With Malaria As an Entry Point

THE CLOVER PROJECT

HEALTH SYSTEMS STRENGTHENING ROUNDTABLE CLOVER COUNTRY REPORT: ZAMBIA

Improving health systems: working together, with malaria as an entry point

Malaria Consortium Irish Aid Development House Department of Foreign Affairs 56-64 Leonard Street Riverstone House London, EC2A 4LT 23-27 Henry Street +44 20 7549 0210 Limerick +353 1 408 2000 Malaria Consortium disease control, better health www.malariaconsortium.org www.irishaid.gov.ie Introduction 2

Malaria Consortium Zambia began its work on health systems strengthening in 2005, under the second phase, Irish Aid-funded Clover II project.

Malaria Consortium Zambia began its work malaria will focus primarily on IEC/BCC and 5km from the nearest health center. There on health systems strengthening in 2005, research. Clover III, however, is the only is approximately one health center per under the second phase, Irish Aid-funded programme in Zambia at present that uses 6,780 people. Only 43% of trained health Clover II project. At that time, Clover was malaria technical interventions as a means workers in Zambia reach the WHO-recom- implemented only in Southern Province. of building capacity across systems at the mended level of 2.4 workers per 1,000 pop- Clover II’s most important achievements district-level. ulation and less than 50% of frontline health were 1) the establishment and support for workers are available relative to the need district-level Malaria Task Forces, the first Background for primary health care services. Turnover sub-national, public-private partnerships of staff at all levels of the health system is for malaria prevention and control in South- Zambia is a land-locked, Central African high and the Ministry of Health (MoH) is re- ern Africa and b) the creation of innovative country sharing boarders with Democratic stricted from hiring new staff due to highly rapid diagnostic test (RDT) training modules Republic of Conga, Tanzania, Malawi, Mo- indebted poor countries (HIPC) completion targeted to both rural health facility work- zambique, Zimbabwe, Botswana, Namibia conditionality. The National Decentraliza- ers (HFWs) and community health workers and Angola. Zambia is made up of nine tion Policy, launched in 2003, has meant 14 (CHWs), the IEC/BCC materials for which Provinces and 72 Districts. The estimated that districts have a degree of autonomy in Figurewere 1: Map adopted of Projects Areas and scaled up by the World current population is 12 million based on planning and budgeting health activities at

Health Organization (WHO). the sub-national level. a population growth rate of 2.4 percent per

annum.

Zambia is making moderate progress meet-

Zambia has a high disease burden and faces ing a number of its health-related MDGs

a number of challenges common to devel- and its progress is immediately noticeable

oping countries [Table 1]. Immunization in Zambia’s malaria prevention and con-

trol efforts [Table 2]. Zambia is the sixth coverage rates, while high at the national

level, vary considerably from province to largest recipient of malaria funding in Af-

province, with some regions falling signifi- rica, with most of its funding coming from

cantly below the national average. Diar- Global Fund and USAID. Bed net coverage

rhea and acute respiratory illness (ARI) still is much higher than many of its neighbors.

account for 35% of deaths among children 4.8 million LLINs were distributed between

2006 and 2008. 3.1 million courses of ACT <5 years of age. Neonatal factors account

for another 20%, while malaria accounts for were distributed in 2008, reaching close to

Following the extension of funding via the 17%. Under-5 mortality rate (170 per 1,000) 1/3 of patients diagnosed with malaria in

third phase Clover III project in 2008, Ma- and infant mortality rates (103 per 1,000) public sector health facilities. It is one of

laria Consortium expanded its activities into remain much higher than the regional av- only nine countries in Africa with evidence

Eastern Province. Presently, Malaria Consor- of a greater than 50% decrease in malaria erages (145 and 88 respectively). The HIV tium Zambia works in all 19 districts across incidence cases in between 2000 and 2008, prevalence rate is estimated to be as high as

Southern and Eastern Province, reaching 17% and, largely due to the ravages of the along with a 35% decrease in under-5 all

