ZIMBABWE ASSISTANCE PROGRAM IN MALARIA ANNUAL REPORT
REPORTING PERIOD: OCT 1, 2017 – SEPT 30, 2018 SUBMISSION DATE: OCTOBER 30, 2018
Recommended Citation: ZAPIM Year Three Annual Report, October 1, 2017–September 30, 2018. Rockville, MD, U.S., and Harare, Zimbabwe. Zimbabwe Assistance Program in Malaria, Abt Associates. Contract and Task Order Number: AID-613-A-15-00010 Submitted to: United States Agency for International Development/President’s Malaria Initiative Submitted on: October 30, 2018
Abt Associates Inc. 1 6130 Executive Boulevard 1 1 Rockville, Maryland 20852 1 T. 301.347.5000 1 F. 301.913.9061 1 www.abtassociates.com
Contents
LIST OF FIGURES ...... iii
LIST OF TABLES ...... iv
ABBREVIATIONS AND ACRONYMS ...... vi 1. Executive Summary ...... 1 2. Background ...... 1 3. Technical Activities ...... 3 3.1 Clinical Case Management ...... 3 3.1.1 Entering of CM Training Data into Training System Monitoring and Reporting Tool (TrainSMART) Database ...... 4 3.1.2 Malaria Clinical Mentorship Pilot...... 4 3.1.3 Malaria Death Audits ...... 8 3.1.4 Supportive Supervision of Facility-based Health Workers ...... 11 3.2 Community Case Management ...... 12 3.2.1 Post-Training Follow Up of VHWs ...... 13 3.2.2 Supportive Supervision of VHWs ...... 17 3.2.3 VHW CCM District Review Meetings ...... 21 3.2.4 Availability of Commodities ...... 23 3.3 Long Lasting Insecticide Treated Nets...... 24 3.3.1 LLIN Continuous Distribution Channels ...... 24 3.3.2 Continuous Distribution Procurement and Supply ...... 25 3.3.3 Training on Use of Rectangular Nets ...... 28 3.3.4 Assessment of Ownership and Utilization of LLINs...... 30 3.3.5 Focus on Hwedza District ...... 33 3.3.6 Net Durability Study ...... 37 3.3.7 Lessons Learned ...... 39 3.4 Social and Behavioral Change Communication ...... 40 3.4.1 Chikunda Language Malaria Control Audio Book ...... 41 3.4.2 Assessment of Drivers of Continuing Malaria Transmission in Angwa Ward, Mbire District, Mashonaland Central Province, Zimbabwe ...... 43 3.4.3 Commemorations and Events ...... 45 3.4.4 SBCC Technical & Planning Activities ...... 46 3.4.5 Community Action Cycle in high-burden malaria wards ...... 46 3.4.6 Community Advocacy Meetings ...... 54 3.4.7 LLIN Utilization Promotion in Goromonzi and Hwedza Districts ...... 54 3.4.8 Goromonzi Malaria Outbreak SBCC Support ...... 54 3.5 Monitoring & Evaluation/Operations Research ...... 55 3.5.1 Case/Drug Consumption Study ...... 55 3.5.2 National Malaria SM&E Plan ...... 55 3.5.3 Epidemic Preparedness and Response Guidelines ...... 56 3.5.4 M&E Training of Health Workers ...... 56 3.5.5 Data Quality Assessments ...... 57 3.5.6 Surveillance, M&E Subcommittee Meeting ...... 59 3.5.7 Provincial Malaria Review Meetings ...... 59
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4. Gender and Child Safeguarding ...... 60 5. Environmental Compliance ...... 61 5.1 Medical Waste ...... 61 5.2 Liquid and Solid LLIN Waste ...... 61 5.3 Management of Public Health Medicines and Commodities ...... 61 6. ADMINISTRATIVE ACTIVITIES ...... 63 6.1 Staffing and Management ...... 63 6.2 Conferences, Retreats, Trainings and Meetings ...... 63 7. Challenges, Lessons Learned and Recommendations ...... 65 7.1 Challenges ...... 65 7.2 Lessons Learned and Recommendations ...... 67 Annex A: LLINs Delivered by District, October 2017 – September 2018 ...... 69 Annex B: Short-Term Technical Assistance ...... 71 Annex C: PMP Indicator/Year 3 Milestone Matrix ...... 73 Annex D: Addendum on the Economic Situation in Zimbabwe ...... 90
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LIST OF FIGURES
Figure 1: Matabeleland PEDCO discussing their mentorship plan with the Binga team ... 5 Figure 2: Hwange District VHWs receive T-Shirts and Bags donated by ZAPIM ...... 13 Figure 3: Spaces used by VHWs for CCM ...... 15 Figure 4: VHW prepares to perform an RDT during post-training follow up ...... 16 Figure 5: VHW showing off her neatly covered registers during post-training follow up .. 16 Figure 6: A Tip Tap facility in use at a clinic ...... 17 Figure 7: Review of VHW registers and gap identification...... 21 & 22 Figure 8: VHW commodity tracker ...... 24 Figure 9: LLIN continuous distribution channels used in Zimbabwe, October 2017 – September 2018 ...... 25 Figure 10: Continuous distribution routes of LLINs 11 districts, October 2018 - September 2018 ...... 27 Figure 11: VHW demonstrating the ring method of hanging a rectangular LLIN ...... 30 Figure 12: Participants showing different household items that could be used to deploy nets...... 30 Figure 13: Research assistants and a household member counting holes in Hurungwe District ...... 39 Figure 14: Communities engage in focus group discussion ...... 40 Figure 15: Community members learn how to identify mosquito breeding sites ...... 41 Figure 16: Key stages in developing the Chikunda language audio book ...... 42 Figure 17: Sentiments from Chapoto community member on the Chikunda audio book, interviewed during the rapid assessment ...... 43 Figure 18: Angwa assessment data collection teams prepare to embark on data collection ...... 45 Figure 19: Data collector chats to a family to learn their livelihood patterns...... 45 Figure 20: CAC Cycle ...... 47 Figure 21: Training HCCs to identify mosquito larvae ...... 48 Figure 22: Community SBCC session in Suswe, Mudzi District ...... 52 Figure 23: Community SBCC session in Nyamakoho, Mudzi District ...... 52 Figure 24: Community education session at Kubatsirana clinic ...... 55
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LIST OF TABLES
Table 1: Distribution of CM and MIP Trainees per Province (October 2017 - December 2018) ...... 3 Table 2: Distribution of CM and MIP Trainees per Province by Profession (October 2017 - September 2018)...... 4 Table 3: Mentorship Training Participants by District ...... 5 Table 4: Gaps Identified and Recommendations from the Mentorship Visits, October 2017 - September 2018...... 7 Table 5: Recommendations from Malaria Death Audit Meeting Discussions, October 2017 - September 2018...... 9 Table 6: Key Findings and Recommendations from Supportive Supervision, October 2017 - September 2018 ...... 11 Table 7: VHWs Trained per District in Mashonaland East and Matabeleland North, October 2017- September 2018 ...... 12 Table 8: Distribution of VHWs Followed up by Province, Mashonaland East and Matabeleland North ...... 14 Table 9: Issues Noted during Post-training Follow-ups ...... 17 Table 10: Issues and Recommendations from District Health Worker Orientation to VHW Supportive Supervision Tools and Processes ...... 18 Table 11: Expired Medicines Found at Community Level during Supportive Supervision, October 2017 - September 2018 ...... 20 Table 12: VHW District Review Meeting Recommendations Held in July 2018 ...... 22 Table 13: Distribution of Wards and Health Facilities for CD LLINS by District ...... 