Program for the Advancement of Malaria Outcomes

Quarterly Progress Report January 1, 2019–March 31, 2019

DISCLAIMER: The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development, United States President’s Malaria Initiative or the United States Government.

Submission Date: April 30, 2019

Submitted by: Dr. Caroline Phiri, PAMO Chief of Party

Mailing Address Private Bag E10, Lusaka, Street Address Mikwala House, Stand 11059 Off Brentwood Road, Longacres, Lusaka www.path.org

© 2019 PATH. All rights reserved. Cover photo: PATH Published April 2019 Table of contents

LIST OF ACRONYMS ...... 1

PROJECT OVERVIEW ...... 2

INTRODUCTION ...... 3

Background ...... 3

PAMO focus districts ...... 4

Malaria situation ...... 5

BENCHMARKS AND ACHIEVEMENTS ...... 6

Objective 1: Support proven malaria interventions in alignment with the National Malaria Strategic Plan (NMSP) 2011 – 2016 and the follow-on plan of the MOH ...... 6 Task 1.0: Strengthen national technical working (TWGs) groups...... 6 Task 1.1: Strengthen insecticide-treated net distribution ...... 8 Task 1.2: Improve access to quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment ...... 9 Task 1.3: Increase delivery of IPTp-SP as part of an integral package of ANC services ...... 12 Task 1.4: Strengthen social behavior change implementation for malaria at health facilities and community level through community mobilization and community dialogues ...... 12 Task 1.5: Strengthen malaria policies and guidelines ...... 14 Task 1.6: Support civil society organizations (CSOs) and community-based organizations (CBOs) to implement malaria control activities...... 15 Task 1.7: Conduct operations research ...... 17

Objective 2: Strengthen management capacity of provincial and district MOH personnel ...... 17 Task 2.1: Identify health system deficiencies at the provincial and district levels that constrain delivery of high impact malaria interventions in close collaboration with the MOH and other actors ...... 17 Task 2.2: Develop and implement a plan to strengthen management capacity as measured by set targets within each targeted province and district ...... 17

Objective 3: Strengthen provincial and district health management information system (HMIS) to improve data reporting ...... 17 Task 3.1: Provide technical/material assistance to DHOs, health facilities and communities to improve the timeliness and accuracy of HMIS reporting ...... 17 Task 3.2: Assist with training for the roll out of DHIS2 in the targeted provinces and districts...... 18

i Task 3.3: Provide technical/material assistance to DHOs, health facilities, and communities to strengthen malaria data analysis and use for planning and decision making...... 18

KEY ISSUES ENCOUNTERED ...... 20

SUCCESS STORIES ...... 21 iCCM and community surveillance training cheers newly trained CHWs ...... 21 MOH staff benefit from management and leadership capacity-building ...... 23 District feedback ...... 24

ii List of acronyms

ANC Antenatal care

BRITE Broad Reach Institute for Training and Education

CHW Community health worker

CSO Civil society organizations

DHO District health office

EDS Electronic data system

EPI Expanded program on immunization

GRZ Government of the Republic of Zambia

HFCA Health facility catchment area

iCCM Integrated community case management

ICEMR International Centers of Excellence for Malaria Research

IPTp intermittent preventative treatment in pregnancy

IRS Indoor residual spraying

ITN Insecticide-treated net

LLIN Long-lasting insecticide-treated net

M&E Monitoring and evaluation

MCH Maternal and Child Health

MDA Mass drug administration

MIP Malaria in pregnancy

MIS Malaria Indicator Survey

MOH Ministry of Health

MOP Malaria Operational Plan

NHCs Neighborhood health committees

NMEC National Malaria Elimination Centre

NMESP National Malaria Elimination Strategic Plan

OTSS Outreach training and supportive supervision

PAMO Program for the Advancement of Malaria Outcomes

PBO Piperonyl butoxide

PHO Provincial health office

PMI President’s Malaria Initiative

SBC Social and behavior change

TWG Technical working group

WHO World Health Organization

1 Project overview

Life of project September 30, 2015, to September 29, 2020

Reporting period January 1 to March 31, 2019

Target provinces Eastern, , , and Northern

Target population 5,455,218 (Source: Central Statistics Office, 2018)

Implementing partners PATH (lead), Jhpiego, and BroadReach Institute for Training and Education

Key partners Zambian Ministry of Health (MOH), National Malaria Elimination Centre (NMEC), Provincial Health Offices (PHOs), District Health Offices (DHOs) and health facilities. Malaria Control and Elimination Partnership in Africa (MACEPA), Churches Health Association of Zambia (CHAZ), and other United States Agency for International Development (USAID) implementing partners.

Objectives (1) Support proven malaria interventions in alignment with the National Malaria Strategic Plan 2011–2016 and the follow-on plan of the MOH. (2) Strengthen management capacity of Provincial and District MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions. (3) Strengthen Provincial and District health management information systems to improve data reporting, analysis, and use for decision-making.

Contract number AID-611-C-15-00002

2 Introduction

Background

The Program for the Advancement of Malaria Outcomes (PAMO) is a malaria activity program, funded by the United States President’s Malaria Initiative (PMI) in Zambia. It was designed to assist the Government of the Republic of Zambia (GRZ) in achieving as much progress as possible to reach its goal of eliminating local malaria infection and disease in Zambia. PAMO’s geographic focus is on four provinces: Eastern, Luapula, Muchinga, and Northern. These provinces are located in the northeastern part of Zambia and were selected due to the high malaria disease burden at project inception in 2015. The rural nature of the PAMO-supported provinces, with an estimated population of 5,455,218 (source: Central Statistics Office 2018), makes PAMO project efforts particularly challenging. Its programmatic focus is on:

• Increasing the coverage of long-lasting insecticide-treated nets (LLINs).