a population of approximately 3.2 million epidemic, the average Zambian has a life cause child mortality rates. Malaria preven- Tablepeople 1: Key Health [Figure Statistics 1]. Its relationship with sub- expectancy at birth of only 46 years. tion and control is coordinated centrally by national stakeholders is its greatest strength the National Malaria Control Centre (NMCC), and Malaria Consortium Zambia is continu- The primary mission of the Zambian Na- part of the MoH. At the provincial level, the ally cited by provincial and district adminis- tional Health Strategy is to provide “cost- Provincial Medical Officer oversees disease trators as one of their most important part- effective, quality health services as close control efforts, while Malaria Focal Point ners. to the family as possible.” Public sector People coordinate efforts among District health services are structured as follows: Health Management Teams (DHMTs), which Presently, there is no national framework [Figure 2] Under this structure, most Zam- include District Environmental Health Tech- for HSS in Zambia; however, there has been bians receive their primary health care from nicians (DEHTs), District Health Information a consecutive, 5-year, USAID-funded HSS both rural and urban health centres (HCs), Officers (DHIOs) and other specialists. Be- programs since the mid-1990s. The most and their secondary care from district hos- sides Malaria Consortium, other partners recent, HSSP (Health Systems Strengthen- pitals. Health services have been free at provide financial, technical and logistical ing Program), ended in mid-2010. The new- rural health centres (RHCs) since 2006, but support for malaria including PATH’s MACE- est incarnation – the Zambia Integrated user fees are levied elsewhere. Health cen- PA program, USAID’s President’s Malaria Ini- Systems Strengthening Program (ZISSP) ters should serve a catchment population of tiative (PMI), Society for Family Health (SFH), -- is overseen by Abt Associates. HSSP had 30,000 – 50,000 people, while district hos- UNICEF, WHO and Harvard University’s Har- malaria components built into it (such as pitals 80,000-200,000 people; nevertheless, vard Business Services (HBS). bed net purchase and distribution). ZISSP’s 50% of the rural population lives more than

World Health Organization. 2009. World Health Statistics 2009. Geneva: World Health Organization, p. 55. World Health Organization. 2009. World Health Statistics 2009. Geneva: World Health Organization, p. 43. World Health Organization. 2009. World Health Statistics 2009. Geneva: World Health Organization, p. 42 Government of Zambia. 2005. National Health Strategic Plan 2006-2011. Lusaka: Ministry of Health, p.1. See Annex 1 for facility coverage statistics in Eastern and Southern Province. World Bank. 2008. The International Development Association Country Assistance Strategy for the Republic of Zambia. March 28, 2008. Lusaka: World Bank. Ministry of Health, 2009, Draft concept note for the development of a community health worker national strategy, May 28, 2009, MoH: Lusaka Government of Zambia. 2005. National Health Strategic Plan 2006-2011. Lusaka: Ministry of Health, p.22. World Health Organization. 2009. World Malaria Report 2009. Geneva: World Health Organization, p.32. The Clover project 3

In Zambia, Clover is presently situated in Southern and Eastern Province. With regard to most activities, all 19 districts in these provinces have been reached, with the exception of Case Management trainings, which were implemented in five districts. Clover is managed from the county capital, Lusaka.

In Zambia, Clover is presently situated in medical qualification, were trained in the ac- sors as they can carried out these supervi- Southern and Eastern Province. With regard curacy and administration of RDTs and the sory visits. They are also providing updated to most activities, all 19 districts in these appropriate diagnosis and treatment of un- training for laboratory technicians in South- provinces have been reached, with the ex- complicated malaria. They are also trained ern and Eastern Province hospitals in ma- ception of Case Management trainings, in record-keeping of ACT and RDT supplies. laria microscopy. QA targeted the following which were implemented in five districts. Case Management targeted the following components of the health system: health Clover is managed from the county capital, components of the health system: health workforce, health services delivery, health Lusaka. A Technical Officer and two Projects services delivery, health workforce, health information systems and medical product Officers implement Clover activities in both information systems and medical product supply chain. Provinces. Partnerships with the public and supply chain. private sectors, as well as the willingness of Zambulance Projects Officers to continuously travel, have HMIS Training(HMIS) In January 2010, Malaria Consortium placed played a large role in the success of Malaria Malaria Consortium sought