26 Table 14: Distribution of LLINs in 11 Districts by Channel, October 2017 - September 2018 ...... 26 Table 15: LLIN Distribution Channels by District ...... 27 Table 16: Training of Health Workers in the Use of Rectangular Nets by District, October 2017 - September 2018...... 28 Table 17: Training of VHWs in the Use of Rectangular Nets by Health Facility ...... 29 Table 18: Assessment of Net Ownership and Utilization among Health Workers in Mazowe and Mt Darwin Districts, October 2017 – September 2018 ...... 31 Table 19: Motivation for Use of LLINs and Reasons for Non-use ...... 31 Table 20: Successes, Challenges and Solutions for CD of LLINS in Mazowe District, June 2018 ...... 32 Table 21: Barriers and Solutions to LLIN Promotion in Hwedza District, February 2018 ...... 34 Table 22: Service Barriers and Solutions ...... 35 Table 23: LLIN Mass Distribution in Hwedza District, March 2018 ...... 35 Table 24: Challenges and Solutions of LLIN Mass Distribution Campaign in Hwedza District, March 2018 ...... 36 Table 25: Challenges and Recommendations from the Community Leaders' Meetings, March 2018 ...... 37 Table 26: Distribution of Research Assistants for the 24 Month NDS Assessment, November 2017 ...... 37
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Table 27: HCCs Followed-up by District, October 2017- September 2018 ...... 47 Table 28: Status of HCCs, Challenges and Proposed Solutions ...... 48 Table 29: HCCs Assessed and Audience Reached by District, October 2017- September 2018 ...... 50 Table 30: Distribution of Health Workers Trained in M&E by Province, Cadre and Gender, October 2017 – September 2018 ...... 56 Table 31: DQA Findings and Recommendations ...... 57
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ABBREVIATIONS AND ACRONYMS
ACT Artemisinin-based combination treatment AMC Annual Malaria Conference ANC Antenatal care CD Continuous distribution CHW Community Health Worker CM Case Management CCM Community case Management DHE District Health Executive DHIS2 District Health Information System, Version 2 DMO District Medical Officer DNO District Nursing Office EHO Environment Health Officer EHT Environment Health Technician EPI Expanded Program on Immunization EPR Emergency preparedness and response ESDM Environmental sound design and management HCC Health Center Committee IRS Indoor residual spraying LLIN Long-lasting insecticidal net LSTM Liverpool School of Tropical Medicine M&E Monitoring and evaluation MCHIP Maternal and Child Health Integrated Management MIP Malaria in pregnancy MIS Malaria Indicator Survey MoHCC Ministry of Health and Child Care MPR Malaria program review MSP Malaria Strategic Plan N/A Not applicable NIHR National Institute of Health Research NMCP National Malaria Control Program PEDCO Provincial Epidemiological Disease Control Office PMD Provincial Medical Director PMI President’s Malaria Initiative PSI Population Services International RA Research assistant RBM Roll Back Malaria RDT Rapid diagnostic test or testing vi
RHC Rural health center SADC Southern African Development Community SBCC Social and behavior change communication SMS Short message service STI Sexually transmitted infection STTA Short-term technical assistance TBD To be determined TOT Training of trainer TrainSMART Training System Monitoring and Reporting Tool TWG Technical working group UMP Uzumba Maramba Pfungwe (District) USAID United States Agency for International Development VHW Village Health Workers WASH Water Sanitation and Hygiene WHT Ward Health Team ZAPIM Zimbabwe Assistance Program in Malaria
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1. EXECUTIVE SUMMARY
This report presents the activities implemented by the Zimbabwe Assistance Program in Malaria (ZAPIM) in support of the National Malaria Control Program (NMCP) during the project’s third year. It covers the period October 1, 2017 to September 30, 2018. ZAPIM carried out these activities in eight districts in Mashonaland Central Province, five districts in Mashonaland East Province and two in Matabeleland North Province. Below is a summary of these Year 3 accomplishments that cover the project’s intervention areas – Case management (CM), malaria in pregnancy (MIP), social behavior change communication (SBCC), long lasting insecticidal nets (LLINs), and monitoring and evaluation (M&E) and operational research (OR). In Year 3, ZAPIM provided financial and technical support to the NMCP’s technical sub-committees that provide technical guidance to the Ministry of Health and Child Care (MoHCC) in all the thematic areas. The meetings include the CM sub-committee meeting which reviewed malaria treatment guidelines to allow the use of artemisinin-based combination therapy (ACT) and parenteral artesunate in children weighing less than five kilograms. In addition, ZAPIM’s SBCC lead now chairs the SBCC sub-committee for the current term. The project supported the training of 304 health care workers and 319 Village Health Workers (VHWs) in CM and MIP. ZAPIM sent short message services (SMS) reminders to the trained health care workers (post-training) to reinforce key messages from the training. The majority of trained facility-based health care workers were newly recruited nurses. The trainers entered the details of the trained health care workers into the Training System Monitoring and Reporting Tool (TrainSMART) database in real time. Use of the database allows users to monitor training gaps and ensure there are no repeat trainings of those already trained. ZAPIM also supported the post-training follow up visits and conducted supportive supervision to health care workers and VHWs. The project conducted three supportive supervisions to 36 health facilities in Matabeleland North and Mashonaland East Provinces. The staff carried out supportive supervision to 59 VHWs and 11 VHW peer supervisors in Mashonaland Central. In addition, ZAPIM supported four district VHW review meetings. ZAPIM launched a pilot malaria clinical mentorship program in five malaria high-burden districts – Mbire, Murehwa, Mutoko, Hwange and Binga. The project worked with trainers of mentors from the HIV and TB unit within the MoHCC to train 22 malaria clinical mentors from five districts. The trained mentors started mentorship visits to five health facilities in each district and have made as many as three visits per health facility in some of the districts. With ZAPIM’s support, provinces have continued to hold malaria death audits meetings, which started in 2016. In Year 3, Matabeleland North Province held two meetings and Mashonaland Central Province held one. Mashonaland East Province will hold one in the first quarter of Year 4. The death audit meetings have resulted in better understanding of the causes of death in cases of severe malaria, which has also led to some improvements in care and documentation of severe malaria cases.