• Improving malaria in pregnancy (MIP) services.

• Improving the access and quality of case management.

• Introducing and scaling up social and behavior change (SBC) activities in support of malaria prevention and control activities.

• Improving and scaling up surveillance and monitoring and evaluation (M&E) related to PAMO’s interventions. PAMO provides technical assistance and material support to strengthen the capacity of the government to improve malaria outcomes in the four PAMO-supported provinces and their districts. To that end, PAMO established and maintains effective partnerships with the National Malaria Elimination Centre (NMEC), provincial health offices (PHOs), district health offices (DHOs), health facilities, communities, civil society organizations (CSOs), and other stakeholders and partners to ensure effective and sustained implementation and scaling up of internationally and nationally accepted strategies to fight malaria. PAMO is currently in its fourth year of project implementation. During Year 4, PAMO will implement activities outlined in two work plans described below. PAMO Year 4 work plan (January to December 2019)

PAMO’s Year 4 work plan outlines PAMO’s support to the Ministry of Health (MOH); it is aligned strategically with Zambia’s National Malaria Elimination Strategic Plan (NMESP) 2017–2021 and the PMI FY2018 Zambia Malaria Operational Plan (MOP). PAMO Year 3 work plan addendum (September 2018 to August 2019)

PAMO is currently operating under a separate but complementary Year 3 work plan addendum that covers three pre-elimination districts (, Katete, and ) in Eastern Province. The Year 3 work plan addendum outlines malaria pre-elimination activities that are being implemented in these three districts.

3 PAMO focus districts

From the project’s inception, PAMO has worked in all districts (originally 36, now 47) of its four focus provinces to bring to scale coverage of effective preventive and curative malaria interventions and strengthened information systems. This is to ensure that the entire at-risk population is protected by effective evidence-based interventions, in line with the current NMESP and the PAMO contract. Practically, it can be challenging to show year-to-year local impact when limited resources are spread across a vast geographic area in a high-burden zone. Therefore, in Year 3, PAMO introduced the concept of “focus districts,” where resources would be concentrated to scale up interventions in a limited area. was selected as the first focus district in Year 3, and in Year 4, Chama, , Mambwe, Senga, and were added as additional focus district. PAMO is also supporting three districts—Chadiza, Katete, and Sinda—for focused malaria pre-elimination activities.

Each month, researchers sample a range of malaria and entomologic indices from a cross-section of households in Nchelenge in . This provides a set of malaria indicators that allow for longitudinal tracking of the impact of malaria control programs, dating to at least 2014 and extending through 2022 and beyond. The objective in Nchelenge District is to implement the “full package” of interventions for high burden areas called for in the NMESP by applying PAMO resources in tandem with indoor residual spraying (IRS) and in close collaboration with the GRZ and local partners. PAMO has ensured that the district was prioritized for interventions such as management capacity building, LLIN distribution, outreach training and supportive supervision (OTSS) and integrated community case management (iCCM). PAMO will also support active neighborhood health committees (NHCs) in all catchment areas, backstopped by a CSO that has been contracted to engage in SBC activities across the district. Chadiza, Katete, and Sinda districts (pre-elimination districts)

Chadiza, Katete, and Sinda districts in Eastern Province’s higher, cooler plateau areas provide an opportunity to support pre-elimination activities, as they have lower malaria transmission potential. Functioning as full-package PAMO focus districts, PAMO is working with the MOH to ensure universal coverage of LLINs, enhance malaria case management, strengthen SBC implementation, increase coverage of intermittent preventative treatment during pregnancy (IPTp), build management and leadership capacity, enhance surveillance and reporting, and to conduct a baseline assessment. Chama, Mambwe, Mbala, Senga, and Nakonde districts

Building on the successful Year 3 iCCM investments, in Year 4 PAMO is ensuring continued scale-up deployment of community health workers (CHWs) (while also investing in enhanced data generation and analysis) in Eastern Province’s , ’s Chama and Nakonde districts, and Northern Province’s Mbala and Senga districts. Four of these districts represent high- burden areas (Chama, Mambwe, Mbala, and Senga), where community-level efforts are focused on passive malaria case management, and Nakonde represents a low-burden area, where reactive case detection (“Step D”) activities are supported.

4 Malaria situation

Recent national surveys of malaria burden and intervention coverage show progress across the country in delivering interventions and reducing malaria burden. The results from the national Malaria Indicator Survey 2018 (MIS 2018) indicate that the four PAMO-supported provinces are still among the five highest malaria burden provinces in Zambia (Figure 1). While it appears that malaria prevalence among children under five years of age is declining, Luapula has shown essentially no movement since 2012. Northern, however, has shown clear improvement, and Muchinga and Eastern have shown progress as well.

Figure 1: Malaria prevalence among children under age five by province, 2010–2018 (MIS 2018).

The malaria prevalence rates in the PAMO-supported provinces, justify the need for further investment in malaria control and elimination. In 2019, PAMO will continue to work closely with the MOH to further reduce the malaria disease burden in these four provinces. This quarterly progress report outlines the activities that PAMO has implemented in a bid to further reduce malaria disease burden.