to empower 57 bike ambulances (Zambulances) at the Consortium. Since 2008, there has been District Health Information Officers (DHIOs) community level in target districts in South- a number of mutually-reinforcing health and Data Associates (DAs) to not only better ern and Eastern Province after a request for systems strengthening projects carried manage health systems data, but to identify increased support for CHWs by the provin- out sub-nationally under Clover, targeting gaps and outliers and interpret trends in in- cial and district health teams. Zambulances multiple components of the health system. formation at the health facility and district are manufactured locally by the NGO Zam- Some of the most important include: level. HMIS Data Review Workshops were bikes and are delivered alongside basic carried out, initially in partnership with the bicycle maintenance instruction and stan- Malaria Task Forces (MATF) NMCC, Harvard University, MACEPA and dardized log books (Figure 3). Logbooks Clover-Malaria Consortium sought to cre- WHO. Malaria Consortium then developed were altered by Clover-Malaria Consortium ate district-level public-private synergies a series of follow up trainings. DHIOs and to reflect both the informational needs of – modeled on the AIDS Task Force idea - DAs in Eastern and Southern Province were the CHW, RHC and DHMT. Recipient CHWs for the purpose of malaria prevention and trained to detect incomplete, incorrect and have been identified by DHMTs according control. Between 2005-2008, they funded inconsistent records, prepare data sets, ana- to “activity” level, distance to RHC, and abil- the organization and training of 19 MATFs lyze and present information in graph and ity to ride a Zambulance and transport pa- across Clover project districts. Clover tapped table form, and interpret evidence for use in tients. Recent assessments, July 2010 have not only public sector health officials, but District Health Action Plans. HMIS targeted indicated that over 100 emergency patient’s also non-health line ministry government the following components of the health lives have been saved over a four months representatives, businesspeople, religious system: health services delivery, health period of intervention. The conditions have leaders, utility company executives, police, workforce, health information systems and ranged from malaria to HIV/AIDS, dysentry community-based organizations, NGOs and medical product supply chain. to obstetric emergencies (). Severe ma- other relevant stakeholders. The primary laria and pregnancy complications appear objective of the MATF is the mobilization Quality Assurance of Malaria Micros- to make the bulk of the case transported. of resources in the following categories: copy (QA) Zambulance distribution targeted the fol- financial support, material support, techni- The Improving Malaria Diagnostics (IMaD) is lowing components of the health system: cal support and moral support. Resource a President’s Malaria Initiative-funded proj- health workforce, health services delivery mobilization should directly feed into bet- ect to strengthen malaria diagnostic capac- and health information systems. ter planning, implementation, coordination ity through interventions such as training of and dissemination of information. MATFs lab supervisors and developing monitoring Performance Assessments (PA) targeted the following components of the and quality assurance mechanisms. IMaD Malaria Consortium provided logistical and health system: health financing and health in Zambia is a partnership between NMCC, financial support for PA activities in Eastern leadership and governance. PMI, Medical Care Development Interna- and Southern Province in order to ensure tional, ( MCDI), Malaria Consortium and that, as with diagnostics, quality assurance Case Management (CM) other organizations. A quality assurance of health services regularly takes place. Clover carried out trainings of all HF, Hospi- programme was developed for implemen- As with the IMaD project, supporting PAs tal and Health Post staff in five selected pilot tation across Zambia in the first quarter of helped to ensure provincial technical over- districts (Chama, Gwembe, Itezhi Tezhi, Ka- 2010. Provincial supervisors were trained to sight of appropriate malaria case manage- tete, and Siavonga) from 2009-2010. Recog- carry out quarterly visits to district labora- ment, contributed to the generation of in- nizing that the human resources crisis in the tory facilities. Clover-Malaria Consortium formation on how RHC workers diagnose health sector has left many RHCs staffed by supported IMaD in Southern and Eastern and treat malaria and supported decentral- nurses, medical assistants or even building Province by providing training, funding and ization by strengthening provincial over- caretakers, all workers at RHCs, regardless of technical oversight of provincial supervi- sight capacity. PA targeted the following Achievements and Innovations of the Clover project 4