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The project supported the distribution of 114,132 LLINs in 144 wards in 11 districts through continuous distribution (CD) channels. ZAPIM provided another 4,000 nets which were distributed in Binga, Beitbridge, and Chipinge districts in response to malaria outbreaks. Hwedza District is considered to be a low malaria transmission district with no vector control activities undertaken. However, since 2015, malaria cases increased in four wards which required vector control intervention. In Year 3, the province, through the NMCP, requested ZAPIM to support the district with LLIN distribution. Acting on this request, ZAPIM distributed 11,000 nets in four outbreak-prone wards of the district. For effective net utilization, the project trained 377 health care workers and 729 VHWs on the use of rectangular LLINs. These cadres are responsible for educating communities on proper LLIN use. ZAPIM also introduced a pull system for ordering nets for CD by health facilities from the districts. The trainings and ordering system have resulted in increased demand for LLINs in the communities. Furthermore, ZAPIM developed standard operating procedures for LLIN aeration to address the challenge of itchiness among net users, which can result in reduced net use. In November 2017, ZAPIM conducted the 24 Month Net Durability Study data collection. ZAPIM and NMCP staff trained data collectors, analyzed data, and developed the report currently undergoing review. At present, ZAPIM is preparing for the 36 Month NDS data collection due to take place in November 2018. As part of reaching out to special populations with malaria messages, ZAPIM developed the Chikunda Malaria Audio Book for the hard-to-reach Doma community of Chapoto Ward in Mbire District. ZAPIM engaged local people to develop the tool with support and guidance from Mbire District MoHCC personnel. The messages include topics like malaria prevention through the use of IRS and LLINs, identification of malaria symptoms, and the importance of seeking treatment early. The audio book was well received, reaching about 1,100 people out of a target of 4,000 within just two months of its launch in the community. ZAPIM presented lessons learned from this intervention and the experience at the Roll Back Malaria SBCC Working Group meeting in Zambia. ZAPIM continued to empower Health Centre Committees (HCCs) through the Community Action Cycle (CAC) approach in Year 3. The project provided refresher trainings on the CAC approach to 35 CAC District facilitators. The project launched the Act Together phase in Year 3, carried out CAC Act Together capacity assessments in 67 HCCs, and has so far trained 11 HCCs on the phase in Mutoko. The project will continue training the Act Together phase in the other HCCs in Year 4. In Year 3 as well, ZAPIM extended the CAC approach to Binga and Hwange Districts of Matabeleland North where its implementation occurs through the Ward Health Teams (WHTs). The use of WHTs was a request from the provincial leadership who felt the WHTs are stronger implementing units than the HCCs in the province. Thus, ZAPIM’s implementation in Binga and Hwange was preceded by meetings with district and WHT representatives to create an awareness of the approach, and subsequent training of 10 CAC trainers in the two districts. ZAPIM also supported four clinics in Mbire District to hold community advocacy meetings with traditional leaders to enlist their support in community engagements in malaria prevention. The NMCP intends to re-brand itself. ZAPIM discussed this with the NMCP and stakeholders from various malaria partners and industries familiar with branding. The project also supported the 2017 World Malaria Day Commemorations by providing technical assistance to the NMCP to publish a malaria advertisement in the local newspapers. The project also provided financial and logistical support for Mashonaland Central for World Malaria Day Commemorations held in Chapoto Ward in Mbire. ZAPIM officially launched the Chikunda Malaria Audio Book at the same function.
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ZAPIM supported the revision of the Malaria Epidemic Preparedness and Response Guidelines and the development of a new Malaria M&E Plan for the National Malaria Strategic Plan 2016-2020. The project trained 101 health care workers in M&E and conducted Data Quality Audits in 47 health facilities across three provinces. The project also supported quarterly provincial malaria review meetings. Several studies were implemented and completed in Year 3. ZAPIM carried out a Case Drug Consumption Survey to explore the factors responsible for the observed discrepancy between malaria cases and ACTs consumed. The project also supported the presentation of preliminary findings of this survey at the Multilateral Initiative on Malaria Conference in Dakar, Senegal in April 2018. This presentation was done by the ZAPIM Logistics Coordinator, Department of Pharmaceutical Services (DPS) staff, and MoHCC staff. At the same conference, ZAPIM presented findings from the 2016 Mazowe Net Endline survey. Finally, ZAPIM carried out an Assessment of Drivers of Continuing Transmission of Malaria in Angwa Ward in Mbire District. The project is awaiting finalization of the laboratory analysis by Africa University in order to complete the report. ZAPIM staff stayed abreast of developments in the international malaria space by participation in capacity- strengthening opportunities. In June 2018, the ZAPIM M&E manager attended training on Evaluation Methods of Malaria Programs in Ghana. In addition, the CM Specialist participated in a Malaria Elimination TOT in Mutare in June 2018 and the LLIN Specialist attended the Pan Africa Mosquito Control Annual Conference in Victoria Falls in September 2018.
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2. BACKGROUND
The President’s Malaria Initiative was created in 2005 to reduce malaria-related mortality by 50 percent in 15 high-burden countries in sub-Saharan Africa. The PMI’s commitment to combating malaria was bolstered with the 2008 passage of the Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act (www.pmi.gov/about). In fiscal year 2011, Zimbabwe was chosen to be a PMI country. The United States Agency for International Development (USAID) previously had provided some limited support for indoor residual spraying (IRS) and commodity procurement (Zimbabwe Malaria Operational Plan 2016). The PMI supports an array of malaria prevention and treatment activities in Zimbabwe, including: LLIN procurement and distribution; IRS in high-burden areas; rapid diagnostic tests (RDT), ACT, and sulphadoxine-pyrimethamine procurement and distribution; and the training of health care workers in the diagnosis and treatment of malaria. On September 25, 2015, Abt Associates and its partners Save the Children, Jhpiego, and the Liverpool School of Tropical Medicine (LSTM) were awarded the ZAPIM project. This five-year project’s purpose is to support the NMCP in providing comprehensive malaria prevention and treatment services to Zimbabweans with the goal of reducing malaria morbidity and mortality. The project has five main intervention areas: 1) CM/MIP, 2) LLINs), 3) SBCC, 4) OR, and 5) M&E. The project operates in 15 districts in three provinces: Mashonaland Central (Bindura, Centenary/Muzarabani, Guruve, Mazowe, Mbire, Mt Darwin, Rushinga and Shamva); Mashonaland East (Goromonzi, Mutoko, Mudzi, Murehwa, and UMP); and Matabeleland North (Binga and Hwange). In Year 3, the project scaled up support for community work in CM and SBCC to include Hwange and Binga Districts. This annual report provides a synopsis of the activities implemented in ZAPIM’s third year, which covered October 1, 2017 through September 30, 2018.
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3. TECHNICAL ACTIVITIES
3.1 CLINICAL CASE MANAGEMENT The following is a summary of case management achievements performed during Year 3 of the project.
In Year 3 of the project, ZAPIM continued to support training health care workers in CM and MIP targeting those who were not trained since the introduction of new malaria treatment guidelines in 2016. ZAPIM trained a total of 304 health workers over the course of the year. The cumulative total of health workers trained with ZAPIM support since Year 1 (2016) is 1409. Table 1 shows the distribution of health care workers trained from 2016 and table 2 shows the distribution of those trained in Year 3. Most of the trainees in Year 3 were newly recruited nurses. ZAPIM supported these trainings which were strategically scheduled before the malaria peak season. In addition to the three-day, workshop-based didactic training and practical skills development, all of the trained workers received SMS reminders to reinforce the subjects learned and to remind them of key CM and MIP issues.
