Quarterly Progress Report (January – March, 2017)

Approval Date: September 30, 2015

QPR Number: [002]

Contract/Agreement Number: [AID-611-C-15-00002]

Activity Start Date and End Date: [October 1, 2015 to September 30, 2020]

Total Award Amount: [$24,389,716.00]

Submitted by: [PATH Office, Stand 11059, Brentwood Lane, ] [Tel: +260211378950]

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

List of Abbreviations

ANC Antenatal care BRITE Broad Reach Institute for Training & Education CBO Community-based organizations CD Continuous distribution CHA Community Health Assistant CHAZ Churches Health Association of Zambia CHW Community Health Worker COP Chief of Party CSO Civil Society Organization DHD District Health Director DHO District Health Office DHIS2 District Health Information System 2 DHS Demographic Health Survey DIM District Integrated Meeting EPI Expanded Program on Immunization GRZ Government of the Republic of Zambia GUC Grants under contract HMIS Health Management Information System iCCM Integrated community case management IEC Information, education, and communication IPTp Intermittent preventive treatment in pregnancy IRS Indoor residual spraying ITN Insecticide-treated net JHUCCP Johns Hopkins University Center for Communication Programs LLIN Long Lasting Insecticide Treated Net MACEPA Malaria Control and Elimination Partnership in Africa MATF Malaria Task Force M&E Monitoring and evaluation MIP Malaria in pregnancy MIS Malaria Indicator Survey MOH Ministry of Health NHC Neighborhood Health Committee NMEC National Malaria Elimination Center NMEP National Malaria Elimination Program NMSP National Malaria Strategic Plan OR Operations Research OTSS Outreach Training and Support Supervision PAMO Program for the Advancement of Malaria Outcomes PHD Provincial Health Director PHO Provincial Health Office PIM Provincial Integrated Meeting PMI President’s Malaria Initiative PMP Performance Monitoring Plan SBCC Social and behavior change communication SMAG Safe Motherhood Action Groups STTA Short-term technical assistance TOT Training of Trainers TWG Technical working group ZMLA Zambia Management and Leadership Academy ZCAHRD Zambian Center for Applied Health Research and Development

CONTENTS

1. EXECUTIVE SUMMARY ...... 4

2. BENCHMARKS AND ACHIEVEMENTS ...... 5

3. KEY ISSUES ENCOUNTERED ...... 22

4. SUMMARY OF ACHIEVEMENTS DURING THE CONCLUDING QUARTER TOWARDS PLANNED TARGETS ...... 22 4.1 SUCCESS STORIES ...... 22

5. APPENDIX I: THE PERMANENT SECRETARY’S CIRCULAR ON AVAILABILITY AND USE OF FOLIC ACID (400 MICROGRAMS) ...... 23

6. APPENDIX II: MAPS OF HEALTH FACILITIES FOR PAMO SUPPORTED PROVINCESError! Bookmark not defined.

7. APPENDIX III: BACKGROUND INFORMATION ...... 25

8. APPENDIX IV: KEY TASKS & TARGETS BY OBJECTIVE ...... 27

9. APPENDIX V: PAMO GEOGRAPHIC SCOPE ...... 29

1. EXECUTIVE SUMMARY

The Program for the Advancement of Malaria Outcomes (PAMO) is a United States President’s Malaria Initiative (PMI) funded project currently in the second year of implementation. The PAMO consortium comprises of five members namely PATH, JHUCCP, JHPIEGO, BRITE and ZCAHRD. PAMO works with the Ministry of Health (MOH) and the National Malaria Elimination Centre (NMEC) to strengthen implementation of malaria control and elimination efforts. The project works at provincial, district, and community levels to support proven malaria interventions in alignment with the National Malaria Strategic Plan; strengthen management capacity of provincial and district MOH personnel to provide oversight/supervision of malaria interventions and; to strengthen the Health Management Information System (HMIS) at the provincial, district and facility levels to improve data reporting, analysis, and use for decision-making.

The period under review is the first three months of implementation of Year 2 of the PAMO project. The major activities reported on include the key findings of the Management Capacity Assessment. The capacity assessment was conducted in quarter 4 of 2017, data analysis was concluded during this quarter. The data showed that there is a n urgent need for management and leadership training for district staff and health centre in-charge. There is also an urgent need to strengthen data management and recruit data clerks to support entry of the backlog of data found at the district health office.

PAMO focused on providing support to the NMEC who plan to conduct a nationwide mass campaign for the distribution of Insecticide Treated Nets (ITNs). The mass campaign will begin in Province were PAMO will provide full support to the NMEC and the PHO to successfully implement this campaign. During the first quarter, PAMO worked closely with the NMEC to set up sub-committees of the ITN TWG for effective coordination of the upcoming campaign. In addition, PAMO provided technical support to the Principal ITN Officer to develop a detailed action plan for .

In case management, PAMO supported mentorship training Trends in Incidence Rates for 55 health workers (17 Female and 38 Male). PAMO 900 819.3 827.5 also supported quarterly 800 670.1 facility supervisory visits. The 700 634.4 653 650.6 work supported in case 600 490.4 management is contributing to 500 reductions in malaria incidence 403.4 400 in the four PAMO supported provinces. The graph shows a 300 comparison of malaria 200 incidence in the first quarter of 100 2016 compared to the first 0 quarter of 2017. Luapula and Eastern Luapula Muchinga Northern Muchinga are showing a greater decline then Eastern Jan to Mar 2016 Jan to Mar 2017 and Northern Provinces. This quarterly progress report focuses on the period 1st January to 31st March 2017.

2. BENCHMARKS AND ACHIEVEMENTS A summary of the key achievements and activities undertaken by the consortium during this quarter are described below:

Objective 1: Support proven malaria interventions in alignment with the National Malaria Elimination Strategic Plan (2017-2021) of the Ministry of Health  Task 1.0: Strengthen National Technical Working Groups Technical Working Groups are structures that provide a critical framework for coordination, planning, and mainstreaming of national strategic and technical guidance on malaria. PAMO is currently supporting five focus areas including Insecticide Treated Nets, Case Management, Social and Behavior Change Communications, Safe Motherhood, Surveillance, M&E and Operations Research (SMEO). During this quarter, PAMO provided material support to the NMEC to host one quarterly TWG meeting for each of these areas. The key achievements for this quarter include:  Safe Motherhood TWG: The Ministry’s official approval of the World Health Organization (WHO) recommendation to use a low dose of 400 micrograms folic acid supplementation as part of the antenatal care. This is a huge achievement for the country, PAMO provided technical and material support to the Ministry of Health to move along this process through this TWG. A scanned copy of the circular is attached in Appendix I.  Case Management TWG: PAMO facilitated and participated in the Malaria Case Management Technical Working Group meeting which was held at the NMEC on the 14th March 2017. Members of the TWG met and agreed on priority activities for 2017. They developed a road map for the review of the malaria treatment guidelines as well as the QA/QC manual. The revision of the malaria diagnosis and treatment guidelines was done during the week of the 27th to 31st March 2017 while the revision of the QA/QC manual will be done in April 2017. An update of the number of community health workers trained in iCCM nationwide was provided (2,370). Some of the challenges in iCCM program implementation were that CHWs are inactive in some areas, they lack bicycles and CHW community registers, some have resorted to using ordinary hard cover exercise books. Last year PAMO played a vital role in facilitating discussions for the change of the folic acid policy in accordance with revised guidelines for the WHO. In addition, WHO has revised the antenatal guidelines with a recommendation of at list eight contacts per pregnant woman, moving away from the four focused antenatal visits. In the eight contacts a woman must be seen by a qualified health worker or community volunteer depending on the context of the facility. The Permanent Secretary has issued a memo to relating to the change in folic acid policy, this has since been circulated in all PAMO provinces and districts. PAMO will continue to support the NMEC as required to ensure that the guidelines are fully adopted and disseminated to front line workers  Social & Behavior Change Communications: The NMEC has formed various sub- committees to support the upcoming mass ITN distribution campaign. PAMO was elected to chair the SBCC sub-committee for the 2017 ITN mass distribution campaign. PAMO SBCC advisor participated in the development of TORs for the sub-committee, the ITN communication strategy for the mass distribution, developed a timeline for the mass distribution of ITNs, and identified support materials for the distribution. Adaptation of the first draft Champion Communities tool kit is now done. Champion Communities 2.0 Tool kit reviewed by JHU, ITN communication messages have been integrated into the tool kit.  ITN TWG: In support of the upcoming nationwide mass distribution campaign, the ITN TWG is holding monthly preparatory meetings. The main focus of these meetings is to receive updates on progress towards the implementation of the nationwide ITN mass distribution. PAMO’s ITN advisor, SBCC advisor and Technical Director are all highly involved in these monthly meetings, they will provide on-going technical and material support to the NMEC to ensure that this mass campaign is successfully executed. Minutes of these meetings can be shared with PMI upon request.