Malaria Consortium Eastern and Southern Province Projects Officers have managed, in a very short period of time, to create robust working relationships with Provincial and District Health Managers, as well as carry out a critical mass of HSS activities across most Clover programme areas in all 19 target districts. components of the health system: health malaria cannot be over emphasized. We tency and infrequent feedback to primary leadership and governance, health services are confident that with strengthened part- health care providers and district-level plan- delivery and health information systems. nerships at all levels, local, district, national ning officers. Health facilities and districts and international, it is possible to attain our lacked the capacity to generate high quality Malaria Consortium Eastern and Southern vision of a malaria-free Zambia.” data and, most importantly, to understand Province Projects Officers have managed, in Dr. V.C. Mtonga - Acting Permanent Secre- and make use of it. This situation has been a very short period of time, to create robust tary, Ministry of Health progressively changing since the MoH be- working relationships with Provincial and Outcomes: MATFs have had mixed, though gan up-grading its HMIS system. District Health Managers, as well as carry out generally positive, results. In Livingstone, a critical mass of HSS activities across most Southern Province, the MATF is a key stake- Under Clover III, the MoH and Clover-Malar- Clover programme areas in all 19 target dis- holder in malaria prevention and control, has ia Consortium sought to empower District tricts. The commitment Malaria Consortium a strong mix of private sector, line ministry, Health Information Officers (DHIOs), Data demonstrated to the needs and interests of utility and other partners, and is integrated Associates (DAs) and Malaria Focal Point district managers, the willingness of Pro- fully into DHMT activities. It is a benchmark Persons (MFPPs) to not only better manage gram Officers to continually visit and revisit districts for the model and has received re- health systems data, but to identify gaps stakeholders, and the range, relevancy and gional visitors seeking to emulate MATFs in and interpret trends in information at the volume of activities that were carried out in other countries. Other MATFs have proven health facility and district level. In Febru- an 18 month period of time were all duly to be reasonably active, holding regular ary - June 2009, 6 HMIS Data Review Work- noted by sub-national partners. As a con- meetings, and being key partners in IRS mo- shops were carried out, in partnership with sequence, Malaria Consortium is very highly bilization, World Malaria Day organization, the MoH, Harvard University, MACEPA and regarded at the sub-national level. ITN distribution and other targeted activi- WHO. DHIOs, DAs and MFPPs in Eastern and ties (Figure 4). Still others – especially those Southern Province were trained to detect The primary achievements and innovations lacking a wide array of reasonably prosper- incomplete and inconsistent records, pre- that Clover brought to HSS in Eastern and ous partners -- have struggled to move for- pare data sets, analyze and present informa- Southern Province can be understood both ward. All have been hampered by problems tion in graph and table form, and interpret programmatically – that is, in terms of the with buy-in at central level by non-health evidence for use in District Health Action specific project areas of Clover – and, more line ministries or by the head offices of pri- Plans. Following a radical restructuring of generally, in the way that Clover activities as vate business. Many too have had a difficult the HMIS to increase its flexibility and its integrated and mutually-reinforcing to cre- time prioritizing realistic or relevant ac- usefulness at provincial and district levels, ate value across multiple levels of the health tivities. In most instances, however, these reorientations were carried out in March system. The most important accomplish- challenges are not insurmountable and 2010 to familiarize DHIOs/DAs/MFPPs in the ments of Clover Zambia are: there are clear, targeted interventions that new data management system. In total, could take place to strengthen those that 209 district health information managers 1. Sub-National Level Public-Private are weak, and to boost the capacity of those trained, covering 481 health centres across Partnership for Malaria Prevention which could do more. In short, the way for- 19 districts, and 209 HMIS manuals were and Control ward for MATFs, perhaps more so than any printed and distributed. The updated ver- One strategy to mobilize financial and hu- other Clover intervention, is clear and very sion of the HMIS manual is scheduled for man resources at the district- and sub-dis- easily realized. distribution at the end of 2010. trict level has been the establishment of The Government and other organizations health problem-specific task forces. Starting have embraced Malaria Task Forces. Clover Outcomes: The original exercise in part- in 2005, and scaling-up in 2008, Clover part- is working closely with them for improved nerships with MoH, Harvard and MACEPA nered with DHMTs and other stakeholders planning and coordination of malaria con- resulted nationally in the retrieval of 1,901 to establish district-level public-private syn- trol interventions at district level. The USAID missing quarterly reports and the addition ergies for the purpose of malaria prevention supported Health Communications Partner- of 28 facilities into the HMIS, thereby mark- and control- the Malaria Task Force (MATF). ship (HCP) and Rapids have formed 16 and ing a major improvement in quality of ma- The Secretariat for the MATF is located at 3 District MATFs respectively in 7 Provinces laria data in the national HMIS. At the same the DHMT, while the Chair and Vice-Chair in addition to 19 formed by Clover bringing time, partners pulled out of the follow-up are representatives from line ministries or the total to 36 District Malaria Task Forces activities after the initial series of train- the private sector. The primary objective of in 36 out of 73 Districts. Currently, the gov- ings in 2009. Shortly after, the HMIS was the MATF is the mobilization of resources in ernment is developing the National Malaria changed radically and the MoH underwent the following categories: financial support, Strategic Plan for 2011 – 2016. Formation major restructuring. Malaria Consortium material support, technical support and and strengthening of District Malaria Task carried on with refresher courses tailored moral support. Ideally, resource mobiliza- Forces is a priority under the communica- to the updated version and added compo- tion should directly feed into better plan- tion strategy component of this plan. nents on evidence-based decision-making. ning, implementation and dissemination These follow-up trainings in March 2010 of information. Clover III supported the 2. Empowering Districts in Informa- demonstrated that 11 out of 19 DHIOs had organization and training of all 19 district tion Management arrived at their posts after the original train- Malaria Task Forces (MATFs) across South- The Health Management Information Sys- ings and, following adoption of the new ern Province and Eastern Province. In total, tem (HMIS) is a critical component of evi- HMIS. Among those attending the March 456 stakeholders were trained and over 500 dence-based policy making in Zambia. For 2010 refresher course, 29% of those trained copies of the MATF training manual were a number of years, data was collected at the did not know or were unsure of what an Ex- produced and distributed (Figure 6). local level, aggregated at the district and cel Worksheet was, 22% did not know how “The need for concerted efforts and stake- then sent on to central health authorities to scroll on an Excel sheet, and 20% did not holder involvement in the fight against with limited checks on quality and consis- understand what a Menu or a Toolbar was. 5