Table 1: Distribution of CM and MIP Trainees per Province (October 2017 - December 2018) by ZAPIM in Zimbabwe
Province Target for Total trained in Year 3 (Oct 2017 - Sept Cumulative total trained Year 3 2018) (Oct 2015 – Sept 2018) Mashonaland 150 155 (103%) 719 Central Mashonaland East 80 79 (99%) 432 Matabeleland 80 70 (88%) 258 North Total 310 304 (98%) 1,409
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Table 2: Distribution of CM and MIP Trainees per Province by Profession (October 2017 - September 2018) by ZAPIM in Zimbabwe
Mashonaland Matabeleland Profession Mashonaland Central East North Total Doctor 2 7 0 9 EHT 6 3 1 10 Nurse 141 63 66 270 Pharmacist/Technician 5 1 0 6 Other 1 5 3 9
Total 155 79 70 304
3.1.1 ENTERING OF CM TRAINING DATA INTO TRAINSMART DATABASE CM trainers, who were trained on TrainSMART in Year 2, started entering ZAPIM-supported trainings into the training database in real time in Year 3. ZAPIM provided TrainSMART registers for these trainings. The use of the TrainSMART database helped to identify and exclude health workers coming for repeat trainings to pave the way for those who had not been trained before. ZAPIM used the training data to determine training gaps during the ZAPIM Year 4 work planning process. However, there are some challenges in the implementation of TrainSMART. Poor internet connectivity at training venues hinders the entering of trainings in real time. ZAPIM overcame these challenges by providing trainers with data bundles. The other gap in the implementation of TrainSMART database was ensuring that CM trainers consistently enter non ZAPIM-supported training data. ZAPIM will continue to emphasize the importance of entering training data into the database and assist NMCP in strengthening guidance to other partners.
3.1.2 MALARIA CLINICAL MENTORSHIP PILOT To complement existing malaria CM trainings and supportive supervision, ZAPIM introduced a malaria clinical mentorship program in its three supported provinces. This mentorship program has been adapted from the existing HIV/TB Clinical Mentorship Program, which has been in existence in the country since 2012. The project engaged the AIDS/TB Program extensively during the development of guidelines and the selection and training of mentors to ensure that the malaria mentorship program builds on lessons learned and best mentorship practices. Piloted in five districts, the main goal of the program is to produce highly competent health care workers capable of providing CM and MIP care that meets the highest standards. In February 2018, ZAPIM supported a mentorship meeting with provincial and district health executives (DHEs) from the pilot mentorship districts to sensitize them on the objectives of the malaria mentorship program and guide the selection of trainee mentors.
Following this meeting, the DHEs selected five trainee mentors per pilot district. The criteria for selection of mentors included expertise in malaria CM and MIP, knowledge of the Zimbabwe health care system and possession of excellent interpersonal skills. After the initial selection process, the DHEs shared the names of prospective mentors with the Provincial Epidemiological Disease Control Officers (PEDCO) and ZAPIM who reviewed and advised the districts to make necessary adjustments to suit the selection criteria.
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In May 2018, ZAPIM supported the training of selected prospective mentors. The participants included doctors, nurses, pharmacists and laboratory personnel. Provincial HIV mentorship trainers, Mashonaland East and Matabeleland North PEDCOs, and ZAPIM case management specialists trained the mentors. The training covered the following aspects: overview of the Zimbabwe health delivery system, management of severe malaria, approaches to clinical mentorship, adult learning methodology, communication skills and continuous quality improvement. The National HIV mentorship coordinator also shared experiences from the HIV program. The training approaches used included PowerPoint presentations, review of health facility records to identify good practices and gaps, health facility visit and role-playing. During the training, mentorship teams came up with mentorship plans, which involved selection and justification of health facilities to visit. Table 3 below shows the breakdown of mentorship training participants.
Table 3: ZAPIM-Supported Mentorship Pilot Training Participants by Province and District in Zimbabwe 2018
Province District Target Number of participants Matabeleland North Hwange 5 5 Binga 5 5 Mashonaland East Mutoko 5 4 Murehwa 5 4 Mashonaland Central Mbire 5 4 Total 25 22
Figure 1: Matabeleland North PEDCO discussing their mentorship plan with the Binga team
3.1.2.1 HEALTH FACILITY VISITS BY DISTRICT MENTORS In June 2018, the district mentors commenced health facility visits to selected sites. These first mentorship visits introduced the malaria mentorship program to health facility staff and served as a platform to explain the mentorship rationale, agree on implementation approaches and communication channels, provide sensitization on mentorship tools, and, in instances where there were conflicts, agree on how to tackle them. Furthermore, this visit served as a baseline assessment of the quality of care for malaria at selected sites. The mentors used the Mentee Self-Assessment, Clinical Performance Assessment of Mentees by Mentor, and Health Facility Assessment mentorship tools. The teams used assessment findings to identify challenges or gaps that mentors and mentees will address during program implementation. The image
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below shows excerpts of some findings and recommendations from the Murehwa mentorship team after their first visit.
Image showing findings and recommendations from the Murehwa mentorship team after first visit
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3.1.2.2 PROGRESS TO DATE All five districts commenced mentorship visits, but progress varies across districts. By the end of Year 3, pilot districts achieved the following number of visits: Murehwa (3), Mutoko (2), Mbire (2), Hwange (2) and Binga (1). Districts suspended activities between mid-July to mid-August because of the national elections. Binga has lagged behind because they did not have a vehicle available to conduct mentorship visits. ZAPIM will engage the PEDCO and District Medical Officer (DMO) to find a lasting solution to this problem.
3.1.2.3 MALARIA CLINICAL MENTORSHIP GAPS AND RECOMMENDATIONS
Delayed dissemination of intermittent preventive treatment in pregnancy (IPTp) guidelines: a barrier to achieving recommended sulfadoxine-pyrimethamine (SP) doses
Since 2014, Zimbabwe has been implementing IPTp with SP as one of the key malaria in pregnancy (MIP)-preventive interventions. However, the 2014 Zimbabwe IPTp policy recommended commencing IPTp after quickening contrary to World Health Organization (WHO) recommendations to start at 13 weeks gestation. In March 2018, NMCP reviewed the policy to align it with that of WHO. However, during health facility visits carried out in September and October 2018, mentors noted that this change in policy had not been communicated to most health facilities resulting in delayed commencement of IPTp. In response to this challenge, ZAPIM assisted in printing the new policy for dissemination during mentorship visits.
On finding out that there were new IPTp guidelines, a nurse from Binga district said, “The guidelines are at times not well disseminated…… Implementers should be informed about these changes as soon as possible.” As a result of mentorship and dissemination of the new IPTp guidelines, most health facilities are now commencing SP administration at 13 weeks. However, at some facilities, health workers who are absent during the mentorship visit still commence at quickening. To address this, mentors recommend that health workers should give feedback to those who are absent during mentorship visits. Mentors will also continue to mentor health workers on the new IPTp policy.
T able 4 shows other gaps which were identified during mentorship visits and the solutions instituted by mentors working with health facility staff.