 Task 1.1: Insecticide Treated Net Distribution Use of insecticide treated nets (ITN) is widely recognized as one of the main interventions to prevent malaria. The two main indicators to assess outcomes have been household ownership of at least one ITN and population use of ITN the previous night. Consistently, evaluations have found a significant gap between these indicators with ITN use always much lower than ownership of at least one ITN. Several authors have pointed out that the main reason for non-use is lack of access to an ITN and having enough ITNs for all within a household is the strongest determinant of ITN use1. There have been strong gains in ITN household ownership in the four PAMO provinces over the last few years. The 2015 Malaria Indicator Survey (MIS) shows that household ownership of long lasting ITNs stood at 93.5% (Eastern Province), 84.5% (Luapula Province), 79.6% () and 78.3% (Northern Province) respectively. However it is more important to move beyond the basic indicator of household ownership and focus on indicators that reflect the proportion of fully protected households (i.e. full coverage). The ITN to sleeping space ratio of 1:1 remains low in Northern Province (49%) but is much higher for Luapula (72%), Muchinga (75%) and Eastern (84%) provinces. As already stated ownership is a key determinant of use thus PAMO is working closely with the NMEC to ensure that mass campaign is rolled out successfully and that the ITN-sleeping-space ratio of at least one to one among households with an ITN reaches the program target of 85%. Over the life of the project, PAMO will provide support to the NMEC to raise this indicator where applicable and maintain it in areas where it is already achieved. PAMO will continue to work with the NMEC to ensure that sufficient plans and processes are in place to sustain coverage of ITNs in the coming years.

Last year (in 2016), the focus of PAMO’s work was to conduct a pilot of continuous distribution of ITNs through primary schools in four districts (, , , and Mansa). During this quarter, PAMO worked with the PHO to secure the ITNs which remained from the pilot. Following approval from PMI to move the excess ITNs, the PAMO team spearheaded the process by providing all logistical requirements. A total of 190,571 excess ITNs were retrieved from various storage places in the four districts. PAMO is pleased to report that no ITNs have been lost, all excess ITNs were accounted for. Arrangements were made with institutions which had facilities to store the ITNs for four months. The ITNs were stored with Council, Catholic Parish, Mansa Diocese and Samfya Community Christian Partnership. The Luapula Provincial Health Office had decided to use these ITNs at the beginning of the mass distribution exercise in order to minimize the amount of time that these ITNs will be in rented storage facilities. The ITNs for the mass campaign will have containers which are remaining in the district. Therefore stakeholders agreed that as the distribution begins, it makes more sense to offload those in rented storage facilities first and the excess ITNs after the mass campaign will remain in free and secure storage containers.

1 Eisele TP, Keating J, Littrell M, Larsen D, Macintyre K (2009) Assessment of insecticide-treated bednet use among children and pregnant women across 15 countries using standardized national surveys. Am J Trop Med Hyg 80: 209–214

In addition, PAMO focused on providing support to the MOH to conduct a nationwide mass campaign for the distribution of ITNs. The mass campaign will begin in Luapula Province were PAMO will provide full support to the NMEC and the PHO to successfully implement this campaign. During the first quarter, PAMO worked closely with the NMEC to set up four sub- committees of the ITN TWG for effective coordination of the upcoming campaign. The four sub- committees are Technical and Implementation Sub-Committee; Social Mobilization Behavioral Change Communication Sub-Committee; Monitoring & Evaluation Sub-Committee; and the Procurement & Logistics Sub-Committee. These sub-committees meeting frequently to ensure smooth implementation of the various task of the main ITN TWG. In addition, PAMO provided technical support to the Principal ITN Officer to develop a detailed action plan for Luapula province. The action plan is organized in line with three stages in the implementation of mass distribution: i. Stage 1: Preparatory Activities ii. Stage 2: House Hold (HH) Registration, Collation & Validation iii. Stage 3: Distribution Processes

Stage 1 activities commenced in January with the NMEC sending letters to the Luapula Provincial health office to provide information about the upcoming campaign. The PHO in turn sent letters to the districts. An information sharing and micro-planning meeting was held on the 6th to the 7th March 2017. With financial support from PAMO, the Luapula PHO was able to hold an orientation and planning meeting. Participants in the meeting included, Churches Health Association of Zambia (CHAZ), NMEC, PAMO and other MOH staff. Important agenda items at this meeting included: i. Experiences and lessons learned from the 2014 Mass ITN distribution were shared by participants from CHAZ and from the NMEC. A discussion was held to look at the positives and negatives and best practices will be adopted. ii. The proposed processes for mass distribution was presented (extracted from the 2017 mass distribution plan of action and proposed 2017 PAMO work plan) and adopted with three stages namely, (1) preparatory activities, (2) data collection, collation and validation (3) distribution. iii. A presentation on the activities for the SBCC plan for mass distribution was held and pertinent points for the activities were discussed and firmed up iv. Tools for use in mass distribution were presented and reviewed v. The timelines for the mass distribution was further developed following inputs from the provincial team present in the meetings