Most of those who stated “don’t know” or have often relied upon cascade models of ly and accurately diagnose and keep record “unsure”, moreover, were MFPPs who had training to limited effect. The top tiers of of malaria prevalence, RDT use and ACTs received training in 2009 and, due to lack of the cascade rarely had the resources to train consumption and create a more accurate practice and access to computer resources those lower down the cascade. Moreover, and consistent set of data feeding into Dis- at the district level, had forgotten what they the negative impact that one-off, high level trict Health Information Systems. The latter learned. Of those who did receive training, trainings have on sub-national stakeholders’ helped District Health Information Officers however, 84% felt that training was help- perceptions of partner commitment and se- to do data collection and management, and ful to their work “all the time” and 63% felt riousness -- as well as the corrosive effect present it more effectively to district and that they used the information from past on morale and creates jealousy among col- provincial managers. Performance Assess- trainings in their work “all the time.” As a leagues who are left behind -- is enormous. ments, in turn, drew up the data that was consequence, the refresher courses were By targeting every HCW – 542 individuals generated and, in turn, fed it back down to immediately valuable to those taking part. – irrespective of whether they had received the facility level to help improve quality at In qualitative interviews, moreover, District ‘professional’ training or not – in every facil- the primary health level. Directors of Health, DHIOs and MFPPs con- ity (rural, urban, hospital and health post) in tinually emphasized the value of HMIS train- the five districts, Clover-Malaria Consortium In this way, the Malaria Consortium Zambia ings and had a number of suggestions for sought to both challenge the cascade mod- team treated Clover as an interconnected, future trainings with specific emphasis on el and guarantee some degree of continu- integrated set of activities, rather than a set improving data management at the health ity even in the face of the human resources of disconnected, malaria-specific technical facility level. crisis. interventions targeted to separate compo- In view of this, Clover conducted case man- nents of the health system. All the activities 3. The 100% Model for Case Manage- agement training on site, using hands on that were implemented all built capacity ment of Malaria Training approach in 5 districts which have had a across DHMTs and were appreciated and Since 2005, Zambia’s national guidelines for profound effect on rural health centre (RHC) deemed extremely relevant by Provincial the diagnosis and treatment of uncompli- workers’ understanding of and acceptability Medical Officers, District Directors of Health cated malaria have emphasized laboratory- of RDTs and blood slides in confirming ma- and the beneficiaries of the trainings them- based confirmation of malaria followed by laria diagnosis. selves. treatment with first-line artemisinin-based combination therapy (ACT). In the Zam- Outcomes: 5. Home Management of Malaria / bian public sector, ACT consists solely of The case management training resulted in Community Fever Case Management Coartem®. Prior to the adoption of ACT in improved case management of non-malaria Zambia’s Health Strategy prioritizes delivery 2003, and the increased availability of Rapid fevers, reduced reported cases of malaria of health care as close to the family as pos- Diagnostic Tests (RDTs), health workers in and lots of ACTs saved (Fig 5-6). In Zambia, sible. CHWs - undervalued and poorly sup- hospitals and rural health centers (RHCs) RHC workers are now better equipped to ported in the past - are expected to play an traditionally diagnosed malaria clinically – both look for and treat alternative causes of increasingly important role in the primary that is, through presentation of fever and fever. health system. At the community-level, the other symptoms – due to a lack of supplies, only options available for suspected malaria electricity and laboratory technicians. RDTs The most significant barrier to the success presently involve either traveling - some- have now allowed for laboratory-based of case management has been RDT short- times at great distance and expense - to confirmation to take place even in RHCs ages, but that immediately before and af- the RHC, or self-treatment. This is why the which lack these resources. Because RDTs ter trainings, in instances where both RDTs NMCC is active in the process of rolling out and Coartem® are new technologies, many were stocked in and RDT registers exist, case Home Management of Malaria (HMM) which health workers still distrust their validity and management trainings have had significant involves training public sector and CHWs to reliability. Many health workers still fail to impact on CHWs following the case appro- carry out tests and provide treatment. follow national guidelines and the Ministry priately (positive RDT followed with correct of Health (MoH) has limited capacity to en- malaria medication; negative RDTs followed Malaria Consortium-Clover trained CHWs in force proper adherence to the guidelines at with no malaria drug). The main challenge RDT administration, appropriate treatment, RHCs. The human resources limitation has is how to ensure sustainability of these and fever management (Figure 7). This ex- meant that many RHCs are dependent on trainings over time. perience has fed into a new, non-Clover, a single technician or nurse and rely upon CIDA-funded pilot in Luapula Province in support from casual, untrained laborers, 4. HSS through Integration of Imple- which Malaria Consortium is training 100% such as cleaners or guards. mentationClover-Malaria Consortium sup- of district-identified CHWs in community fe- port for Case Management, HMIS, Perfor- ver case management (CFCM), which adds In 2009, Malaria Consortium partnered with mance Assessment, Malaria Task Forces and diagnosis of pneumonia and treatment with Provincial and District Health Management other activities in many instance, fed into amoxicillin to the model. By training at the Teams to carry out trainings in appropriate and added value across multiple Clover pro- community level, Malaria Consortium is case management of malaria in 5 districts gramme areas and consciously built upon supporting the MoH in its commitment to – Gwembe, Itezhi Tezhi, Sivaonga, Katete separate but inter-related ideas to strength- primary health care and decentralized ser- and Chama – known to have high burden of en the system as a whole. For example, the vice provision, enhancing the skill sets of malaria. Malaria Consortium trained 100% Malaria Consortium Case Management in- volunteer CHWs, creating a mechanism by of HCWs, regardless of whether they had tervention which was targeted at the health which data on malaria, fever and pneumonia professional status, in 100% of facilities in facility level fed into and supported district- can be recorded and collected at commu- these districts. In the past, case manage- level Malaria Consortium HMIS trainings. nity level and, most importantly, integrating ment trainings in Zambia – whether related The former ensured that Health Facility typically vertical malaria programming into to malaria or other programs, like IMCI - Workers had the capacity to more effective- management of childhood illness. 6