5 Benchmarks and achievements

Objective 1: Support proven malaria interventions in alignment with the National Malaria Strategic Plan (NMSP) 2011 – 2016 and the follow-on plan of the MOH

PAMO’s first objective is to support proven malaria interventions in alignment with the country’s national malaria strategic plan, namely the NMESP 2017–2021, which places emphasis on key interventions such as sustained universal coverage of vector control interventions (distribution of LLINs, IRS, and larval source management), case management (diagnosis and treatment), MIP, health promotion (community engagement and SBC), surveillance, monitoring, evaluation, and operations research. PAMO has aligned its “tasks” and implementation of activities with the NMESP in order to contribute to the overall MOH goals and objectives. It is worth noting that, depending on the Task being implemented, PAMO directs its support at either the national or provincial/district level. Through Task 1.0 and 1.5, PAMO supports the NMEC at the national level by supporting national-level coordination, planning, and development of policies, strategies, and technical guidelines. Through the other tasks (namely Tasks 1.1, 1.2, 1.3, 1.4, 1.6, and 1.7), PAMO directs the bulk of its efforts to the sub-national level (i.e., by supporting the implementation of key NMESP interventions at provincial, district, health facility, and community level).

Task 1.0: Strengthen national technical working (TWGs) groups

The national level technical working groups (TWGs) for malaria are important structures that provide a platform to facilitate coordination and planning, and contribute to the development, dissemination, and mainstreaming of national strategic and technical guidance on malaria. By supporting the TWGs, PAMO contributes to better coordinated and harmonized implementation of the national strategy under the leadership of the NMEC. PAMO provides technical and/or material assistance to national level TWGs. They are the Vector Control; Case Management; Surveillance Monitoring, Evaluation and Operations Research (SMEO); and SBC. TWG meetings are held quarterly. During this quarter, the Vector Control, Case Management, and SBC TWGs met; key highlights of these meetings are outlined below.

Table 1: Highlights of the TWGs in Quarter 1.

TWG Key Highlights

Vector Control The first quarter Vector Control TWG meeting was held on the March 1, 2019. The focus of the TWG meeting was planning for the 2020/2021 LLIN mass distribution campaign. Key issues discussed are listed below: 1. The NMEC outlined requirements for the 2020/2021 LLIN mass distribution campaign. The total need for the mass campaign is 7,512,678 LLINs and the total need for routine distribution (antenatal care [ANC] and expanded program on immunization [EPI]) is 1,948,203 LLINs

6 TWG Key Highlights

2. In the 2020/2021 mass campaign, the NMEC plans to provide LLINs to only 50% of the population (headcount population estimated at 22,920,034). The other 50% will be protected by IRS. 3. Due to growing pyrethroid insecticide resistance within Zambia and in line with the World Health Organization (WHO) recommendation,1 the NMEC would prefer to procure piperonyl butoxide (PBO) LLINs. 4. NMEC intends to engage Against Malaria Foundation in order to secure the LLINs required for the upcoming mass distribution campaign.

Case Management The first quarter case management TWG meeting was held on the March 20, 2019. A number of pertinent issues were discussed, a summary of these are outlined below: 1. NMEC plans to conduct mass drug administration (MDA) in ten districts. The TWG members have agreed to develop a comprehensive policy to guide implementation of MDA. MACEPA reported that there is an upcoming survey to look at the long-term impact of MDA in Southern Province (former MDA trial areas). The research findings will be used to inform the policy development process. 2. The NMEC reported that a consignment of 100,000 vials of injectable artesunate for the treatment of severe malaria was delivered in January 2019 and another order for procurement of 200,000 vials of artesunate has been made. 3. A subcommittee of the Case Management TWG has been established. The sub-committee will design a more comprehensive training module for training of CHWs in the use of rectal artesunate (pre-referral treatment for severe malaria). The current CHW training materials that cover rectal artesunate are inadequate. A more comprehensive training module for the use of rectal artesunate will be included in all iCCM trainings. The subcommittee was also tasked to quantify the country requirements for rectal artesunate because the World Bank has shown interest in procuring it for the country.

SBC 1. During this quarter, the SBC TWG met frequently to prepare for the commemoration of World Malaria Day, which falls on April 25 each year.

1 https://www.who.int/malaria/publications/atoz/use-of-pbo-treated-llins/en/

7 Task 1.1: Strengthen insecticide-treated net distribution

In February 2019, the project distributed 72,297 LLINs to address a gap from an LLIN mop-up distribution campaign conducted in February and March 2018 in the malaria pre- elimination districts. In that 2018 campaign, 250,341 LLINs were distributed in Eastern Province’s in Chadiza, Katete, and Sinda districts, addressing 82 percent of the initial requirement of 305,014 LLINs, leaving an estimated gap of 54,673 (18 percent). The 72,297 distributed to cover the gap came from a provision 85,000 LLINs from the USAID Global Health Supply Chain Program-Procurement and Supply Management. The remaining 12,703 LLINs have been reserved for school-based distribution that will commence in April 2019. Table 1 shows that apart from , the gap has been filled in the rest of the pre- elimination districts. PAMO staff will follow up to verify the gap in Chadiza in April 2019 to ensure that all targeted LLINs which were distributed in the pre- households are provided with enough LLINs to cover all elimination districts sleeping spaces.

Table 2: Number of LLINs distributed in the pre-elimination districts.

Name of district Number of Number issued Gap after LLIN issued to Total LLINs required in 2017/18 2017/18 fill gap in Feb. Distributed per district distribution distribution 2019 (Cumulative) exercise

Chadiza 61,318 50,328 10,990 9,324 59,652

Katete 130,904 107,440 23,464 25,106 132,546

Sinda 112,792 92,573 20,219 37,867 130,440

Totals 305,014 250,341 54,673 72,297 322,638

To ensure effective use of LLINs, PAMO worked with the DHO and sub-contracted CSOs during LLIN distribution, to conduct SBC activities that included:

• The use of a public address system to raise awareness. In 34 health facilities, to prepare the community for the LLIN distribution, health facility staff used a public address system to inform community members on the dates and distribution points, and emphasized the need for people who did not receive adequate LLINs in the last round to go to the distribution points and collect theirs. PAMO worked with mobilization teams to develop key messages for community sensitization exercises.