The meeting was followed by a training session for master trainers. Provincial and District Mass Distribution Committees have been formed and microplanning meetings for all stakeholders have been on-going. All districts in Luapula have developed micro plans. These were all received by the NMEC on the 16th March. Micro plans were are being reviewed at the time this report was written. The micro plans will be used to inform budgets and requirements for forms and SBCC materials. In addition, health workers and in particular EHTs have been trained on Household Registration. District level trainings of health workers (1 EHT and one Health Centre Advisory Chairperson [HCACP] per health facility) was held from Monday, 27th to Friday 31st March 2017. This exercise will be followed by training of CBVs and VHMs at Health facility Level on HH Registration in April. The national team comprising of the NMEC, PAMO and other key stakeholders supervised the district and facility level trainings by Provincial Level teams. Lastly Strategic Storage Points at the district level have been identified. Stage 2 activities will begin in the second quarter. Activities for Eastern, Muchinga and Northern will be fashioned according to the Luapula action plan but execution is dependent on expected arrival dates per province. ITNs for Luapula are expected to arrive in the country a month before the ITNs for the other three provinces. The timelines for the other three provinces have therefore been adjusted accordingly. As a first step, a meeting was held in Lusaka on the 2nd and 3rd February 2017 at the PATH offices. The meeting was attended by PAMO Provincial Staff, Luapula PHD, JHUCCP, CHAZ and Connie Saunders for the Global Fund. Provincial Health Directors (PHDs) from Eastern, Muchinga and Northern Province were invited but were unable to attend. PAMO plans to hold another meeting soon were all they can all attend. The key objectives of this meeting were to: o Share the implementation schedule for Luapula province which will be prototype for the other provinces, o Provide guidance on preparations for household registration to ensure 100% of households and residents are registered in target provinces, o Provide guidance to the provinces to prepare to distribute ITNs to 100% of all registered households, and to o Prepare to sensitize 100% of beneficiaries on how to hang and use the ITNs throughout the year

 Task 1.2: Improve access to and quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment PAMO is working closely with the MOH to improve access to and quality of malaria case management in public health facilities through in-service training for health workers and revitalization of Outreach Training and Supportive Supervision (OTSS) in the four PAMO provinces. At community level PAMO is supporting the expansion and strengthening of integrated community case management. In Luapula province, 1181 community health workers were trained in 2015 and 2016 by World Vision. The province therefore requires 154 iCCM supervisors but World Vision only trained 40 before the project came to an end in February 2016. PAMO provided support to the Provincial Health Office to train additional iCCM Supervisors. Thirty-nine (39) supervisors were trained (9 female and 30 male) including Provincial Staff, District staff and front line health workers. The training was held from the 23rd to 27th January 2017. The objectives of the training were to provide an overview of the community case management concepts, to strengthen skills in supervision and monitoring of iCCM and enhance ownership of the iCCM program at facility level. The rationale for this support is to improve the community health workers program by building capacity of the facility in-charges in basic supervisory skills. It is expected that more iCCM volunteers will receive adequate supervision and that Health Facility staff will take more interest on community level work. This training helped to close the gap between the Community and the Health Facilities as the supervisors now have the necessary skills to adequately supervise trained iCCM volunteers in the community. During this year PAMO will support training of volunteer Community Health Workers and Supervisors in a bid to strengthen iCCM further.

In Eastern Province, PAMO provided support for the training and rollout of OTSS for Provincial Supervisors. PAMO supported this activity to strengthen their mentorship skills using the JHPIEGO/MOH approach. The workshop was conducted from the 20th – 24th January in . A total of 17 participants (2 female, 15 male) attended the training. The participants included laboratory personnel and clinicians from 6 out of the 9 districts in Eastern Province. The trainers included National trainers drawn from different provinces. This training will enable the Provincial OTTS teams in Eastern province to conduct OTSS and mentorship in malaria microscopy

and malaria case management across 39 facilities conducting malaria microscopy in the province. This will support the province to improve quality of malaria case management at public health facilities to ensure prompt, accurate diagnosis and appropriate treatment of malaria as outlined in PAMO’s work plan. Competencies in malaria case management and diagnosis for facility staff will ultimately be improved through OTSS. By strengthening mentorship skills in the staff, it is expected that this will also directly contribute to improved provider adherence to RDT results and therefore increased numbers of confirmed malaria cases at facility level as opposed to clinical malaria, resulting in cost-effectiveness of the usage of malaria drugs for clients with confirmed malaria. Mentorship will further contribute towards the attainment of national set targets to ensure that at least 75% of children under 5 years old with fever have a malaria test and 90% of confirmed cases receive appropriate treatment. Following the training, PAMO supported the province to conduct OTSS and Mentorship rounds to facilities that offer Malaria microscopy in six districts from the 23rd – 28th March. The Provincial OTSS team comprised a total of four clinicians and six laboratory personnel pulled from nine districts. The Provincial OTSS team divides into two teams with team 1 visiting district hospital, Lumezi, Central, Kapata and Muzei. Team 2 visited St. Francis, Urban, and Minga Hospital.

PAMO in Muchinga supported DHO to conduct the quarterly facility supervisory visits. Out of 31 health facilities that exist in 15 were supervised during the period under review. This activity is expected to improve health facilities competencies in malaria case management, provision of IPT3, malaria logistical management, and community engagement and mobilization for malaria action. PAMO also supported DHO to conduct the quarterly facility supervisory visits. This activity was a follow up to the monthly data review meeting held in the month of February 2017 in . Out of 10 health facilities that exist in Chinsali district 6 were visited. As a result of PAMO’s support for the quarterly health facility supervisory visits, Chinsali DHO was able to learn the following lessons: o The delay in the delivery of community registers has generally inhibited deployment of the cadre of CHWs trained in iCCM by most facilities o Some health facilities have still gone ahead to innovate and deploy the CHWs despite the non- delivery of registers. This innovation has included: a. 100% retention of all iCCM trained CHWs, though it was also observed that most health facilities have not managed to have a 100% retention. b. Retirement of all used RDTs before restocking. c. Used RDTs being used for quality control purposes. d. Positivity rates of above 80%. e. Identification of need for more CHWs due to distances covered and need for sustainable livelihoods among CHWs Another lesson was that some facilities are having stock-outs of RDTs because they using RDTs for screening also. It was also observed that the delay in the integration of CHWs kits in the supply chain or drug/medical commodities orders of the HFs is creating stock-outs and challenges. Among the issues causing this are: a. The failure by some HFs staff to recognize CHWs as a relief system to the overstretched healthcare system. b. The misallocation and non-use of the Community Health Assistants. c. The delay in the deployment of the CHWs is making some CHWs lose the skill. d. The health facility staff are inadequately prepared to provide mentorship and oversight to the CHWs. e. Some facilities do not have dedicated individuals for data collection, entry, cleaning, analysis and sharing

In Northern Province, PAMO supported the Provincial Health Office to train 20 Health Workers in Mentorship using the JHPIEGO Curriculum. From this group 15 were previously trained as ToTs in Malaria Case Management and Diagnosis in and in OTSS in Petauke in Eastern Province. 5 MCH coordinators were also added to this group and trained in Mentorship with a view to address Malaria in Pregnancy. The Mentorship/OTSS/ANC training was held in Luwingu from 22nd to 29th January 2017 for Provincial Supervisors. A total of 20 were trained (12 Males and 8 Females). Those trained in Mentorship included Clinical Officers, Nurses, Nurse Tutors, Medical officer and Laboratory staff. The training of the 20 Provincial supervisors in Mentorship implies that supervision to facilities in malaria case management will be effectively done to facilities in the province. The Provincial Trainers should now start to train facility staff through mentorship in all areas of clinical health care delivery services for Malaria case management.

The graphs below illustrate progress being made in the four provinces. These graphs were generated from Zambia HMIS and show that there is a slight reduction in malaria case in Quarter 1 of 2017 as compared to Quarter 1 of last year 2016.