Like with Case Management Trainings, HMM The models - Model A -Health facilities and commodity management in 16 pilot and CFCM are only as effective as the supply placed orders with the district planner who districts. chain allows them to be. There is currently sent an aggregated order to central medi- • Support supervision to all 16 dis- no nationwide system in place to support cal Stores. The commodities were sent back tricts monitoring and evaluating the pilot the sort of supply chain logistics required to the districts that were responsible for as- project. to sustain an efficient and effective primary sembling orders for the facilities and deliver- health system. The National Essential Drugs ing them. Model B - Health facilities placed Model B dramatically improved the drug Pilot Logistics System is an important first their orders directly with central medical availability in health facilities with the avail- step, but it is vital that CPs provide financial stores. Orders were assembled by medi- ability of six-pack ACT rising from 45% to and technical support to the supply chain cal stores and delivered to the districts as 88%. Nearly double the 51% availability in all the way down to the level of the user. sealed packages for the individual facilities. control districts. The availability of SP (ma- Districts were only responsible for verifying laria preventive treatment for pregnant 6. Drug Supply Management orders from the health centres and coordi- women) was 84% in pilot areas compared The delivery of malaria drugs, supplies and nating delivery. to 39% in the control districts. The avail- commodities are carried out centrally in ability of Depo-Provera (injectable contra- Zambia with the national drug store (Medi- Health facilities in the control districts con- ceptive) was available for 100% of the time cal Stores Ltd) supplying drugs and com- tinued to receive the health centre kits that compared with 60% in control districts and modities using the push system. A partner- contain a set amount of drugs and supplies Amoxicillin 92% compared to 63% in the ship was identified with JSI/USAID | DELIVER and other supplementary supplies using control districts. Model A saw similar im- PROJECT. Malaria Consortium-Clover pro- the old system where there was no formal provements but not to the same scale. vided technical and financial support to the ordering system partnership. The partnership carried out It is estimated that if Model B is scaled up the following activities to identify the most The following activities were done during nationwide 27,000 children could be saved cost-effective way to improve the availabil- implementation of the pilot; from dying of malaria between now and ity of drugs through piloting two models • Assessments of malaria drugs, 2015. National scale up would require a for delivering medicines and supplies to the supplies and commodities systems in all 73 significant medium term investment but health facilities. districts of Zambia the impact could be substantial and deliver A one year pilot called the Essential Drugs • Quantification for ACTs and RDTs better value for money on the health invest- Pilot Logistics System (EDPLS), tested two requirements in the public sector forecast- ments in Zambia. different models (A&B) for getting drugs to ing up to 2015. health facilities in Zambia’s remote districts. • Developing a training manual for The government has now adopted Model The availability of these drugs in the pilot improved drug and supply management B of the pull system for scaling up country districts were compared with availability in • Training District Health personnel wide in the near future. control districts. and health centre personnel on drug supply