Table 4: Gaps Identified and Recommendations from the Mentorship Visits in ZAPIM Pilot Districts, October 2017 - September 2018, Zimbabwe
Gaps Recommendation Timeline Responsible person Capacity needed in terms of Mentorship on interpersonal skills, June 2018 onwards Mentors and mentees interpersonal skills, history taking, history taking, physical examination, with periodic review physical examination, diagnosis, and diagnosis, and treatment gaps using on progress made treatment gaps various approaches such as one-on- one and group mentorship Delayed dissemination of the Mentorship on new IPTp guidelines By July 2018 Mentors updated IPTp policy, which specifies
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starting SP at 13 weeks gestation rather than at quickening Print and share new guidelines ZAPIM Case Management Specialist, PEDCO, NMCP
Shortage of malaria commodities Mentorship on calculation of By July 2018 Pharmacist/pharmacy Possible reasons at different levels: minimum and maximum stock levels technician who is part of the Health facility: delayed ordering of mentorship team commodities because of not Mentorship team to notify district Ongoing Mentors, District Pharmacy checking on stock status regularly pharmacy managers overstocked Managers e.g. available stock versus and understocked health facilities to consumption be targeted when redistributing commodities District and provincial level: Not Problem to be discussed and the July 2018 NMCP, DPS, PMI and other redistributing commodities from magnitude documented at higher partners overstocked to understocked level meetings, e.g., CM health facilities subcommittee, PMI meeting,
Provincial Health Team meetings,
etc. Department of Pharmacy National level: Shortage of Services can share Fulfillment commodities at national level Reports quarterly to create awareness of this issue. Stock levels and buffer stock needs to be corrected
3.1.3 MALARIA DEATH AUDITS
The NMCP aims to reduce malaria-related deaths by 90% by 2020 (from 462 in 2015). Since 2016, ZAPIM has supported malaria death audit meetings, a platform where health care providers, and district and provincial leadership meet to discuss malaria deaths. The discussions seek to get to the root causes and circumstances surrounding malaria deaths. The audit process involves presentation of malaria deaths, identification and discussions of gaps/challenges using standards of practice, and formulation of recommendations to address identified gaps. Findings from malaria death audits are used during clinical mentorship, training and supervision to improve the quality of patient care.
In Year 3, ZAPIM supported three malaria death audits, two in Matabeleland North and one in Mashonaland Central. The Mashonaland East PEDCO rescheduled the planned meeting to October/November 2018 due to other competing activities in the province. Traditionally, health care workers have attributed most malaria deaths to late care-seeking behavior. However, the audit process unmasked other key contributory factors which were:
Lack of blood for transfusion in patients with severe anemia secondary to malaria and/or active bleeding due to disseminated intravascular coagulation, a severe complication of malaria infection
Inadequate supportive care for patients with severe malaria and a reduced level of consciousness
Inadequate case assessment and documentation
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Traditional practice of “scratching the throat” as part of treatment for patients with malaria symptoms. This has a tendency to create complications and delay presentation and initiation of appropriate care. There is need for tailored messages to address this practice as harmful.
Delays in presentation by patients who first seek treatment from traditional and faith healers
Lack of rectal artesunate at the community level, which results in the absence of pre-referral treatment for the majority of severe cases
Health workers can still save lives despite late presentation at health facilities
According to findings from malaria death audits, delayed care seeking contributes to most
deaths. However, during discussions, participants were encouraged to look beyond delayed care seeking and identify other rectifiable contributory factors. Commenting on this issue one health care worker had this to say; “We always blame late care- seeking behavior as a cause of malaria death…coming late should not be a death sentence.” This realization has resulted in a holistic approach to death audits, putting more effort on the health systems challenges leading to malaria deaths and their possible solutions.
Table 5 shows gaps and proposed recommendations from the death audit meetings, including the location, proposed date, and responsible person(s) or institution(s).
Table 5: Recommendations from Malaria Death Audit Meeting Discussions, October 2017 - September 2018
Gap Recommended Location Proposed Responsible activities date person/institution Capacity needed in assessment -Improve assessment and All districts Ongoing Doctors and nurses and documentation of malaria documentation of malaria cases cases through development and use of malaria job aids/clerking sheets, mentorship and supportive supervision - Health worker behavior change/attitude talks Delayed care seeking and harmful Involve health center All districts Ongoing Health Promotion traditional practice such as committees and Officers at provincial ‘scratching the throat’ community leaders to and district level address delayed health seeking and harmful behavior
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Avoidable/solvable factors to Districts to review and All districts Ongoing DMOs malaria deaths audit all their malaria deaths and take corrective measures to prevent further similar deaths Unavailability of supportive - Health facilities to All districts Ongoing Facilities supplies such as glucometer strips consider setting aside funds administration and blood for transfusing anemic from results-based patients financing for malaria- specific supportive supplies such as glucometer strips and blood for severely anemic patients - Continue advocating for ZAPIM case procurement of supportive management specialist supplies at national level -Representatives from National Blood Services attend the malaria case management sub- committee meetings and are engaged on the blood supply. Shortages of malaria medicines Provincial and District Province As soon as Provincial Pharmacist and commodities Pharmacists to set up a All districts possible and District dashboard to enable Pharmacists commodity tracking in facilities. The dashboard should also consider the shelf life of commodities and enable movement of stock between facilities as appropriate. Pharmacy to improve use of available data for decision making. ZAPIM will work with Global Health Supply Chain Management (GHSCM) to harmonize the approach on commodities tracking with Logistics Management Information System (LMIS) and Zimbabwe Assisted Push System (ZAPS). Improved liaison and Province As soon as NMCP, Provincial and ordering of commodities All districts possible district pharmacists from Nat. Pharm to improve order fulfillment rates.
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3.1.4 SUPPORTIVE SUPERVISION OF FACILITY-BASED HEALTH WORKERS In 2018, ZAPIM supported Matabeleland North and Mashonaland East Provinces in carrying out malaria CM supportive supervision. Its purpose was to provide a platform for supervisors and health workers to work together to solve problems and improve performance resulting in improved quality of care and health outcomes. Supportive supervision also complements malaria mentorship by identifying gaps that could be addressed through mentorship and assessing progress resulting from mentorship. The supportive supervision teams – ZAPIM, PEDCO, Provincial Environmental Health Officer (PEHO), Provincial Pharmacist, and District Health Information Officer (DHIO) – visited 36 health facilities in Binga, Hwange, Mudzi and UMP Districts. The teams targeted facilities based on malaria burden and history of outbreaks. The objectives of the activity were to assess: Availability of Emergency Preparedness and Response plans at facility level The facility-level health information system in terms of availability of tools, registers, timeliness and accuracy of reporting Malaria case management service delivery practices The availability of malaria commodities in the visited health facilities
Table 6: Key Findings and Recommendations from ZAPIM Supportive Supervision, October 2017 - September 2018 in Binga, Hwange, Mudzi and UMP Districts Zimbabwe
Findings Recommendations Timeline Responsibility No updated emergency Request emergency preparedness Immediately Nurse in Charge preparedness plan at all health plan from the district facilities visited Threshold limit values not updated Update threshold limit values Weekly Nurse in Charge & in some health facilities weekly Environmental Health Technician VHW data not disaggregated by VHW data should be disaggregated Every month Nurse in Charge week by week on submission monthly Malaria treatment guidelines not Malaria treatment guidelines charts Immediately Nurse in Charge readily accessible should be readily accessible Artesunate/Amodiaquine (ASAQ) Order drugs that are out of stock Immediately Nurse in Charge and clindamycin out of stock at most health facilities Expiry of SP at all the health Remove all expired drugs from Immediately Nurse in Charge & facilities visited shelves District Pharmacy Order SP from National Manager Pharmaceutical company Stock-out of some ACT Order drugs that are out of stock. Immediately Nurse in Charge & presentations at some health Meanwhile cut and combine as District Pharmacy facilities appropriate to treat cases. Manager Limited knowledge on management Practice preparation of parenteral Bi-weekly Nurse in Charge of malaria complications, artesunate regularly preparation of artesunate and management of malaria in pregnancy
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3.2 COMMUNITY CASE MANAGEMENT In Year 3 ZAPIM expanded the training of VHWs in community case management (CCM) to Matabeleland North Province. To ensure standardization of CCM, ZAPIM supported the training of 40 trainers in Matabeleland North from all seven districts of the province. The trainers included nurses, EHTs, laboratory scientists and pharmacists to ensure that all disciplines concerned with malaria CM trainings are equipped with the necessary skills to conduct competency-based training for VHWs. The PEDCO, Provincial Nursing Officer (PNO), Senior Nursing Officer from Lupane Hospital, District Nursing Officer (DNO) from Lupane, Provincial Laboratory scientist, and a Provincial Pharmacist facilitated the training.