Trends in Malaria Cases (Clincal & Confirmed) in Eastern Province 1200000

1000000 954547

800000 770729 682622 638344 600000

400000

200000 66781 32348 0 Clinical Cases of Malaria Confirmed Cases of Malaria Malaria (Confirmed & (total) (total) Clinical) (total) Jan to Mar 2016 Jan to Mar 2017

Trends in Malaria Cases (Clincal & Confirmed) in Luapula Province 1200000

1000000

800000

600000

400000

200000

0 Clinical Cases of Malaria Confirmed Cases of Malaria Malaria (Confirmed & (total) (total) Clinical) (total)

Jan to Mar 2016 Jan to Mar 2017

Trends in Malaria Cases (Clincal & Confirmed) in Muchinga Province 900000 800000 700000 600000 500000 400000 300000 200000 100000 0 Clinical Cases of Malaria Confirmed Cases of Malaria Malaria (Confirmed & (total) (total) Clinical) (total)

Jan to Mar 2016 Jan to Mar 2017

Trends in Malaria Cases (Clincal & Confirmed) in Northern Province 1000000 900000 800000 700000 600000 500000 400000 300000 200000 100000 0 Clinical Cases of Malaria Confirmed Cases of Malaria Malaria (Confirmed & (total) (total) Clinical) (total)

Jan to Mar 2016 Jan to Mar 2017

Source: Zambia Health Management Information System (www.zambiahmis.org )

 Task 1.3: Increase delivery of IPTp – SP as part of an integral package of ANC services PAMO is working to integrate the promotion of IPTp-SP in mentorship activities, strengthening provider capacity to implement new national guidelines; promoting early ANC attendance, IPTp uptake, and ITN use during and after pregnancy; consistently provide appropriate iron/folate supplementation and encourage early care seeking for prompt case management; and correctly complete registers and monthly summary forms. Therefore, PAMO supported mentorship training with focus on Malaria Case Management and Malaria in Pregnancy for Provincial Supervisors in Muchinga Province. This training targeted Provincial Trainers trained in Malaria Case Management, OTSS, and Focused Ante-Natal Care (FANC) in Year 1. A total of 18 GRZ personnel were trained as Provincial Mentors and out of this number, 11 were males while 7 were females. The 18 GRZ personnel trained included 3 Clinicians, 5 Biomedical/Laboratory personnel, 1 Information Officer, 1 MCH Coordinator, and 8 FANC Supervisors. In Northern Province, PAMO supported the Provincial Health Office to train 20 GRZ staff in Mentorship using the JHPIEGO Curriculum. From this group 15 were previously trained as ToTs in Malaria Case Management and Diagnosis in Kabwe and in OTSS in Petauke in Eastern Province. 5 MCH coordinators were also added to this group and trained in Mentorship with a view to address Malaria in Pregnancy. The Mentorship/OTSS/ANC training was held in Luwingu from 22nd to 29th January for the Provincial Supervisors. A total of 20 were trained (12 Males and 8 Females). Those trained in Mentorship included Clinical Officers, Nurses, Nurse Tutors, Medical officer and Laboratory staff. The training of the 20 Provincial supervisors in Mentorship implies that supervision to facilities in malaria case management will be effectively done to facilities in the province. The Provincial Trainers should now start to train facility staff through mentorship in all areas of clinical health care delivery

services for Malaria case management. PAMO will provide support to the MOH in all four provinces to conduct mentorship throughout the life of the project.

 Task 1.4: Strengthen SBCC implementation for malaria at health facility and community levels through community mobilization and community dialogues ITN Mass Campaign: The NMEC has formed various sub-committees to support the upcoming mass ITN distribution campaign including the Social Mobilization Behavioral Change Communication Sub-Committee. PAMO was elected to chair the SBCC sub-committee for the 2017 ITN mass distribution campaign. PAMO SBCC advisor participated in the development of TORs for the sub-committee, the ITN communication strategy for the mass distribution, developed a timeline for the mass distribution of ITNs, and identified support materials for the distribution. Adaptation of the first draft Champion Communities tool kit is now done, ITN communication messages have been integrated into the tool kit. The Communication strategy for the ITN mass distribution was developed and shared with the main ITN TWG. The SBCC advisor is working to develop communications support materials for the upcoming campaign. An inventory of existing ITN mass distribution materials was conducted and it revealed that none of the materials reviewed are specific to mass distribution. Therefore JHUCCP shared materials from other countries with the NMEC and the SBCC subcommittee. The PAMO SBCC Advisor then developed content for radio spots, print materials, t-shirts, posters, job aides, PA, drama skits, and advocacy materials to include talking points and briefs for the traditional leaders, media houses, teachers and other material to form an SBCC toolkit. This was reviewed and endorsed by JHUCCP who have ensured that appropriate ITN communication messages have been integrated into the toolkit. The PAMO SBCC advisor worked to finalize the pretesting of radio spots which will be used for the mass campaign. The following five community radio stations have been selected to air the air radio spots: KFM, Tuta, Bangwela, Luapula and Yangeni. The SBCC advisor met with the media houses to review their contracts and to orient them on the upcoming campaign and the purpose of airing the radio spots. Some talking points were shared with the media houses. In addition, job aids for the Community Based Volunteers (CBVs) who will support the mass campaign have been developed in both English and Bemba. These job aids have been finalized, printed and delivered to Luapula.

Champion Communities Toolkit: Community and mass media activities will roll out under the banner of “Champion Communities’ and the “Malaria Ends with Me” national brand. In Year 1, PAMO facilitated the review of materials from the Champion Communities program. This year PAMO will roll out a new version of Champion Communities. The SBCC Advisor has completed the adaptation of the first draft of the Champion Communities tool kit and synthesis of the report.

World Malaria Day: PAMO will support World Malaria Day preparations. In view of this, the publicity technical committee met to plan for the event. There will be a major event will be held in Mansa, Luapula Province as well as in Lusaka. The meeting identified materials and activities to support the event. The committee agreed that the main World Malaria Day launch will be in Luapula and it will be combined with the launch of the mass distribution of ITNs in the province.

USAID Partner’s Launch: The SBCC Advisor and Program management specialist have been actively participating in the planning launch for the USAID partners. The activity is due to take place on the 16th May at the Polo field in the Showgrounds. It is expected that the Republican President and the United States Ambassador will grace the occasion. PAMO has released an RFA for PAMO branded materials which will be used for the event.

Community Radio Program: In order to contribute to strengthening of SBCC implementation for malaria at health facility and community levels through community mobilization and dialogue, PAMO in Muchinga Province supported a radio program in hosted by Kwenje Community Radio. The radio program participants included three officers one from the province and the rest from the district namely the Clinical Care Officer and the District Surveillance Officer. As result of PAMO’s support for radio program, the DHO was able to disseminate information to the wider community upcoming Mass Distribution for ITNs in Chama district and called for community participation in awareness creation.

 Task 1.5: Strengthen Malaria Policies and Guidelines PAMO’s Technical Director has been instrumental in the development and finalization of key national documents. This includes the National Malaria Elimination Strategic Plan 2017 – 2021, the National Malaria Elimination Operational Plan 2017-2019, the National Malaria Monitoring and Evaluation Plan, the End Term Review and Aide-Memoire. All these strategic documents are essential for the smooth operations of the National Malaria Elimination Program (NMEP). In addition, the NMEP is currently working on the Malaria Global Fund Application and PAMO’s Technical Director and Technical Specialists have provided important technical support to activities that support this important process such as the Malaria Program Financial Gap Analysis, and the Proposal Writing Retreat in various focus areas such as Program Management, Case Management, Social and Behavior Change Communications, Insecticide Treated Nets, Surveillance, Operations Research, Monitoring and Evaluation.