Case Management Leads to Geographic Plotting of Malaria and Improved Public Health Re- sponse Several days after case management training, Malaria Consortium staff found the health in-charge busily carrying out RDTs on dozens of fever cases. The in-charge had discovered that almost all RDT- positive cases were coming from a single village along the shore of Lake Kariba. The vast number of fever cases from other villages were testing negative. The in-charge was able to inform the District Environmental Health Technician of the fact that, far from being endemic, malaria incidence at that moment was localized and potentially epidemic. Interventions could now be targeted more effectively and efficiently to a single village and non-malaria patients could be appropriately treated. Most importantly, the in-charge now understood malaria differently, seeing it not simply as a common disease with a primarily clinical solution but viewing malaria patients epidemiologically – as geographi- cally distinct populations to which public health solutions could be quickly and more easily applied. 7 18 Key lessons learned

Clover III faced considerable challenges in Zambia. Throughout 2009 and much of 2010, donors froze health assistance due to MoH mismanagement of funds. 18

Clover III faced considerable challenges in ally undermined by a) the human resources Zambia. Throughout 2009 and much of crises and b) medical supply chain con- 2010, donors froze health assistance due straints. Both projects had the potential to to MoH mismanagement of funds. Subse- be ground-breaking interventions and were quently, the MoH halted all implementation greatly appreciated and praised by district of activities at various points during the leadership. But unless all components of duration of the project. Additionally, from the health system function fluidly, and are January 2010 onwards, the MoH stopped targeted in an integrated manner, building paying most staff salaries at NMCC which capacity in only one or two components will led to a serious decline in morale and a only lead to short-term gains. In the future, slow-down in the production of necessary HSS program development should clearly permissions and paperwork. Also, Malaria visualize goals, objectives, outputs and ac- Consortium had not previously had a domi- tivities as being mutually-reinforcing. Zambulance Distribution in Eastern nant presence in Zambia and yet there were FigureProvince 3. Zambulance Distribution in Eastern Province a number of other malaria partners who Create Infrastructure for Public-Pri- had entered the scene and claimed priority vate Partnership: MATFs have proven to from the MoH. Clover team members spent be powerful models for implementation of much of the second half of 2008 building malaria control and prevention activities. trust with the MoH, NMCC and other part- When successful, MATFs are mutually ben- ners, as well as generating relationships in Figure 3. Zambulance Distribution in Eastern Province eficial synergies in which both private and Eastern Province where Malaria Consortium public sector stakeholders fully compre- had never worked. hend and respect the interests of the other, and put into place infrastructure to maxi- Support Sub-National Institutions: In mize their relationship. Too often, however, spite of the challenges of working through public sector actors either lack the legal, fi- decentralized budgets and decision-mak- nancial, technical and administrative capac- ing structures, primary health care is best ity to manage MATFs, or the culture to fully strengthened through sub-national inter- appreciate the private sector as a ‘partner’, ventions. Clover III’s main strength was its as opposed to a ‘patron’. partnerships at the provincial and district- levels. Here Malaria Consortium Zambia Improve supply of essential commodi- and Clover III continually and consistently Monze District MATF at the district IRS ties: The effectiveness of the case manage- FigureLaunch, 4: Monze Zambia District August MATF 2008at the district IRS Launch, Zambia August 2008 added value. Its input by design was mini- ment intervention depends on a functional mal at the national level. Clover Zambia 20 and efficient supply chain of RDTs, ACTs and was most effective when doing work sub- other essential supplies. For long term sus- nationally and it is here where most, if not Figure 7: Community health worker conducting an RDT, Zambia 2008 tainability, improving DHMT – RHC linkages all, future HSS activities should take place. should be a target for support for strength- Figure 4: Monze District MATF at the district IRS Launch, Zambia August 2008 ening commodity supply all the way down Find National Level Policy Champions: to the level of the user. At the same time, buy-in by national technical experts in Zambia is a critical component to the success of programs targeting health Support Performance Assessments: systems capacity. Programs need to be fully PA’s are vital to quality assurance of health endorsed at the level of the MoH, with high- services delivery; however there is a larger level advocates in place to ensure commit- question of the sustainability of PAs if their ment from those at lower levels. Without implementation only occurs according to this support, it is difficult to ensure that pro- the occasional availability of external funds vincial, district or sub-district officials will and technical support. Cooperating part- participate constructively. ners (CPs) should consider, when financing Community health worker conducting

health systems strengthening, how to en- an RDT, Zambia 2008 Encourage Integrated Programming: sure sustainable, dependable quality assur- HSS activities are at the mercy of the health ance of health services delivery. system as a whole. Clover III was continu- Going forward beyond the Clover Project 8

The activities that have been done in partnership with other CPs and have been endorsed by MoH have the high potential for scale up.

The activities that have been done in part- 2. District Malaria Task Forces: As more 4. Drug supply chain management – nership with other CPs and have been en- resources become available for malaria The pull model of the supply chain which dorsed by MoH have the high potential for prevention and control there is need to in- was piloted in only 16 districts and dem- scale up. The systems are already estab- crease coordination of efforts to maximise onstrated a high level of efficiency requires lished and running and need resources for benefits. MATFs have been tried and have funds to scale it up to countrywide to realize their continuity. demonstrated mixed results of their added more impact. values for mobilisation and coordination of 1. Support capacity to Use HMIS Data: resources, and advocacy. This effort should Enhancement of health information and be examined further to improve its effec- M&E systems is a critical component of the tiveness. With improvements, MATFs will National Health Strategy. Financing and have a role on a larger scale. technical support to health information systems must continue to be strengthened 3. Strengthening malaria case and expanded. Interventions targeting management-malaria microscopy HMIS or M&E systems must have feedback and RDTs mechanisms that allow information to flow The foundation is laid, there is more work at back to the people who actually collect it, the community level, and there is a decreas- thus enabling realistic targets, monitoring, ing trend in the disease burden. It is critical and responses to trends. Strengthening the to target resources appropriately to mini- community component of HMIS is critical to mise wastage. success and usefulness of the increased focus of interventions at community level

Figure 2: Structure of the Zambian National Health System

Ministry of Health

Provincial Health Offices Central Hospitals (3rd Level Referral)

District Health Offices Provincial Hospitals (2nd Level Referral)

District Environmental Health Technicians

Health Centers District Hospitals st (1 Level Referral) Neighborhood Health Health Affiliated Clinic (HHAC) Committees

Community‐ Level Community Health Workers Voluntary Route of Referral Positions Traditional Birth Attendants 9