• Drama performances. In 12 communities, 4 in each district, community drama groups carried out community-based performances to educate the community on the benefits of correct and consistent use of LLINs on ensuring that they are not misused in any way.

• Community meetings. In 15 health facility catchment areas (five in each of the three districts), PAMO supported health facility staff to work with traditional, religious, and other community leaders. Selected community leaders facilitated community meetings during which both traditional leaders and health care workers emphasized the benefits of sleeping under an LLIN

8 and the importance of curbing their abuse or misuse. Besides traditional leaders, the project also worked with religious leaders who informed congregants in their churches on LLIN distribution and the importance of using these LLINs for malaria prevention.

• Radio spots. These were aired before, during, and after the distribution exercise. Two radio jingles were developed in English and translated into Nyanja. One jingle was aired before the commencement of the distribution campaign to inform community members that had not previously received the LLINs to go and collect LLINs from the distribution points. The second jingle, which has continued to air on radio, encourages beneficiaries to sleep under an LLIN every night, and every season to protect them from contracting malaria.

Community volunteers teaching community members to hang a LLIN correctly

PAMO, the NMEC, and the DHO staff formed teams to monitor the LLIN distribution and SBC activities in order to verify that they were appropriately carried out. In their feedback, the NMEC and DHO staff were pleased with both the messaging for distribution and the actual distribution of the LLINs. The major challenge experienced, however, was that some community meetings and LLIN distributions were affected by the heavy rains, which delayed the distribution exercise slightly.

Task 1.2: Improve access to quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment

PAMO is working with the NMEC and MACEPA to roll out iCCM trainings for CHWs using a new curriculum. PAMO’s target in 2019 is to train 1,379 CHWs by the end of June 2019. During this reporting period, PAMO trained 1,099 CHWs (79.7 percent of the 2019 target) (Table 3).

9 Table 3: Cumulative results of PAMO supported CHW training. Province District CHW Actual Number Trained % Achieved training Male Female Total target

Eastern Mambwe 146 0 0 0 0

Luapula Nchelenge 80 61 19 80 100%

Muchinga Nakonde 165 105 15 120 72.7%

Chama 60 0 0 0 0

Northern Mbala 145 93 52 145 100%

Senga Hill 80 59 21 80 100%

Pre-elimination Chadiza 130 96 36 132 101.5% districts Katete 294 156 106 262 89.1%

Sinda 279 182 98 280 100.4%

Total 1,379 753 347 1,099 79.7%

The roll-out of Step B and Step D activities in Eastern Province is of importance to PAMO because this is where pre-elimination activities are occurring. By the end of the first quarter, Chadiza and Sinda were saturated with trained CHWs and Katete had 89.1 percent coverage.

During iCCM training, the CHWs were transported to nearby health facilities to practice

10 To ensure CHWs effectively deliver services in their communities, PAMO also trained health facility staff as iCCM supervisors. PAMO’s target in 2019 is to train 115 supervisors. By the end of the first quarter, 108 had been trained representing 94 percent of the target (Table 4).

Table 4: Cumulative results of PAMO supported iCCM supervisors’ training. Province Districts Target Actual Achieved % Achieved

Male Female Total

Eastern Mambwe 9 0 0 0 0

Luapula Nchelenge 4 4 0 4 100%

Muchinga Nakonde 11 6 1 7 63.6%

Chama 4 0 0 0 0

Northern Mbala 4 11 3 14 *233%

Senga 8 5 3 8 100%

Pre- Chadiza 20 20 1 21 105.0% elimination Katete 32 22 8 30 93.7% districts Sinda 23 17 7 24 104.3%

Total 115 85 23 108 94.0%

*To reach the target of training 145 CHWs in Mbala, PAMO recruited CHWs from 14 health facility catchment areas in Mbala, therefore 14 health facility staff needed to be trained as iCCM supervisors.

iCCM supervisor addressing recently trained CHWs

11 Additionally, in the three pre-elimination districts, PAMO worked with the MOH to provide refresher trainings for 24 laboratory personnel (14 male, 10 female). The training was conducted to boost the skills and proficiency of laboratory personnel in microscopy for malaria examination in line with the NMESP 2017–2021. It is expected that there will be an improvement in the quality of malaria parasitological diagnosis in the health facilities, a reduction in clinical cases of malaria, and, subsequently, a rational use of antimalarial drugs. Additionally, the refresher training provides a basis for laboratory staff who are preparing for the External Competency Assessment for Malaria Microscopy, which is conducted by the WHO. During this quarter, training was also provided to 30 PHO and DHO staff to be OTSS supervisors in the three pre-elimination districts. Twenty-four (19 male, 5 female) DHO staff from each of the three pre- elimination districts (eight each from the three districts) were trained. This included the District Health Director, Clinical Care Officer, Laboratory Technologist, Pharmacist, District Health Information Officer, Maternal and Child Health (MCH) Coordinator, Malaria Focal Point Person and Surveillance Officers. From the PHO, five (four males, one female) staff were trained. The participants included the new Senior Health Information Officer, the Principal Nursing Officer MCH, the Biomedical Scientist, and a Medical Officer from Chipata General Hospital. One female Pharmacist from the NMEC was also trained as an OTSS supervisors. The trained supervisors will begin conducting their OTSS rounds in April 2019.