 Task 1.6: Support civil society and community based organizations to implement malaria control activities PAMO Grants team have been taking practical steps to get the CSOs/CBOs that will implement Malaria control activities on board. During this month, PAMO has worked on an RFA which was finalized on 26th March and released on Monday 3rd April 2017. PATH’s Office of Grants and Contracts (OGC) provided short term technical assistance for the completion of the RFA process and schedule of activities complete with timelines and a RACI (Responsible, Accountable, Consulted and Informed) matrix. The matrix will be used throughout the RFA process up to the time the sub grantees will come on board the PAMO project. As previously reported, the PAMO GUC manual is ready to be printed and copies of these will be circulated to the PAMO Provinces. The Operations and Grants Manager met with PAMO Provincial Coordinators from Eastern, Muchinga and Northern Provinces to review the RFA and the process proposed for getting CSOs/CBOs on board. The PAMO Grants under Contract manual is approved. The PAMO provincial teams have identified and mapped prospective CBOs and CSOs which have capacity to support malaria control efforts in the target districts. When they come on-board, these organizations will receive funding for community based SBCC activities after undergoing a risk assessment and receiving approval from PMI.

 Task 1.7: Conduct Operations Research No activities to report on for this task

Objective 2: Strengthen management capacity of provincial and district MOH personnel to provide supervision and mentoring to improve delivery of proven malaria interventions

 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/NMCP, and other malaria actors One of PAMO’s objectives is to strengthen management capacity of provincial and district MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions. In view of this, a Management Capacity Assessment was conducted by PAMO, the data collection was done between October and December 2016. The assessment team comprised of one BRITE staff and two local consultants that utilized a BRITE developed Performance Assessment tool to assess management capacity in Malaria control in Zambia. In January 2017, the team analyzed the data and produced a detailed final report. The purpose of this assessment was to gather information which will be used to strengthen management capacity of provincial and district MOH personnel to provide oversight/supervision of malaria interventions. The assessment addressed the following areas: i. How the assessment tool will build on PAMO’s Performance Assessment framework and link directly to results of the Malaria Health System’s Gap Analysis assessment to ensure that functional management gaps in malaria programs management are strengthened. ii. Based on the capacity assessment, PAMO will plan processes that will target GRZ systems strengthening through a practical and focused approach. The systems that will be targeted for strengthening are management of HMIS systems; planning for continuous distribution of ITNs and improved core management practices such as annual planning and budgeting. The Management Capacity Assessment was conducted in two (Luapula and Eastern Provinces) of the four PAMO provinces. Specifically, a comprehensive assessment of all eleven districts in Luapula, and five out of nine districts in Eastern Province was required. Qualitative data was collected through a questionnaire tool developed and used for key informant interviews with health care staff at province, district and health facility level. Focus group discussions with health care staff and a desk review of relevant documents supported the data collection. Data was tabulated and analyzed, themes were identified from the tabulated data regarding areas with apparent deficits in skills which impact the general management and delivery of effective health services. These themes include: Management and Leadership Skills, Human Resources, Supervision and Mentorship, Data Management, Partner Collaboration, Supply Chain Management, Community Engagement, Implementation of Malaria Interventions and Health Promotion. Key findings from the capacity assessment: - There is need for PAMO to organize management and leadership training for District staff specifically DMO’s, Planners, Environmental Health Officers (Malaria Focal Person), and Information Officers. The training should incorporate management and leadership skills, project management, data management, human resource management, problem analysis and health promotion / behavior change communication - Health Centre in Charge (HCC) staff at health facility level would benefit from an adapted, practical management training which incorporates organization skills, co-ordination, human resource and finance management, project management, data management and health promotion/ behavior change communication skills. - NHC and HCCs require capacity building through an adapted leadership training program to strengthen community involvement in health. This will potentially enable health facilities and their communities to develop their own locally based capacity building plans. Traditional leaders need to be brought on board to help engage and educate the community on malaria interventions. - There is a need to locate a health promotion trainer at district level. The Health Promotion trainer can conduct training for all health facility staff and district supervisory staff in Health promotion and behaviour change communication skills. Health promotion is essential in community sensitization which can be used to improve acceptance of malaria interventions. In addition, across the provinces and districts, limited IEC material was either inappropriate or only available in English. There is a need to develop appropriate material for IEC on malaria interventions in Icibemba and Icinyanga. Material should target the fears of the community that inhibit acceptance of the malaria interventions. - There is a need for PAMO to strengthen data management at district and facility level through employment of a data clerk/trainer at district level. The data clerk/trainer can assist with entry of the backlog of data at district level and mentor health facility staff and community health workers to ensure accurate data management from entry to analysis.

 Task 2.2: Develop and implement a plan to strengthen management capacity as measured by set targets within each targeted province and district PAMO will utilize the findings and recommendations from the capacity assessment in provinces and targeted districts to ensure that these provinces and districts develop improved management processes which will be aligned with capacity building plans, these activities will begin later in the year.

In order to strengthen the delivery and acceptance of community programs, PAMO is promoting effective involvement of key community leaders in malaria task force (MATFs) meetings at various levels. MATFs provide a platform for effective implementation of malaria elimination through a multi sectoral approach. Support towards MATF and coordination meetings is in line with PAMO’s objective 2. Therefore, PAMO supported Eastern Provincial Health Office to convene a MATF meeting. The overall objective of the meeting was to create platforms for consultation with districts on the malaria elimination agenda 2018. And the specific objectives were presented as follows;  To align District Malaria Elimination Plans to National Malaria Elimination Agenda  To revamp MATFs at District level  To discuss preparations for the 2017 ITN Mass Distribution Campaign  To agree on the way forward as regard to Agenda of Malaria Elimination by 2018.

The meeting was held on 9th to 10th March, 2017 in . The following key action points arose from the meeting and will be followed up in subsequent meetings: a. To form provincial MATF committees which should meet twice a year, b. District MATF Chairpersons and secretaries must attend Provincial MATF committee meetings, c. Revamp District MATFs that are not active and plan for activities in line with the national agenda for malaria elimination. d. District to develop annual malaria work plans and align these to MOH malaria agenda and consider partners contributions by the 3rd April 2017. PAMO will continue to support EPHO to convene another MATF Meeting in the next three weeks to look at implemented action items and district work plans.

PAMO supported coordination and malaria planning by sponsoring the formation of District Malaria Task Force in Chama district. The task force formation meeting started off with a brief explanation of the issues at hand and the justification for the formation of the Task Force. Then the terms of reference for the operational structure was discussed and nominations for office bearers where done concurrently. Of the 23 participants at the Malaria Task Force Formation Meeting, 6 were females while 17 males. As result of PMI-PAMO’s support for the formation of the District Malaria Task Force in Chama, the Council Secretary made a public announcement that they would enforce a backyard maize cultivation ban in the 2017-2018 farming season after some sensitization on the dangers have been undertaken. That the local authority would promote cultivation of legumes and other small low crops instead. The council is going to form Ward Development Committees (WDCs) immediately and integrate malaria activities in the WDCs plans after formation of MATF as part of the implementation of the decentralization policy and plan. Some key agreements included:  Monthly meetings with a commitment to more regularly in the event of urgent business.  DHO obligation to provide technical guidance to the Task Force.  The identification and inclusion of the police as an important stakeholder to address law enforcement for nets used for fishing among other things.