In total, ZAPIM supported the training of 319 VHWs in malaria CCM in four districts in Matabeleland North and Mashonaland East. The project prioritized the training of VHWs from the high-burden malaria facilities in the respective districts. Table 7 below shows the distribution of the trainings conducted during the year. Table 7: VHWs Trained per District in Mashonaland East and Matabeleland North, Zimbabwe October 2017- September 2018
Province District Target Achievement Mashonaland East UMP 40 39 Mudzi 80 80 Total 120 119 Matabeleland North Hwange 80 80 Binga 120 120 Total 320 319 NB. One VHW from Mudzi did not turn up for training for unknown reasons
Most of the VHWS (99.7%) invited for the trainings were able to attend. ZAPIM administered pre- and post-course assessments to enable facilitators to assess whether trainees gained knowledge. It was encouraging to note that most of the VHWs demonstrated knowledge gain although some especially from Binga had difficulties in achieving the 50% pass mark. This was because some of the VHWs gave only one response to questions that needed multiple answers. During the review of the pre- and post-test in class, most VHWs expressed that they had not understood the instructions nor had sufficient time to respond. This finding on the test format and time allotted for test taking is a lesson learned. In future trainings, the facilitators will be encouraged to clearly explain clearly the requirements of the course assessment and the VHWs will be given adequate time to respond to the questions. In addition, to promote knowledge retention the VHWs will be allowed to keep and continue to use the participant manuals from the training so they can refer to and review the information. The health facilities with also provide support to the VHWs.
The trainers observed all VHWs (319) performing an RDT during the training sessions. It was encouraging to note that almost all of the participants were able to perform an RDT according to the guidelines. The VHWs further practiced these RDT skills under observation at the health clinics during the 5-day immediate post-training period. During this time VHWs received commodities to test and treat malaria in their villages.
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ZAPIM supported each trained VHW with job aids and promotional materials, which included participant manuals, referral note books, managing a sick child job aid, VHW monthly reporting tool, satchel bags, timers and T-shirts. This support was highly appreciated by the VHWs and trainers, as well as the DNOs. The DNOs would want all the VHWs in their districts supported with the same tools to promote documentation of activities done.
Figure 2: Hwange District VHWs receive T-Shirts and Bags donated by ZAPIM
3.2.1 POST-TRAINING FOLLOW UP OF VHWS Post-training follow-up assesses the retention of knowledge and skills taught during training. This is implemented at four to six weeks after training. There are four objectives of the visits to: Assess VHW CCM performance Assess availability of malaria commodities and other supportive medicines at VHW/household level Assess the documentation of cases and commodities by VHWs Orient health workers to the VHW supportive supervision process ZAPIM supported all the four districts that conducted trainings to conduct post-training follow-up visits. Over 80% of the VHWs followed up had done their post training attachments at the health facility. The reasons given by those who had not done the attachment include commitment to harvesting and sickness in the family; hence these VHWs were not able to go to the clinic for the practice as recommended in the training guidelines. Two VHWs from Manjolo in Binga, who did not do their attachment prior to the post-training follow-up visit, were attached to Binga Hospital under the supervision of the Community Health Nurse and the Laboratory Scientist. In Mudzi, 12 out 16 VHWs at Makaha had not done the required attachment by the time of follow-up. Reasons given included that there were political campaigns in their areas and commitment to harvesting crops from the fields. The clinic had one male VHW who
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was contesting in the elections while two other male VHWs were involved in gold panning to fend for their families and so had not committed themselves to do the attachment. Since the Mudzi Community Health Nurse was part of the follow up team, she promised to look into the issue with the DNO. The post training follow-up involved meeting VHWs as a group at the facility and randomly selecting 2-3 VHWs for home visits to assess the feasibility of carrying out CCM at their homes. Table 8 shows the distribution of the trainings and percentages of VHWs reached at follow up visits. Table 8: Distribution of VHWs Followed up by Province, Mashonaland East and Matabeleland North, Zimbabwe February – June 2018
District VHW trained VHWs reached through follow up visits UMP 39 15 (38%) Mudzi 80 41 (51%) Hwange 80 59 (74%) Binga 120 99 (83%) Total 319 214 (67%) During the post-training follow-up, trainers assessed the testing areas to ensure patient comfort and commodity protection from sunlight, dust, insects and rain. The trainers used simulation exercises to assess VHWs grasp of CCM especially focusing on assessment of a sick child, infection prevention and control, as well as assessment of waste disposal. The following is a summary of findings from the post-training follow-up: CCM at the VHW’s homesteads enables members of the community to easily access malaria services. This also makes it easy for the VHWs as they do not have to carry around their registers, medicines and sharps boxes in the village. During the post-training follow up all the VHWs (55) who were contacted at their homes had suitable spaces where they conduct CCM, either under shade during the warm months, on verandas, and some in their sitting rooms. Figure 3 below depicts some of the selected sites.