Task 1.3: Increase delivery of IPTp-SP as part of an integral package of ANC services

In the PAMO-supported provinces, OTSS was initially implemented by the PMI-funded MalariaCare project and the MOH OTSS modules did not cover MIP adequately. Recognizing this gap, PAMO advocated for and developed an MIP module to include in OTSS rounds. This module has been used by PAMO since 2016. It is for this reason that PAMO’s Case Management and MIP Specialist participated in the review of the OTSS curriculum to include more MIP content. There was also a need to include the new WHO guidelines into the OTSS curriculum. WHO guidelines recommend that a pregnant woman should have eight antenatal contacts with a health care provider and that IPTp should be initiated as early as possible in the second trimester of pregnancy. PAMO has advocated for inclusion of this in the OTSS modules. PAMO has designed a tool which can be incorporated into the OTSS electronic data system (EDS) to monitor improvements in IPTp uptake. It is anticipated that this tool will improve the tracking of uptake of IPTp and pregnancy outcomes. As a result of PAMO’s advocacy, the NMEC has found value in this tool and is now working with PAMO to formally include this module on to the EDS.

Task 1.4: Strengthen social behavior change implementation for malaria at health facilities and community level through community mobilization and community dialogues

PAMO collaborated with the DHOs from the three pre-elimination districts to hold a two-day media engagement workshop on March 26 and 27 in Chipata. A total of 25 journalists (21 males and 4 females) from six radio stations, one television station, and one print media house participated in the orientation workshop. They were oriented on the contents of the NMESP and on how to package key information to improve their ability to report on malaria interventions in order to increase the visibility of malaria control and elimination efforts.

Furthermore, as outlined in the PAMO Year 4 work plan, PAMO has planned to support one district from each of the four provinces to harmonize district community engagement plans in order to ensure that the SBC activities at the community level are aligned with the district health plans and consistent

12 with the national malaria elimination strategy. The four districts which were selected are Chama, Mbala, Nchelenge and . In Luapula Province, a workshop to operationalization the Nchelenge District Community Engagement Plan was held on February 26, in Muchinga Province, a similar workshop was held in Chama on March 25, in Eastern province, the workshop was to operationalize the Community Engagement Plan was held on February 28 and in Northern Province the meeting was held on the February 15 in Mbala. The main objective of these meetings was to harmonize the Community Malaria Engagement plans for the respective DHOs in order to ensure that one Community Engagement plan for the district with activities that are harmonized and coordinated with specific timelines was developed. The participants in these workshops included representatives form the PHO, DHO, health facility staff, traditional leaders, private sector representatives as well as representatives from other government line ministries. The NMESP, the district malaria interventions profile, the PAMO work plan, and the DHO community engagement plan were presented. Thereafter, the harmonized plans were finalized. This should help the district to streamline implementation of SBC activities. Additionally, in the pre-elimination districts in Eastern Province, at a series of two-day meetings that ran between February 11 and 18, PAMO’s SBC Specialist and SBC Pre- elimination Officer supported the Eastern PHO and DHOs in Katete, Sinda, and Chadiza to orient CSOs and health facility staff on the Champion Community initiative,2 which encourages community members to find solutions to their health problems and to work collectively to improve health outcomes within their communities. A total of 50 people including representatives from CSOs, the DHO, health facility staff, and representatives from media houses were oriented. Notably:

• In each of the pre-elimination districts, ten health facilities have been selected for implementation of the approach with the plan to select two community volunteers (change champions) from two villages in each of the target communities. The champion initiative will therefore be implemented in 60 communities across the three districts

• 30 SBC plans were developed by health facility staff and incorporated into the district community engagement plans for 2019.

Lessons learnt from the orientation meetings included:

• Mphangwe’s community radio station management stated that they had previously participated in the champions initiative when they partnered with Communications Support for Health in the past. The radio station had documented various activities, aired radio spots, and produced and aired community radio programs. They trained community radio listening groups to ensure community members listened to the radio programs. The radio station is well-positioned to support PAMO’s SBC activities.

• Facility staff shared that they feared that some of the community volunteers would shun the champion community initiative if it did not provide incentives for the volunteers since most of the NGOs working in their catchment areas have been providing incentives to the volunteers. PHO staff advised the health facility staff to find innovative ways of ensuring community

2 Champion Communities is an innovative SBC approach that has been adopted by PAMO and the National Malaria Elimination Program (NMEP)

13 participation and encourage the sustainability of the initiative. Health facility staff were also encouraged to engage traditional leaders for acceptance and support of the initiative The orientation meetings provided an opportunity for implementation of SBC activities to create awareness among communities in the pre-elimination districts on key malaria interventions. The implementation of SBC activities will follow the champion community approach. Traditional leaders (120 headmen and religious leaders) were also oriented on the Champion Community initiative and the malaria pre-elimination agenda. Supported by PAMO’s SBC team in collaboration with the PHO, this activity was implemented in the three pre-elimination districts. The team started by paying courtesy visits to seven chiefs before inviting participants for an orientation meeting. The orientation meeting aimed to facilitate a common understanding of the pre-elimination agenda, solicit the support of the traditional leadership for the successful and sustainable implementation of the pre-elimination agenda, and introduce the traditional leaders to the champion community initiative and define roles with corresponding responsibilities. The traditional leaders shared that although they were happy to be engaged in the orientation and are committed to mobilizing their communities to participate in the various malaria elimination activities in their villages, they advised that PAMO and the DHO need to engage them from the onset of the activities in their catchment areas.