PAMO also provided support for the revitalization of the Malaria Task Forces (MATFs) in Mungwi and Kasama Districts of Northern Province. In order to identify health system deficiencies in the district that constrain delivery of high impact malaria interventions at district, health center and community levels the districts with support from PAMO and the provincial health office supported the districts in revamping the malaria taskforces. This activity involved the district level members that were identified and involved in malaria activities so that they could be able to engage different stakeholders in the district to deal with malaria burden at all levels of service delivery. These levels include, district, health center, community and household. In , 32 people attended the MATF meeting of which 24 were males and 8 were females during the 21st February MATF meeting held at NATASHA (Missionary of Sisters for the Blood of Jesus). The attendance to the meeting included the District Commissioner who was elected Chairperson for the Mungwi MATF, representatives from the traditional leadership, business houses representatives, the Neighborhood Health Committees (NHCs) representatives, media personnel and the district government representatives. After the deliberations of the meeting the newly elected MATF members agreed on the following way forward:  Hold monthly MATF meetings to consider the introduced weekly malaria reports from all the district health center catchment areas  Share the MATF terms of references to all the MATF members so that each one of them become conversant with them  Engage all the line ministries that were not present during the meeting so that they become part of the MATF as malaria does not choose who to attack  Identify the resource mobilization activities in order to raise funds that could be used to deal with malaria activities in the district  The MATF secretariat should provide the malaria situation updates to all the members, the health center staff and the communities so that everyone could take part in malaria elimination  Engage traditional leaders in community mobilization on all malaria activities  Sensitizing the community members on the upcoming mass ITN distribution  Formation of Community malaria task forces (C-MATFs) in all the health facilities involving the traditional leaders  Orient the MATF members so that they know their roles and responsibilities in getting involved in malaria elimination at all the levels In 36 people attended the MATF meeting of which 22 were males and 14 were females during the 22nd February MATF meeting held at Sinamu Lodge. The attendance to the meeting included the District Commissioner who was elected unopposed as the Chairperson for Kasama MATF, Neighborhood Health Committees (NHCs) representative from one health center catchment area, media personnel from two local radio stations, health shop owners, local authority representative, Kasama Christian Community Care (KCCC) and district government representatives. After the deliberations of the meeting the newly elected MATF members agreed on the following way forward:  MATF to meet every month in order to review all malaria activities and the performance in reducing malaria incidences in the district  Strengthen IEC/BCC activities on ITN use through radio programs and the local radio station representatives were urged to provide air space for health activities  Engage traditional and community members on ITN mass distribution and use through sensitization activities  Environmental management; Hold meetings with the environmental health staff from the DHMT and the local authority in order to discuss environmental mitigation measures on malaria  Strengthen the referral system of malaria clients from the health shops to the health facilities for further malaria investigations.  Conduct meetings with NHCs in order to find a solution on how the community could increase the demand of the malaria commodities  Orientation of the MATF members in order to have them acquainted with their roles and responsibilities in the district

Objective 3: Strengthen provincial and district HMIS to improve data reporting, analysis, and use for decision making

 Task 3.1: Provide technical/material assistance to District Health Offices (DHOs), Health Facilities, and communities to improve the timeliness and accuracy of HMIS reporting

Monthly Malaria Data Review Meetings Conducting monthly malaria data review meetings at district, facility and community level is critical in improving timeliness and accuracy of reporting malaria data important for decision making. Malaria data review meetings also offer facilities an opportunity and a platform to compare performance and best practices in reporting malaria data. PAMO plans to support data review meetings in all of the PAMO supported provinces.

During this quarter, PAMO supported several data review meetings in Eastern Province. A provincial level malaria data review meeting was held on the 23rd January. The meeting objectives were to update EPHO staff on malaria data for 2016 and discuss possible solutions to gaps reflected during the district data review meetings. The meeting was held at the Provincial Health Office. PAMO staff were invited to attend the meeting and make contributions towards possible support to some of the gaps relating to training and technical supportive supervision for malaria activities. Some of the issues that came up during the meeting include:

 Challenges in supply chain management of RDTs in the high volume districts including Chipata, Petauke and Lundazi.  Low numbers of confirmed malaria case in the high volume districts as a result of stock outs in RDTs.  Data quality and program related challenges relating to more numbers of antimalarial drugs given out compared to the total number of malaria cases. PAMO also supported Petauke to hold data review meetings in March 2017. The two districts are among the largest districts in terms of population and both have high malaria incidence in the province. The objectives of this activity for the two districts was:  To share the 2016 malaria performance by Incidence by facility  To review malaria data for first quarter of 2017 by facility  To review malaria elimination activities being implemented The activity in Petauke district was conducted from 21st to 28th March. A total of 4 zones were visited during the data review meetings by the team from PHO and Petauke DHO. Key findings during the data review meetings in Petauke included:  Facilities are still treating and recording clinical malaria despite the district being stocked with enough RDTs  Recording and treating patients for clinical malaria when test results for RDT come out negative.  Most of the confirmed malaria case in some facilities were from patients coming from the neighboring Mozambique.  Some facilities having low stocks of ITNs for pregnant mothers  Facilities are not having regular data review meetings and hence not using data for decision making

Monthly data review meetings were supported in and districts. A total of 10 health facilities including the District Health Office were supported during the 2 day meeting in Nakonde. In Mafinga, the District Health Office and 10 health facilities were supported to review malaria data. Both the district health office and facilities in Nakonde and Mafinga districts were able to identify data quality challenges, logistical challenges such as RDT stock-out leading to treatment of clinical malaria. Action points such as conducting Routine Data Quality Assessments (RDQA) and revision of work plans were discussed. PAMO also supported monthly data review meetings in Mpika, Shiwan’gandu, Chama, and Chinsali districts. A total of 31 health facilities including the District Health Office were supported during the 2 days meeting in Mpika. At the data review meeting, Mpika District Health Director stated that “A reduction has been noted in the case fatality rate of malaria as some clients are able to visit a facility for prompt diagnosis and treatment of malaria to avoid its complications. It is hoped that the downward trend of malaria case fatality will continue. However, in 2016 only 12/31 health Facilities recorded above 80% malaria confirmation”. In Shiwan’gandu, the DHO and 11 health facilities attended the malaria data review meeting. It was resolved that ANC/FANC activities should be integrated in all outreach programs by health facilities in order to increase IPT coverage and RHCs will need to actively involve NHCs and other community groups in malaria programs. In Chama, the DHO and 30 health facilities were supported to review malaria data. As a result, the DHO came up with the following action points based on gaps identified:  Intensify community sensitization and health promotion to enhance patient adherence to treatment and, correct and consistent use of ITNs  Produce a schedule of health promotion locations  Identify and groom “champions” for malaria to; carry the malaria agenda in communities, promote case studies and reviews, and focus group discussions  Attach NHC members to specific diseases or health areas so as to create ownership and accountability e.g. malaria, child health and pneumonia. In Chinsali district, 12 health facilities and the DHO attended the data review meeting, by bringing health facilities to the central place in the districts, the District Health Director from Chinsali DHO, who chaired the meeting used the opportunity to encourage facilities to own data. He provided new direction in terms of holding data review meetings, where facilities will now be required to present and justify their own data at monthly review meetings. This approach was aimed at enhancing facility data analysis and subsequently information based decisions as well as interventions. Chinsali DHO presented the following focus areas for the district for 2017:  Access to quality-assured diagnosis and treatment.  Integrated Vector Management.  Advocacy and information, education and communication for behavior change.  Strengthen surveillance, Monitoring &Evaluation on malaria.  Program management, coordination and governance.  Prevention and prompt treatment of malaria in pregnancy.  Revamp Malaria task force. As a result of the support rendered to the Monthly District and Facility Data Review Meetings, district health offices and health facilities in Mpika, Shiwan’gandu, Chama, and Chinsali districts were able to identify data quality challenges, logistical challenges such as RDT stock-outs. Action points such as conducting Routine Data Quality Assessments (RDQA) and revision of annual work plans were also discussed in all the meetings. The data review meetings also provided an opportunity to select health facilities for the Quarterly Health Facility Supervisory Visits. A total of 15 facilities were visited as a result of PAMO’s support during the period under review.

