total project estimated a revised amount of $41,363,422. 4.3 Personnel The opening staff number on 1st January 2019 was 42. As of March 31, 2019, SBH had 40 staff due to the following movements;

• In February 2019, one (1) project staff, the Grants/HIV Linkages Advisor was declared redundant due to changes in the scope of the project and end of the HIV Linkages activity.

• One (1) driver for the Lusaka head office resigned in March 2019 and the position will not be replaced due to the scaling down of the project.

The project anticipates declaring redundant three more staff in the next quarter. 4.4 Subcontracts Abt Associates is implementing its 2019 work plan activities in collaboration with partners Akros Inc. and Save the Children. Akros Inc. continues to provide expertise for the project’s TA for HMIS within the Continuum of Care program. Save the Children worked to document the Kitwe Linkages Activity for HIV exposed and positive infants, children, and adolescents. Four original partners in the SBH project team completed their work in 2018: the American College of Nurse-Midwives, the BroadReach Institute for Training and Education, Imperial Health Sciences, and Initiatives, Inc.

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5. Success Stories Electronic Financial Management Improves Transparency and Efficiency in Muchinga Province

While the Zambian government has made great strides in increasing access to quality health services, its health management systems still require strengthening to maximize efficiency and improve resource management. Until recently, Zambia’s public health sector used Excel spreadsheets for accounting tasks. This made accounting and procurement more cumbersome and time-consuming and left the system vulnerable to mistakes or misappropriation. The US government is supporting the Zambian government to roll-out Microsoft Dynamics NAV enterprise resource planning solution, an online system that automates and connects purchasing, accounting, and inventory management functions. The goal of this initiative is to strengthen compliance with financial management and procurement systems. The US government initiative helped procure and install the software and train and mentor more than 438 personnel from Provincial and District Health Offices, Regional and Central Hospitals, and Training Institutions. Muchinga province has led the way in NAV implementation, with eight “From my point of view, as a province, we are able districts, two hospitals, and one training to observe what other districts and institutions are institution now successfully using NAV in live doing – how they are spending their funds if they are spending them according to the required stipulated mode. The ninth district, Mafinga, batches and guidelines and are able to monitor that. So the posts transactions offline every two weeks transparency and accountability [are improved].” because the district does not have internet. Fiona Nkweto, NAV Internal Auditor, While the transition to NAV was not without its Muchinga Provincial Health Office challenges, the commitment of leadership to see it work was cited as a major reason for Muchinga’s success. One of the many managerial benefits of NAV is that the software can automatically identify errors and/or missing information, thus supporting review and decision making. However, when faced with error messages that impede submission, users can become frustrated. Moreover, internet connectivity is a major challenge in Muchinga and transactions would sometimes come to a standstill when there were issues with the server. Fortunately, staff from the Zambian MOH and the US government The Muchinga Provincial Health Director and Public Health Specialist with the initiative were ready to support the District Health Directors, Hospital Superintendents, Planners, and Accountants from institutions which succeed in implementing Microsoft Dynamics NAV transition through constant throughout the province. communication with NAV users and to troubleshoot problems. They used WhatsApp and email to provide quick feedback and resolve problems: users would send screenshots of error messages to the group so that others who experienced the same could respond and all could benefit from the shared information.

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Provincial and district accountants really appreciated the idea of using NAV, as it allowed for the automation of many different accounting processes. Whereas previously the accountants had to make cash books and manually check that all the numbers tallied after each transaction, NAV produces these reports automatically allowing them to move through requests more quickly, while maintaining accuracy. “[The introduction of NAV has] really helped, this time you don’t have to move from one office to the other with the papers, have them approved, recommended, then you come back. Now where you are seated you are able to do the transactions: you just do the requisition, then they are approved online, then it comes back, you check, then you print. It’s also open so you are able to see. There is more transparency,” said Sr. Mercy, the Accountant at Chilonga Mission General Hospital. The District Health Directors also see the benefit of the new system as it provides them with more oversight of financial processes, with the convenience of being able to work remotely. The old system inevitably led to issues with lost paperwork, unauthorized or misappropriated payments, and major delays due to signatories being out of the office. Now managers are able to track payments in the system, see if and where delays are occurring, and able to monitor how funds are being used. NAV also adds a level of transparency that helps ensure funds are used for intended purposes. “It is good for internal controls,” Dr. Chola, District Health Director of Nakonde District stated, “as a manager, you can get a snapshot of all the transactions . . . and you can easily go back to see whoever is a part of [each] transaction.” In addition to the added level of transparency, NAV has significantly reduced the amount of time “Payments are executed in a more efficient way as you don’t necessarily need to be in the office so long required between a request and payment. Prior to as you have a computer where you are, payments NAV, any time money was needed to conduct an can still be made. The impact is positive because we activity, someone would need to fill out a paper are doing our payments and expenditures in a more request form and physically take it from office to efficient way than we use to -- with fewer delays.” office to get appropriate approvals before dropping Paul Phiri, Accountant at Mpika District it off in the (likely overflowing) inbox of an Health Office accountant. Now, “it’s quick!” said Sr. Mutamba, Hospital Administrator at Chilonga Mission General Hospital, “once a payment is raised and everything is done, you just recommend, authorize, and approve. Within a few minutes, it is done.” With strengthened financial and health management systems, MOH leaders at Muchinga Province are operating with greater ease and efficiency and able to focus their time and resources on improving the health and wellbeing of Zambians.