Task 1.5: Strengthen malaria policies and guidelines

The NMEC held a five-day work planning and partner harmonization meeting in Kabwe from January 29 to the February 2 to harmonize 2019 national, provincial, district, and partner work plans. The second objective of the meeting was to introduce the African Leaders Malaria Alliance electronic planning and harmonization tool to all malaria program managers. PAMO Technical Specialists and Provincial Coordinators all participated in the meeting. From March 4 to 8, in collaboration with the Senior Advisor, Malaria, Policy, Strategy and Management and NMEC, PAMO played a critical role preparing for and leading a high-level scoping mission visit from the RBM Partnership to End Malaria Financing Task Force. The visiting delegation included Joy Phumaphi, the Executive Secretary of African Leaders Malaria Alliance, Richard Kamwi, Ambassador of the Elimination 8, Melanie Renshaw, Interim CPO of RBM, and Matthew Boslego, Policy Specialist with RBM. Successful consultations with the NMEC, the EMC, development partners, and various private sector partners took place that were able to lay the ground work for further consultations to develop an investment case for Zambia. PAMO is also providing technical and financial assistance for the mid-term review of the NMESP 2017, of which the concept note and budget have been developed with the latter circulated to NMEC partners, who have committed to supporting different aspects of the process. The MTR process continues in Quarter 2

14

The Honorable Minister of Health Dr Chitalu Chilufya and MOH Permanent Secretary -Technical Services, Dr Kennedy Malama are members of the End Malaria Council

PAMO provided critical technical support to the March 7 launch of Zambia’s first country-level End Malaria Council (EMC) through the Senior Advisor, Malaria, Policy, Strategy and Management, who co- chaired the meeting alongside the Minister of Health, Chitalu Chilufya. Convened by President , the EMC aims to close the country’s malaria funding gap by promoting national investment and resource allocation, fostering efficiencies in program implementation, and securing and sustaining donor commitments from the public and private sectors. Council members include business leaders, key government officials (Minister of Finance, the Minister of Tourism and Arts, the Minister of Defense), and senior traditional and religious leader representatives.

Task 1.6: Support civil society organizations (CSOs) and community- based organizations (CBOs) to implement malaria control activities.

In a bid to strengthen the implementation of CSO SBC activities, PAMO has contracted CSOs to conduct community-based SBC activities. Some of the activities undertaken by the CSOs in Quarter 1 include:

• Supporting DHOs and NHCs to host radio programs where malaria prevention (such as prompt treatment seeking behavior, malaria prevention and the need for malaria testing before treatment) is discussed.

15 • Supporting NHCs to hold community meetings to discuss key malaria interventions and review community reports on SBC activities aimed at increasing demand for key malaria interventions at community level. The key messages shared during these meetings focus on insecticide-treated nets (ITNs), IPTp, and IRS. The CSOs use SBC materials that were provided to them by PAMO such as flip charts, job aids, and score cards.

• Visiting community change champions who are implementing SBC activities in their communities.

• Supporting health facility staff to hold community level activities such as community recognition ceremonies/celebrations to show case community efforts and to motivate other communities.

• Conducting door to door visits to households to educate them about the importance of seeking early treatment and using ITNs to prevent malaria.

The CSOs reported experiencing some challenges, including:

• Heavy rainfall in the PAMO-supported provinces made it difficult for community activities to take place frequently. In addition, some communities cannot be reached easily due to flooding of access roads and paths.

• Some health facilities are not sticking to the agreed upon plan to hold monthly meetings with the community members

• DHO staff have competing priorities and at times don’t meet up with the CSOs at the agreed upon time. The DHO staff are carrying out multiple health promotion activities with various partners within their respective districts.

PAMO staff from the central and provincial level have been conducting regular monitoring visits to the different CSOs. These visits provide PAMO staff with an opportunity to address the challenges as they arise. PAMO staff will continue to work closely with the CSOs to ensure that the program implementation is successful and effective.

16 Task 1.7: Conduct operations research

In 2019, PAMO did not receive funding for operations research, therefore no operations research activities will be implemented this year.

Objective 2: Strengthen management capacity of provincial and district MOH personnel

PAMO’s second objective focuses on strengthening the management capacity of provincial and district managers.

Task 2.1: Identify health system deficiencies at the provincial and district levels that constrain delivery of high impact malaria interventions in close collaboration with the MOH and other actors

PAMO conducted a Malaria Health Systems Gap Analysis and a Management Capacity Assessment in 2016. In 2019, PAMO will not implement any activities under this Task.

Task 2.2: Develop and implement a plan to strengthen management capacity as measured by set targets within each targeted province and district

PAMO is working to strengthen management capacity of PHO and DHO staff. This includes strengthening the individual’s ability to plan, budget, and implement all areas of the malaria program, including resource allocation, financial management, personnel management, training, supervision, commodities, logistics, communications, monitoring, and evaluation. In Quarter 1, PAMO, working through the Broad Reach Institute for Training and Education (BRITE), trained 14 DHO staff (10 males, 4 females) in management skills in order to strengthen the management and leadership capacity of district managers in the pre-elimination districts. The training will continue in all four PAMO provinces in the next quarter.

Objective 3: Strengthen provincial and district health management information system (HMIS) to improve data reporting

Task 3.1: Provide technical/material assistance to DHOs, health facilities and communities to improve the timeliness and accuracy of HMIS reporting

No activities were planned in this quarter.

17 Task 3.2: Assist with training for the roll out of DHIS2 in the targeted provinces and districts.

In Luapula province, PAMO worked with the PHO to train 25 health facility staff (14 males, 11 females) from various districts. The participants were selected after a rapid assessment which was carried out to ascertain the training needs in the province. The main objective of the training was to strengthen health facility staff’s ability to report HMIS data accurately and timely. The majority of participants were newly recruited health workers and those that were not previously trained in HMIS. The training is meant to improve the understanding and usage of HMIS tools such as registers, tally sheets, and various health aggregation forms. After training these health workers, it is expected that HMIS reporting, data capturing, and management will improve in the health facilities that they were drawn from.

Task 3.3: Provide technical/material assistance to DHOs, health facilities, and communities to strengthen malaria data analysis and use for planning and decision making.