In Northern Province, PAMO supported seven malaria data review meetings in 7 districts in March as indicated on the dates below:  Kaputa: 14-15th March, Kasama: 15-17th March, Mungwi: 16-17th March, Nsama: 17-18th March, Mporokoso: 17-18th March, Luwingu: 23-24th March, and Chilubi: 23-24th March

The meetings were hosted in Mporokoso at Kutemwa and Fairview Lodges for Mporokoso and Nsama Districts respectively. In Kaputa district 15 people attended the review meetings (20 Males and 5Females) while for 17 people attended the meeting (11Males and 6 Females) and in 22 people attended the meetings (18 Males and 4 Females). In Kasama, the meeting was held at JB lodge were 45 people attended the meeting (28 Males and 16 Females) while Natasha Hall for the Missionary Sisters of the Precious Blood was the venue for the Mungwi Malaria Data Review Meeting were 27 attended the meeting comprising 18 Males and 9 Females and 29 staff attended with 22 males and 7 females at Namukolo lodge in Luwingu. Three Monthly Malaria Review meetings for Mpulungu, Mbala and Senga were postponed due to the Performance Assessment that the Provincial Health Office will be undertaking from 26th March to 1st April 2017.

For the meeting held for Kaputa, Nsama and Mporokoso all facilities in the districts attended and presented their data. Generally the incidences are showing an increase as a district aggregate. Although Nsama showed a downward trend for the 2015-2016 fourth quarters. Detailed activity reports will be shared after compilation. The conducting of these meetings will assist the districts to look into data and gauge their performances, share good practices from the facilities and know which

facilities are making positive progress towards malaria elimination and which ones are lagging behind. This will help in making performance improvement related decisions and preplanning to channel resources towards areas and facilities requiring assistance. Mporokoso and Nsama districts presented the malaria incidences by zones which made it easier to know the high burden communities. However, there was a noted evidence from the three districts that data from facilities and the DHO were not matching in most cases. The same districts are not yet trained in HMIS. PAMO Northern province team also facilitated district malaria task force meetings in each of the districts in Northern Province.

 Task 3.2: Assist with training for the roll out of District Health Information System (DHIS2) in the targeted provinces and districts

PAMO will provide technical and material assistance to DHOs and facilities to ensure that at least one individual in from each of these is trained in HMIS reporting. During this quarter, four PAMO staff were trained in the use of DHIS2. The MOH has commenced the nationwide rollout of DHIS2, a web- based application available on www.zambiahmis.org/dhis It is the main source of routine health facility statistics in the country and is used by program managers and other stakeholders at all levels of the health care delivery system, for planning and evidence-based decision making. DHIS2 is the main decision making tool for program managers in planning for the provision of health services. Therefore, in order to ensure that data is accessed by all users, there is need for an orientation meeting on the system. The main objective of the training was to orient PAMO Technical Specialists (Program Management, Monitoring and Evaluation, Case Management & MIP, Social and Behavior Change) in DHIS2 and for MOH to grant authority to access data from the DHIS2. The training was conducted through group work discussions on various aspects of the DHIS2 database, starting with the background to DHIS2, Organization units, Data elements, Data sets and data entry forms, User management, Dashboards, among other functionalities of the DHIS2 system. A DHIS2 user manual was also circulated to all training participants.

To further support strengthening of HMIS in Northern Province, a training for was conducted from 21st to 26th February in Luwingu at Namukolo Lodge. 25 health workers (9 Males and 16 Females) were trained. These health workers had not been trained in HMIS before, this implies that the challenges they faced in collecting, analyzing, reporting and using data will now improve the quality of data in the district. Next steps will be to follow up through DHIOs and the SHIO to check the quality of data and reporting improvements in the district. PAMO will support additional training for those are still untrained and provide refresher to those trained a long time ago.

 Task 3.3: Provide technical/material assistance to District Health Offices (DHOs), Health Facilities, and communities to strengthen malaria data analysis and use for decision making PAMO Northern Province supported the Provincial Surveillance and Information Departments to host a Malaria Surveillance Bulletin meeting in Mporokoso from 15th to 17th February, 2017. All districts and General hospitals were in attendance. A total of 42 people (7 Female and 35 Male) were trained. As a result of this meeting a Malaria Surveillance Bulletin template was developed and is will be fine- tuned before it can be used in Malaria data review meetings. By training 42 staff from all ten districts, ten information officers and two information officers from Kasama and Mbala General Hospitals, District and Health Facility will start to calculate Malaria Incidences correctly and improve reporting for the newly formulated malaria surveillance bulletin. In the next Malaria review meeting, health facilities at all levels of operation will report according to the training guidelines.

3. KEY ISSUES ENCOUNTERED This section looks at the key problems or issues encountered, how they were resolved, and mission level recommendations to facilitate their timely resolution.

 No issues encountered yet, PAMO is currently awaiting approval of the Year 2 work plan.

4. SUMMARY OF ACHIEVEMENTS DURING THE CONCLUDING QUARTER TOWARDS PLANNED TARGETS

 PAMO has successful reinvigorated the TWGs by reestablishing routine meetings each quarter in five focus TWGs, all these have met a minimum of three times each this year.  A total of 190,571 ITNs which were left over for the continuous distribution pilot were retrieved from various storage places and delivered to facilities which could store the ITNs for four months. The ITNs were stored with Kawambwa District Council, Nchelenge Catholic Parish, Mansa Diocese and Samfya Community Christian Partnership.  A total of 55 (17F, 38M) provincial supervisors have been trained in mentorship a 100% achievement.  Job aids for the Community Based Volunteers (CBVs) who will support the mass campaign have been developed in both English and Bemba. These job aids have been finalized, printed and delivered to Luapula

4.1 SUCCESS STORIES

 There are no success stories to share this quarter. However PAMO has procured digital cameras for the provincial teams to help them photograph activities and these will be used for success stories in the future.