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Health Leaders in Western Province Gain a New Appreciation for the Use of Data for Decision Making

When reviewed and analyzed on a routine basis, data can be a powerful tool for management, decision making, and performance improvement. The Zambian MOH has a robust Health Management Information System (the DHIS2 software) to monitor routine health information and measure progress on key indicators. They also have systems and processes in place to ensure the quality and use of data. In practice, however, many districts and their health facilities either do not use these systems and processes on a routine basis or lack the skills to implement them effectively. As a result, the management of health resources and the quality of health care services have room for improvement. The US government has been supporting the Government of Zambia to strengthen management systems and ultimately improve the quality of health services throughout the country. As part of this effort, provinces and districts receive technical support and mentorship, as well as tools and processes to improve the use of data to drive management decisions. One example, called a scorecard, is a data visualization tool automatically generated from DHIS2 that provides a snapshot of performance on key health indicators using easily interpretable color codes and arrows to compare performance against targets and across organizations. The US initiative trained Provincial and District Health Office teams to use the scorecard to facilitate data use. The scorecards help focus attention on outliers. Quality improvement plans are developed based on scorecard analysis. Another tool supporting improvement is the Management Systems Inquiry (MSI), a self-assessment tool that systematically takes teams through a series of questions to monitor adherence to systems, and helps them identify issues and solutions. Western Province has been very receptive to and appreciative of this support. On a recent visit to the region, the Provincial Health Specialist, Dr. Jacob Sakala, noted significant improvements in the quality and use of data since the US initiative began their mentorship. He observed that the content provided in reports and the discussions held at District Integrated Meetings (DIMs) are more substantial now as the staff is able to interpret data and use it for decision making. By identifying districts and facilities with lower performance, they have been able to provide Meeting to review district performance using the RMNCAH&N scorecard in Sioma District of Western targeted support and have seen improvements in Province the quality of and access to care including: earlier initiation in and higher attendance of ante-natal care visits, increased immunization coverage, greater access to family planning and sexually transmitted disease screening, as well as a greater percentage of deliveries taking place in facilities with skilled providers and improved follow-up care for newborns and their mothers. In Mwandi District, the District Health Information Officer (DHIO), Emmanuel Kandemanji, reported that his team is now able to accurately analyze and report district data using the scorecard and has begun helping health facilities to do the same. He added that the DIMs have become more productive with the use of scorecards that focus attention on outliers (both high and under-

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performing areas), as opposed to the old system which relied heavily on repetitive and long displays of data. The District Planner, Rebecca Mukumbuta, added, “the last DIM we held . . . was very effective because we were guided to even come up with action points that helped us to follow up health facilities on identified gaps and we have seen improvements in some indicators.” Mwandi District managed to increase attendance at 1st ante-natal care visits from 8% to 30% in the last year; this is a considerable achievement as most districts are well below the target and early ANC care is a key point of intervention to promote healthy pregnancies. In Sioma District the District Health Director, Dr. Neto Mbwayo, has noticed that his team now looks at data “SBH has helped us with data in a way we look at data, how we plan, and how we differently; he said, “we did not understand data analysis; connect with activities. planning has improved as we are now able to plan based Dr. Neto Mbwayo, DHD, Sioma on data while following the Government of Zambia’s planning guidelines.” The District now uses the scorecard and MSI to go through a structured process of identifying gaps, conducting bottleneck analysis, and developing action plans. Mooto Sichebo, the DHIO, added his appreciation for the mentorship approach; while he was first skeptical of an outside group coming to assess performance, he came to realize that the technical staff from the US government initiative were partners for improvement and not simply looking to find faults. Mr. Sichebo is now a master of using the scorecard and uses it to guide planning meetings. The effects of this improved culture of data use have gone “Before the entire DHO team would go for beyond planning. In the past, the district would leave for PA but this tool [MSI] has helped us to Performance Assessment (PA), a system for assessing the identify who should go. The PA tool has helped us to get consistent data that has performance of its health facilities, without much helped us to compare the health facilities preparation and would travel as a full team. Now, they for decision making.” hold pre-PA meetings to identify the areas of concern at Mooto Sichebo, DHIO, Sioma each facility and select the most appropriate staff to visit – District a more cost-efficient and effective approach. After PA visits, Dr. Mbwayo said, “We sit and analyze what we have gathered from PA to see how we support the health facilities and give them feedback. We use the performance management tool and assign technical support supervision to appropriate technical officers to specific health facilities based on identified gaps.” Not only have there been improvements in health metrics and management skills, but there is a demonstrable change in staff attitude: motivation to improve has increased in tandem with staff confidence and ability to use data to drive that change.