Figure 3: Example space used by VHW for CCM in Hwange District Zimbabwe
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Trainers used simulations of management of a sick child under five years to assess the ability of VHWs to use the job aid. ZAPIM developed this tool to specifically assist VHWs in correctly assessing sick children less than five years old. Supervisors directly observed 58 VHWs in their assessment of the sick child during the post-training follow up and over 60% of them did not properly assess children for all four general danger signs. The frequently missed danger signs were lethargy or unconsciousness and convulsions. Each VHW thus received immediate VHWs have no lockable medicine boxes; coaching on the assessment of all danger signs in a sick hence they make use of what they already child. have in their households. During the post training follow up, the facilitators noted On simulations of RDT procedures carried out with that commodities were securely stored at most of the VHWs, 98% (57/58) were able to demonstrate community level in different holding how to perform an RDT correctly. This was encouraging places or containers like cupboards in the as it indicated the VHWs had grasped the skill of homes of VHWs. performing the RDT. The majority of the VHWs (90%) washed their hands before performing an RDT; however, they did not wash their hands properly because most of the VHWs did not use the run to waste method that is recommended since they had not put up a hand washing facility as discussed during the training. The importance of hand washing correctly during CCM was emphasized during the visits. During the follow up, most VHWs (80%) had not received commodities to perform CCM as there were shortages of both medicines and RDTs in the districts. For those who had commodities, the facilitators assessed storage of the
The VHW above from Hwange District commodities. Currently the districts report that malaria was commended for her improvised commodities are available and VHWs from high burden medicine cupboard to ensure medicines areas have been given both RDTs and ACTs, however, are safely and securely stored. supplies are said to be inadequate to cater for all VHWs trained in case management. The follow up team had left-over commodities from trainings, which were used for to perform simulations during the follow up visits to the VHWs. ZAPIM discussed the lack of commodities at community level with the DNOs and pharmacy managers who promised to mobilize commodities to this level. Follow up has been made with the CHN who reported an improved supply of commodities with distribution to VHWs being done according to malaria burden in the villages. During the follow-up visits, ZAPIM also noted that health facilities were supporting VHWs with commodities like cotton wool, methylated spirit and sharps boxes to promote proper disposal of the sharps. The VHWs take sharps boxes to the facilities when ¾ full for incineration and receive new ones, if available. If not available the VHWs improvise by using empty medicine containers of five-liter plastic containers however the VHW trainer who was part of the team encouraged the health facility staff to order from their district pharmacy since these were available. Table 9 below summarizes key findings from the follow up visits.
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Sharps box provided to the VHW by the health facility
Figure 4: VHW prepares to perform an RDT during post-training follow-up Trainers assessed VHWs registers. Some VHWs had well-covered registers to protect them from tears and other damage.
Figure 5: VHW showing off her neatly covered registers during post-training follow-up In UMP, the pharmacy manager was part of the team that conducted post-training follow-up to VHWs and he appreciated the exercise as it enabled him to understand the importance of supplying VHWs with malaria commodities. He had this to say:
“I am happy I have participated in this exercise. I never knew the importance of giving the VHWs malaria commodities, but now I have seen the need to save lives.” UMP Pharmacy Manager
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Table 9: Issues Noted during ZAPIM Post-training Follow-ups in Mashonaland East and Matabeleland North Zimbabwe, February – June 2018
Gaps Recommendation Timeline Responsible person
VHWs performing CCM HWs to supervise the VHWs Two weeks to one Nurse in Charge with minimal supervision during the post-training month after every (NIC) during their post attachment training training attachment at the clinic
HWs not reviewing job VHWs to present all the job aids Within one month VHWs aids brought by VHWs given during training to the NIC after the training from training Orientation of HWs to the April 2018 ZAPIM CCM VHW job aids, SS tools and specialist process
HWs not reviewing HWs to familiarize themselves Within one month NIC VHW job aids supplied with VHW job aids supplied after the training during training during training
No tip tap hand washing VHWs to construct tip tap June 2018 VHWs, EHTs facilities at VHW facilities at their homesteads homesteads using locally available resources. EHTs are supporting VHWs under the Water Sanitation and Hygiene (WASH) program to construct these.
Figure 6: A Tip Tap facility in use at a clinic
3.2.2 SUPPORTIVE SUPERVISION OF VHWS Supportive supervision is a regular, ongoing process to improve the quality of malaria CM by VHWs; but this area is not getting the much-needed attention at health facilities due to the overwhelming workload
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and emergencies that nurses – who provide supportive supervision to VHWs – have to manage. Although VHWs require constant support to motivate them in their work, most health workers are not familiar with the tools and processes of VHW supervision. It is against this background of demand on nurses’ time that ZAPIM supported the sensitization and orientation of health workers from Binga and Hwange on the VHW SS tools and processes to equip them to provide this needed support. ZAPIM also supported the districts to conduct supportive supervision of VHWs and VHW peer supervisors, and to hold VHW review meetings.
3.2.2.1 ORIENTATION OF HEALTH WORKERS ON SUPPORTIVE SUPERVISION TOOLS AND PROCESSES IN BINGA AND HWANGE DISTRICTS
ZAPIM conducted a supportive supervision orientation for all health facilities in two districts in Matabeleland North, Binga and Hwange. Participants included nurses (one nurse per facility) and EHTs drawn from hard to reach facilities, DNOs, community health nurses, pharmacy, and laboratory representatives. In total, 48 participants – 24 from each district – attended these meetings. Two participants (one EHT from Binga and one community health nurse from Hwange) did not attend as they had to attend other meetings at the time.
During the meeting, VHW registers were discussed and documentation practice sessions were done to enable the staff to appreciate how the VHWs utilize the tools so that they will be able to provide the necessary support to VHWs at their stations. Clinic staff reported on the support they provide to VHWs who administer malaria CCM, the challenges faced, and how they have tried to address the challenges. A summary of the session report, including recommendations to improve the performance of the program is illustrated in Table 10 below.
Table 10: Issues and Recommendations from District Health Worker Orientation to VHW Supportive Supervision Tools and Processes, Matabeleland North, Binga and Hwange Districts March - April 2018
Issues Recommendation/action taken A number of partners support Binga District, This presents an opportunity for ZAPIM in Year 4 to advocate for namely: Anglican Diocese, Isdell Flowers, Save a district/provincial partners’ coordination meeting at the the Children, Red Cross, World Vision, and community level, where they can share their VHW-specific ZAPIM. The Coordinating Community Nurse activities, discuss areas of coordination, share resources where who supported the training was unsure of each feasible, and standardize VHW tools. partner’s specific VHW interventions. Some VHWs were not reporting weekly data The province has agreed to have the VHWs report monthly but due to long travel distances to health facilities. will disaggregate the data by week. They will also consider other reporting options like providing airtime to one peer mentor to send the statistics from other VHWs via SMS messages. Some VHWs do not have proper registers for ZAPIM handed over 200 RDT/Medicines registers to the two RDTs and were using improvised tools. districts as follows (Binga 120, Hwange 80) to distribute to the VHWs. This is in addition to the registers given to the 200 VHWs trained with ZAPIM support. These registers have adequate pages to last for a couple of years.
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VHWs have inadequate medicines and District pharmacy managers were liaising with the Provincial commodities for CM. The District Pharmacy Pharmacist on the issue. Managers reported that there has been a shortage of RDT kits and ACTs since December 2017 as facilities received less quantities than they ordered. Lack of VHW supportive supervision tools for During the meeting, ZAPIM shared the VHW supportive use during visits supervision tools with all participants. The participants practiced using the tools; and reported that they were easy to use. Health workers at facilities and the community DNO and the ZAPIM CCM specialist encouraged health workers are not following the criteria and guidelines for at facilities to guide the community selection of the VHWs for selecting VHWs. As a result, some selected training to adhere to the MoHCC guidelines. Health facility staff VHWs are not well-qualified and are to provide ongoing support to VHWs who are identified as underperforming. underperforming. VHWs using hard-cover books to order their VHWs to use their RDT/Medicines registers to order malaria commodities from the facilities instead of the commodities to enable facility staff to conduct data verification to malaria medicines and RDT register which is assess what was used and what is remaining in stock their standard tool for resupply of malaria Participants practiced calculating VHW commodity requirements RDTs and medicines. during the meeting so that they could be familiar with the RDT/Medicine register and how it is used to assess the needs of each VHW. ZAPIM urged participants to verify and use the malaria medicines and RDT register to supply VHW commodities. Health workers not tracking commodities ZAPIM distributed VHW commodity register/tracker to all nurses allocated to each VHW at facility level in charge during the orientation meeting for them to use for documenting commodities resupplied to VHWs. The nurses were also taught how to use the tool.