In the pre-elimination districts, all 75 targeted health facilities have been oriented in malaria rapid reporting. In addition, 99 out of the targeted 142 data CHWs have been trained in community surveillance reporting. Figure 2 shows the location of these CHWs. When training in Sinda and Katete concludes in April, 100 percent of planned CHWs will have been trained and enrolled. It is expected that once the CHWs have completed their four-to-six-week health facility training attachment (required before they begin to work in the community), they will be able report on the Step D component on a monthly basis. This information will help the Eastern PHO and the three DHOs track improvements in malaria disease in health facility catchment areas (HFCAs) and helps them identify HFCAs with high malaria burden areas, thus enabling the appropriate package of malaria interventions to be deployed more effectively.

18 Figure 2: Roll out of Step B and Step D activities in Chadiza, Katete, and Sinda (pre-elimination districts).

19 Key issues encountered

The project did not encounter any significant challenges during this quarter. However, it is worth noting that the heavy rains in the north-eastern parts of Zambia did cause delays in implementation of several activities like the mop-up distribution campaign and community meetings. Travel between districts in Muchinga province was also hampered when the Great North Road was washed away and the road to became impassable. However, PAMO was able to work around the challenges which were encountered as a result of the rainy season.

The Great North Road between Mpika and Community members assisting PAMO staff to push the was completely cut-off at Lifune Landcruiser out of the mud Stream for several weeks

20 Success stories iCCM and community surveillance training cheers newly trained CHWs

A case of Alex Luka of Chisenga Island in Nchelenge District This is Mr. Alex Luka. Born on June 18, 1970, in Kampampi Village in Nchelenge District, he grew up living a relatively normal life until he accidentally stepped on a sharp object when he was 12 years old. His injury grew and he was transferred from one hospital to another until his leg become gangrenous, leading to its amputation on December 13, 1995, at Mbereshi Mission Hospital. This made him drop out of school and abandon his dream of becoming a medical doctor.

Despite this setback, in 2007 he joined a group of volunteers that were being trained as Breastfeeding Community Champions at Chisenga Island Rural Health Centre. His

Alex Luka with the PAMO Luapula Provincial dedication attracted the attention of the Coordinator – Bright Katai Neighborhood Health Committee, which decided to recruit him as a community health worker, the job he has been performing on a voluntary basis ever since.

However, Chisenga is a remote island, and very few non-governmental organizations (NGOs) have taken an interest in working with the community in the fight against malaria because of the geographical location and environmental concerns, for example, indoor residual spraying is not conducted on this island.

This changed when PAMO recruited, trained and equipped CHWs, with starter kits and enablers to perform integrated community case management in the community. The trained CHWs only follow up five passive cases each month. The program has been running well so far, Chisenga Island Rural health Centre has recorded a reduction in malaria incidence. This is reflected in the data presented in the last Nchelenge district data review meeting which compared Quarter 1, 2018 (before the CHWs were trained) and Quarter 1 2019 (after the CHWs were trained).

21 Figure 3: A comparison of confirmed malaria incidence rates, Chisenga RHC (Q1 2018 vs Q1 2019)

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400

350

300

250

200

150

100

50

0 Less than 5 years of age Above 5 years of age Total Incidence

Q1 2018 Q1 2019

“The iCCM and community surveillance training l have received has made me become a community doctor because I have learnt to perform malaria diagnosis and treatment at community level. At least l have acquired some knowledge in line with the dream l had of becoming a medical doctor,” said Alex.

He added: “Special thanks to PAMO for the support to the Ministry of Health and for the special consideration of our islands where other NGOs don’t reach. We promise, that we shall work hard for our people, our relatives in Chisenga, to end malaria for good because we now have the knowledge which we were lacking. Thank you very much PAMO and may the almighty God bless you.”

22 MOH staff benefit from management and leadership capacity- building

PAMO conducted a management capacity assessment in PAMO provinces for provincial and district managers to determine to what extent the level of management skills affected planning, management, and resource allocation to priority health areas such as malaria. PAMO also supported the NMEC to conduct the ETR that showed that only 37% of planned deliverables were implemented in the 2011– 2016 NMSP. Based on these findings, PAMO has rolled out a comprehensive Malaria Program Management Capacity Strengthening Plan. In the Northern province, , Chilubi, and Mungwi DHO staff participated in the Management and Leadership Capacity Building training. The health workers have found that this training has helped them build their management skills and feel that this will help them become effective managers. The acting Provincial Nursing Officer – Maternal and Child Health, Lissah Susiku, stated that the course was generally interesting, adding that the training helped in a variety of ways, such as:

• Improving her leadership competencies.

• Helping her to know herself better and what type of a leader she was as well as what type of leadership style that she was going to implement going forward.

• Helping her understand the importance of risk management and mitigation.

• Helping her understand the different stages of planning; from the strategic plan, to the log frame, to the implementation plan and the work plan.

• Helping her to understand financial management and human resource management.

• The fact that the training was online made access easier and motivated her because she was able to view how her colleagues from the four provinces were progressing.

Chief Environmental Health Officer (Sanka Morgan) This training came at the right time when I just assumed high office in the province and whilst settling down to see on how I would manage my fellow environmental health staff in the province. There were so many things I learnt and benefitted from, but the following are the most but important areas; the training made me realize the importance of giving a suitable introduction to environmental health staff when they commenced their work. This provides a good start in their work and feels welcomed and integration in the system quickly. It has also helped me to think about what should be included in an induction program. I have come to learn on how I can improve my own performance management and assess my strengths and your weaknesses and techniques I can use to improve my performance. I strive to be a good manager who should be one with good leadership skills that involves directing, motivating, and leading which are imperative to a team’s success and performance. I also believe in delegation, where one is being able to delegate does not only make a more efficient and effective manager, but it can also create a more productive team. I have learnt that giving your team members additional responsibilities and accountability makes them feel more motivated and empowered. Assertiveness is another characteristic that I learnt where an individual has the ability to negotiate, close deals, and reach objectives. Finally, I am striving to be results-oriented as a crucial quality of a good manager and ensure that officers are constantly motivated to reach their objectives.