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Luapula Provincial Health Director Credits Improved Use of Data with Gains in Maternal Health The Zambian MOH aims to increase access to care and improve the quality of health services for all Zambians. Identifying high-impact and cost-effective solutions is essential to achieving this goal as the country has a high burden of disease, including a generalized HIV epidemic, poor maternal health outcomes, and rising non-communicable disease rates, with limited resources to address these challenges. A US initiative is working to improve health outcomes for Zambians by strengthening the financial and management systems that underpin the delivery of health services. Dr. Bwalya, Provincial Health Director for Luapula “We are very very grateful for the support Province, recently spoke of the positive changes he has for the fact that we have actually seen quite seen since the US initiative began supporting his a lot of improvements in terms of getting to where we want to be in terms of achieving Province. He credits the partnership for strengthening the legacy goals and some of the MOH systems and institutionalizing the use of data for benchmarks that we have set for ourselves.” program management. For example, he said the Dr. Peter Bwalya, Provincial Health introduction of an electronic financial management Director, Luapula Province system has added a level of transparency to the financial and procurement systems that was not possible with the old paper -based system. They are now able to see how financial data align with programmatic priorities to ensure resources are being used wisely. Dr. Bwalya said this increased transparency “will not only improve the usage of resources towards the community members, for which these resources are intended for, but it has also has helped us to actually reduce on the audit queries.” From a programmatic point of view, the Provincial Health Director said that the US Initiative has really contributed to the province’s use of data to guide decision making. He stated that previously they had, “major issues with regard to data review at the province, district and in the health facilities.” However, they have now instituted monthly data review meetings where they are able to identify gaps and put in place focused interventions to address them. One of the tools they now use to guide data analysis and decision making in these meetings is a “scorecard”. The scorecard is a data visualization tool available in the MOH Health Management Information System that was not being utilized prior to the US initiative technical assistance. Dr. Bwalya said, “when you look at reviewing the data, with the introduction of very visible tools [such as] the scorecard . . . [they] indicate where you’d want to really focus your energies.” The scorecard produces ratings for indicators with traffic signal colors of red, green, and yellow so that users can quickly interpret and understand how they are performing in various areas. He said, “it basically brings out those areas where you want to probably focus on and, of course, where you are doing Dr. Peter Bwalya speaks with team members very well, you’d want also to sustain the gains that have from the US Initiative during a recent been made.” technical support visit. In Luapula, the Provincial Health Office has used the scorecard to monitor progress and guide their provision of technical assistance to Districts and health facilities. The Ph.D. was pleased to report that they have seen improvements in a number of health indicators that they track. For example, between 2017 and 2018 they saw an increase in 1st

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ante-natal care visit before 14 weeks from 17.9% to 44.1% and an increase in skilled deliveries from 67.8% to 78.1%. They have also seen a significant reduction in the number of maternal deaths in the facility; from approximated 75 in 2017 to 55 in 2018. Dr. Bwalya credits the improvements in maternal health to his teams’ diligence in using data to guide investments.

“As we continue to work with you we are also very much aware and mindful of that fact, that just as projects start, they also have an ending point so we are working very hard as a management team – both at provincial and district level - to devise mechanisms for how best we can sustain these very positive gains that have been made arising from the introduction of the program.” Dr. Peter Bwalya, Provincial Health Director, Luapula Province

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Annex 1. Central Province Scorecard

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Annex 2. Eastern Province Scorecard

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Annex 3. Luapula Province Scorecard

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Annex 4. Muchinga Province Scorecard

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Annex 5. Southern Province Scorecard

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Annex 6. Western Province Scorecard

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Annex 7. Performance Indicator Tracking Table

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