5. APPENDIX I: THE PERMANENT SECRETARY’S CIRCULAR ON AVAILABILITY AND USE OF FOLIC ACID (400 MICROGRAMS)

6. APPENDIX III: BACKGROUND INFORMATION

Zambia has made impressive gains in controlling malaria in the last decade, contributing to the 56 percent reductions in under-five mortality since 2001, down from 169/1,000 population to 75/1,000, as recently documented in the 2014 Demographic Health Survey (DHS). The Government of the Republic of Zambia (GRZ) prioritizes malaria control through the National Development and Health Strategic Plans, supported by national budget allocations of over $100 million specifically for malaria control commodities in each of years 2013-2017. The National Malaria Strategic Plan (NMSP) 2011–2016 focused on achieving a malaria-free Zambia through a standard package of malaria control approaches and strategies, including indoor residual spraying (IRS), consistent use of insecticide treated bednets (ITNs), improved case management and more proactive attention to malaria in pregnancy. The prospect of a National Elimination Strategy (2016-2020) will further shape a discussion of rationalization and acceleration of proven malaria interventions in the years to come.

Yet gains in malaria burden are uneven across the country. Data from the 2015 Malaria Indicator Survey (MIS) indicate that three of the PAMO target provinces- Luapula, Muchinga, and Northern- have among the highest under-5 year old rapid diagnostic test (RDT) prevalence rates of malaria in the country.

Figure 1: RDT prevalence by province

These data further paint a complex picture of the trends in malaria control efforts, and the relationship between control efforts and malaria prevalence. Across the 4 PAMO provinces, prevalence varied from 20% in Eastern to over 60% in Luapula. Since 2012, two PAMO provinces have seen modest increases in malaria prevalence (Luapula and Muchinga) while Northern and Eastern provinces have seen reductions. Malaria prevalence in Eastern province declined by more than half since the last survey in 2012. In addition, these data indicate that 80% of households have at least one ITN per sleeping space in Eastern, Luapula, and Muchinga provinces, though the sleeping space ratio of at least one net per sleeping space ranged from 84%, 72% and 75% respectively. In Northern Province, however, although 78% of households have at least one ITN, only 40% of households there have at least one net per sleeping space. In addition, the percentage of children under five sleeping under an ITN has shown modest decreases in Luapula and Eastern Provinces since 2012, but these rates are still around 75%. Muchinga saw a modest increase in use to over 60%, while Northern Province saw a substantial decrease—from 65% in 2012 to 49% in 2015—in use in this vulnerable age-group. Importantly, nationally, intermittent preventive treatment in pregnancy (ITPt) coverage is very good, with close to 80% of pregnant women –both rural and urban - receiving two doses and over 60% receiving three doses.

Challenges in coverage and uptake of proven malaria prevention interventions require targeted delivery and promotion approaches. Documented pyrethroid resistance in multiple districts of PAMO-targeted provinces leading to the use of a significantly more expensive insecticide Actellic CS, an organophosphate compound, and the need to maximize the efficiency and quality of IRS operations and improving coverage in targeted communities. For ITNs, while recent mass campaigns have resulted in high coverage overall, going forward, key challenges that will need to be addressed include ensuring increased usage and maintaining high coverage over time. The National Malaria Control Center (NMCC) and partners are increasing emphasis on communication efforts to promote ITN usage and improving timely replenishment of aging and damaged ITNs through continuous distribution approaches such as antenatal care (ANC), Expanded Programme on Immunization (EPI), primary schools, and community structures. These structures can also to be used to promote other critical malaria control interventions—namely IPTp and integrated community case management (iCCM).

Similarly, Zambia’s high levels of IPTp uptake, 73% nationally (DHS, 2014), mask lower rates in rural areas and among poor women. In the PAMO target provinces, overall IPTp uptake levels are high- 69% in Muchinga Province, 70% in Northern, 71% in Luapula, and 72% in Eastern Province, though there is likely to be variability across districts. Stock-outs of sulfadoxine-pyrimethamine (SP) at ANC, late and incomplete ANC attendance and provider’s lack of knowledge and skills as well as confidence to determine early gestational age are some of the key barriers that must be overcome to increase IPTp uptake. Promoting ITN use, especially among pregnant women, remains a priority. Unfortunately, effective case management for pregnant women is poorly documented, if at all.

Other challenges to case management include inadequate rates of diagnosis with a RDT or microscopy and appropriate or timely use of artemisinin-based combination therapy (ACT), in accordance with national policies, resulting in inappropriate diagnosis and treatment. The majority of people live in rural settings in the four PAMO provinces, therefore, lack of access to care is likely an important contributor to delays in seeking care. Strengthening iCCM is a priority across these provinces, and PAMO will need to closely coordinate with the Ministry of Health Global Fund Program Management Unit to ensure that resources are deployed for iCCM in a complementary fashion.

Consolidating gains made in recent years and bridging gaps in implementation requires a concerted, locally driven effort focused on improving coverage of existing approaches and tools, and strengthening linkages between communities and facilities. The effort requires intensive tracking of delivery of malaria control inputs and numbers of malaria cases. The complexity of the malaria landscape has guided PAMO’s objectives and strategic approach.

7. APPENDIX IV: KEY TASKS & TARGETS BY OBJECTIVE

Objective 1: Support proven malaria interventions in alignment with the NMSP 2011–2016 and the follow on plan of the Ministry of Health, likely focused on targeted malaria elimination

Task 1.0 Strengthen National Technical Working Groups Task 1.1. Strengthen ITN distribution in target provinces Task 1.2. Improve access to and quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment Task 1.3. Increase delivery of IPTp-SP as part of an integrated package of ANC services Task 1.4. Strengthen Social and Behavior Change Communication implementation for malaria at health facility and community levels through community mobilization and community dialogues Task 1.5. Strengthen malaria policies and guidelines Task 1.6. Support civil society and community based organizations to implement malaria control activities Task 1.7. Conduct operations research

Targets:  80% of households with an ITN-to-sleeping space ratio of at least one- to- one  75% of children under 5 years old with fever in the last 2 weeks will have a finger or heel stick (malaria test)  85% of children under five will have slept under an ITN the previous night in households that own at least one ITN  85% of pregnant women will have slept under an ITN the previous night in households that own at least one ITN  85% of women who have completed a pregnancy in the last two years will have received two or more doses of IPTp during that pregnancy  Over 90% of children under five years old with fever in the last two weeks treated with an antimalarial will receive ACTs  50% of children under five years old with fever in the last two weeks sought treatment from a facility/provider on same day or next day  60% of zonal community level health organizations/groups in each target health facility catchment area meeting quarterly

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

Targets:  100% of targeted districts will develop management capacity development plans for malaria programming  Over 60% of planned case management supervisory visits conducted at health facilities in all districts in the target provinces

Objective 3: Strengthen provincial and district HMIS to improve data reporting, analysis, and use for decision-making

Task 3.1. Provide technical/material assistance to DMOs, HFs, and communities to improve the timeliness and accuracy of HMIS reporting Task 3.2. Assist with training for the roll out of DHIS 2 in the targeted provinces and districts Task 3.3. Provide technical/material assistance to DMOs, HFs and communities to strengthen malaria data analysis and use for planning and decision making

Targets:  Over 90% of health facilities in all districts in target provinces reporting timely HMIS data  Over 60% of planned district-level planning meetings held to discuss HMIS data

8. APPENDIX V: PAMO GEOGRAPHIC SCOPE

TANZANIA Mbala

Kawambwa Dem Rep of Congo Northern Luapula Kasama

Chinsali

Mansa Chama

Muchinga Mpika

MALAWI Lundazi

ZAMBIA

Chipata Eastern Katete 1 Petauke Chadiza

Luangwa MOZAMBIQUE

ZIMBABWE

NAMIBIA