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District feedback

Lunte District Health Director Paul Mayeya, District Health Information Officer Daniel Sikazwe, and Clinical Care Officer Sinclair Phiri from the Lunte District Health Office in Northern Province participated in the Management Capacity Training in November and December of 2018 and had the following feedback. Positives:

• The training period was adequate.

• Materials were adequate and relevant to the topic discussed.

• Facilitators were able to guide and motivate participants through emails, WhatsApp page groups, and phone calls and were in touch with each and every individual.

• The platform on each course encouraged active participation.

• Face-to-face interaction was also very helpful especially on managing case studies.

• The methodology involved theory, video, scenarios, exercise, and actual documentation, accounts documents, and a human resource reference manual. Gaps:

• The period for participants to understand the online program was very short.

• Challenges with connectivity, especially during the first week, resulted a delay for some participants.

• Delays in relaying case study feedback to participant.

• Face-to-face interaction session was not adequately supported and resulted in other officers not attending the interaction session. The following were some of the skills learned during the management capacity training:

• How to engage community structures on malaria prevention activities using NHCs at the facility level, and stakeholder identification and engagement at the district level.

• How to manage malaria task force meetings at the district and facility level.

• How to prioritize identified problems using atomization to find the root cause of the problem, a good tool in planning malaria activities.

• How to use a prioritization time impact matrix to identify possible solutions to the identified problem.

• How to analyze and present malaria data to specific groups and how to use available malaria data to confirm the extent of the problem.

• How, as a team, to develop malaria problem statements.

• How to motivate and manage community volunteers.

• How to use government control measures to use the available resources to implement malaria activities.

24 Four officers from the Chilubi District Health Office (the District Health Director, District Health Planner, MCH Coordinator, and Health Promotions/Surveillance Officer) attended the training and had the following feedback for the courses they took:

• Project Management & Development (PMD) – “The modules helped us as learners to understand and improve our project management skills as managers.”

• Administrative Management – “This covered both Human and Finance Resources management and highlighted the importance of organizational leadership and culture and other skills that reduce and manages conflict in our work environment to improve productivity and increase efficiency.”

• Management, Leadership & Mentorship – “This course helped us study and understand the science of management and Leadership and encouraged those trained to explore themselves and become managers, leaders and mentors.”

• Planning & Problem Solving – “The objective of this training was to explore tools and processes for identifying and solving problems across all sectors of an organization.”

• Strategic Information Management (SIM) – “This course helped us as learners to examine the system of capturing, categorizing, collating, analyzing and communicating Information.”

• Community Health Management – “The module helped us understand the community and the factors that affect the community leading to understand and control the spread of diseases.’”

Chilubi District Health Office management team has benefited immensely from the training in many ways in that apart from the conceptual tools and skills that we learned during the conference and from modules but also the interactive (online based) forum helped us learn practical experiences in the way health problems are being analyzed and solutions found to resolve them by our fellow participants as well as the trainers. As a district with one of the highest incidences of malaria in the province, we have benefited from all the modules especially on project management, planning and problem solving, strategic information management, and community management styles as they have helped us conceptualize the planning tools to help understand root causes of our malaria incidences which are still relatively high and design strategies to resolve the challenges we identify. The training was timely in that as a district, the skills attained will help us implement practical approaches in relation to the Ministry of Health’s transformational agenda as outlined in the seventh National Health Strategic Plan for 2017–2021 and help us attain the National Legacy Goals which includes malaria elimination by 2021. The District Health Team has since come up with a Malaria Task Force Business Plan to guide the multi- sectoral approach to malaria elimination.

25 Mungwi DHO Feedback on Management Capacity Training (Nursing Officer - Angela Kaoma) As a district we were privileged to be among the districts to participate in the Management and Leadership Capacity Building Training under BRITE. Among the courses learnt include: project management, administrative management, leadership and mentorship, planning and problem solving, strategic information management, and community health. I have learnt a lot of things in these modules which applies to daily work. For example, in project management I have learnt the importance of planning, in our district last year we had challenges with Fansidar and we had a lot of pregnant women presenting with malaria in pregnancy of which one even died because she never took any in pregnancy hence we have planned to be buying the drug in order to supplement on what we receive from medical stores. In addition, I have also learnt that these women need to be monitored when they take the drugs to ensure compliance that is directly observed therapy, because sometimes we may have the drugs, but women are not taking, therefor monitoring is important. I have also leant that information management is important using the correct tool for proper planning and decision making. If wrong data is collected a wrong decision may be made which does not reflect the true picture of the prevailing situation. I have also learnt the importance of stakeholder involvement if we are to achieve the goal. In Mungwi we have an organization called community-based care foundation whose main role is to sensitize the community on malaria prevention through health education done mainly through drama performances this helps in trying to reach the national goal of eliminating malaria by the year 2021. Furthermore, we have district malaria task force committee helping the district in sensitization, educating people on preventive issues like allowing people to spray their homes during the IRS program, this again helps in nearly reaching the national goal off malaria prevention. I have also learnt that community involvement is important in all health programs, use of NHCs, SMAGS, and other volunteers in the community helps in quick dissemination of information in the community, acceptability and sustainability. For example, early ANC booking so that IPT can be started early is helped by the SMAGS. Information on IRS spraying is given by the NHCs among other duties. The program has been so helpful in the work career hope we can have some soft copy material for reference once the program is over.

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