Table 1: Key Health Indicators for Zambia, Malaria Consortium Targets of Eastern & Southern Province, & Sub‐ Saharan Africa Indicators Zambia Eastern Southern Sub‐Saharan Province Province Africa (average) Total population 12 .8 millon 1.7 million 1.5 million 792 million Percentage of population under the age of 15 46% ‐‐‐ ‐‐‐ 46% Adult HIV/AIDS prevalence ***17% ‐‐‐‐ ‐‐‐‐ ***5.2%

Life expectancy at birth (years) 46 ‐‐‐ ‐‐‐ 52

Physician density (per 10,000 population) 1 ‐‐‐ ‐‐‐ 2 DPT/DPT‐HB‐Hib3 coverage (latter introduced 80% *88.4% *87.9% 74% in 2006 to replace DPT) (DPT3 coverage) Under 5 mortality rate (per 1,000) 170 145 Infant mortality rate (per 1,000) 103 *82 *64 88 Children under 5 sleeping under insecticide‐ ****48% ****61% ****40% *****24% treated nets the night before the survey Measles immunization (% 12‐23 months) 85% *89.0% *92.0% 74% Maternal mortality rate (per 100,000 live 830 ‐‐‐ ‐‐‐ 900 births) Fertility rate (per woman) *6.2 ‐‐‐ ‐‐‐ 5.1 Contraceptive prevalence (%) 34.2% ‐‐‐ ‐‐‐ 24.4% Births attended by skilled health personnel 47% *42.9% *36.2% 46% (%) Physicians per 10,000 population 1 ‐‐‐ ‐‐‐ 2 Nurses/Midwives per 10,000 population <1 ‐‐‐ ‐‐‐ 11 Population living on <$1/day 64.3% ‐‐‐ ‐‐‐ 50.8% Total expenditure on health as a % of GDP 6.2% 5.5% General government expenditure on health 16.4% 8.7% as a % of total government expenditure Private expenditure for health as a % of total 39.3% 52.9% expenditure on health Per capita government expenditure on health $48 $52 Sources: All statistics from World Health Organization. 2009. World Health Statistics 2009. Geneva: World Health Organization, except: *Government of Zambia. 2008. Zambia Demographic and Health Survey 2007. Lusaka: Central Statistics Office; ** Government of Zambia. 2003. Summary Report 2000 Census of Population and Housing. Lusaka: Central Statistics Office; ** *United Nations Department of Economic and Social Affairs Population Division. 2008. Population and HIV/AIDS 2007. http://www.un.org/esa/population/publications/AIDS_Wallchart_web_2007/ Population%20and%20HIV‐AIDS%202007.htm. Accessed 3 December 2009; ****Government of Zambia. 2008. Zambia National Malaria Indicator Survey 2008. Lusaka: Ministry of Health; *****World Health Organization. 2009. World Malaria Report. 2009. Geneva: World Health Organization. 10

Figure 5: Reduction in reported cases of malaria before and after the training, Zambia, 2004‐2009

Source‐ HMIS‐Livingstone districting was done in the 4th quarter 2007

Figure 6: Reduction in reported cases of malaria and ACTs after training, Zambia 2007‐2008

Source‐ HMIS & Livingstone district stock control cards

17 11

Table 2: Key Malaria Indicators in Zambia

Table 2: Key Malaria Indicators for Zambia

Southern Eastern Indicators Zambia Province Province % of households with at least one net 71.5% 80.0% 77.7%

% of households with at least one ITN 62.3% 69.9% 74.8%

47.5% 69.9% 74.5% % of children <5 years who slept under net previous night

% of children <5 years who slept under ITN previous night 41.1% 32.3% 57.3%

% of pregnant women who slept under net previous night 50.3% 48.2%

% of pregnant women who slept under ITN previous night 43.2% 46.1%

Percentage of rural households sprayed in the previous 12 months 33.2% 53.5% ‐‐ in target districts* % of mothers who took 2+ doses IPT in the last month, with at least 60.3% 56.4% 61.6% one during routine ANC Children <5 years with fever in previous two weeks who took an 43.3% 41.2% 43.9% antimalarial drug Children <5 years with fever in previous two weeks who took 29.0% 39.9% 31.9% antimalarial within 24 hours of symptom onset Children <5 years with fever in previous two weeks who sought 64.0% 72.0% 49.4% treatment from facility within 24 hours of symptom onset

Children <5 years with fever in previous two weeks who reported 10.9% 17.9% 6.9% having heel/finger stick

Malaria parasite prevalence in children <5 years** 10.2% 7.9% 9.3%

Source: Zambia National Malaria Indicator Survey 2008. Lusaka: Ministry of Health.

*In 2008, Eastern Province was not targeted. IRS campaigns have scaled up considerably since 2008, and new districts have been targeted, including those in the East. **The 2010 MIS is likely to demonstrate significant rise in malaria parasitemia prevalence.

THE CLOVER PROJECT

Improving health systems: working together, with malaria as an entry point