ZAPIM also supported the MoHCC to carry out supportive supervision for VHWs from the third quarter; thus, only one round of visits was done for each of the seven districts visited (Mbire, Centenary, Bindura, Shamva, Mt. Darwin, Mudzi and Mutoko). This limitation is because the CCM specialist prioritized completion of CCM trainings that ended in April. The supportive supervision involved visiting VHWs at their homes where they treat patients. ZAPIM supported supervision for VHWs who were trained in 2017.
In Mashonaland Central, ZAPIM supported Centenary, Mt. Darwin, Shamva and Bindura Districts. This trip was for the CCM specialist to become familiar with the DHEs and provide support to VHWs from one selected facility in each district. Mbire District received supportive supervision in the four health facilities where ZAPIM supported training of VHWs in Year 3.
In Mashonaland East, ZAPIM supported Mutoko and Goromonzi Districts but was unable to support Mudzi within the year due to the stoppage of activities from mid-July to mid-August 2018 because of national elections. The supportive supervision visits reached 59 VHWs and 11 peer supervisors. During the visits, some VHWs were not found at their homes due to other commitments, although they had been informed of the visit.
In future, to ensure all the VHWs are supported, ZAPIM will support motorized EHTs with fuel so that they can conduct the supervision of both the VHWs and VHW peer supervisors. The supportive supervision team also assessed how VHWs used the job aids ZAPIM provided, in particular the sick child registers, RDT/medicines registers, and the commodity trackers. The supervisors used the VHW supportive supervision checklist to guide and standardize supervisions.
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3.2.2.2 VHW SUPPORTIVE SUPERVISION FINDINGS All of the VHWs visited selected suitable settings within their homes where they test and treat patients. Supervisors conducted a retrospective review of the VHW registers; discussed gaps identified, and offered solutions.
During supportive supervision visits facilitators learned that most VHWs were not correctly entering the bracketed totals section (total for the page, total for the month and closing stock) in the RDT/medicines registers. The missing information is critical for calculating the commodity needs of the VHWs. Facilitators discussed this gap with the health workers.
Areas with gaps in the sick child register: -Case number -Date of visit -Name of child -Complaints presented
Information gaps identified were discussed and the VHW appreciated the support. Figure 7: Review of VHW registers and gap identification During supportive supervision visits to the VHW homes, supervisors found three VHWs with expired medicines, which they collected and handed over to the clinic. The supervisors stressed the importance of monitoring the expiry dates of commodities by both the HF staff and the VHWs. Table 11: Expired Medicines Found at Community Level during Supportive Supervision, October 2017 - September 2018, Mashonaland East and Mashonaland Central
Item Description Quantity ACTs 1x6 24 blisters (144 tablets)
2x6 19 blisters (228 tablets)
3x6 6 blisters (108 tablets) 4x6 6 blisters (144tablets)
ZAPIM supervised and supported 11 VHW Peer Supervisors in Centenary District. The supervisors observed the VHW Peer Supervisors supporting one of their peers. The following were some of the findings from the visits:
Three peer supervisors from Muzarabani had conducted supervision to their peers. The team reviewed the checklists used during the peer supervisions and noted that the peer supervisors
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documented their observations well and used language comfortable to them i.e. mixing English and Shona in the comments section.
The team assessed seven peer supervisors on their skills in assessing a sick child and in the performance of an RDT. They demonstrated good retention of the skills required for them to support their peers. ZAPIM commended this performance.
All eleven peer supervisors demonstrated a satisfactory level of confidence during the process of supporting their colleagues.
All the supervisors were able to support their peers in a friendly manner.
The supervisors were able to use the VHW supervision checklist.
Supervisors provided appropriate feedback to their peers using the checklist for supervision.
Peer supervisors were also able to use the checklist to observe their peers and provide feedback correctly on areas done well and those that needed improvement.
3.2.3 VHW CCM DISTRICT REVIEW MEETINGS During Year 3, ZAPIM worked closely with districts and health facilities to support VHW review meetings. Four out of eight districts, Bindura, Shamva, Mutoko and Mudzi conducted one meeting each. Out of a target of 160 participants, 159 attended the meetings. Attendees at the meetings included a representative from the District Health Executive (DHE), one nurse, one VHW and one EHT from the health facilities. A total of 55 VHWs attended the meetings. These were drawn from the high burden facilities. The distribution of the VHWs was as follows: Bindura 14, Shamva 10, Mudzi 15 and Mutoko 16. The platform allowed for VHWs to receive feedback on findings from the post-training follow up activity and supportive supervision and also to reflect on VHW CCM achievements and challenges. Participants also received refresher trainings on the VHW supportive supervision process, use of the checklists, and benefitted from any new information related to malaria CCM. At the meetings, VHWs, nurses in charge, and the DEHOs made presentations highlighting the contribution of VHWs in malaria case management and the challenges they face. Issues/gaps and recommendations are summarized below. Worthy of note is that all the health facilities indicated that the CCM activities have led to decongested clinics and fewer severe malaria cases at the health facilities. A pre- and post-intervention rapid assessment by selected districts with ZAPIM support is recommended to quantify this anecdotal evidence in Year 4. Despite these benefits, some significant challenges were raised which included the inability of the HWs to conduct SS for the VHWs due to lack of transportation and commodity shortages influencing HFs to limit malaria commodities to VHWs. Clinics like Nyamukoho in Mashonaland East and Mupfurudzi in Mashonaland Central reported that they were unable to control malaria outbreaks within two weeks. Although they mobilized RDTs and medicines, they did not give them to the VHWs because quantities were limited. The clinics did not have fuel and access to vehicles to conduct health promotion activities in their catchment areas.
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Table 12: VHW District Review Meeting Recommendations Held in July 2018, Mashonaland Central and Mashonaland East Issue/Gap Recommendation Location Proposed Responsible date person/institution VHWs not VHWs were encouraged Health facility Ongoing VHWs reporting weekly to submit their monthly disease surveillance reports with data data consistently disaggregated by week on time to the health facility, and were informed that ‘zero’ is a number and should be reported. This approach recognizes the difficulties faced by VHWs to get to health facilities on a weekly basis. In the future resources permitting VHWs will be provided cellphones and air time to enable on time weekly reporting. Shortage of RDTs Commodities and Health Facility Ongoing District pharmacist and ACTs medicines supply from NatPharm NatPharm needs NIC improvement to ensure adequate supplies at HF which includes the VHWs needs. When commodities are in short supply clinics to distribute RDTs and ACTs to VHWs according to burden of disease in their areas Expired medicines All VHWs were Community Ongoing VHWs found at discouraged from using NIC community level any expired medicines since it is not safe All the expired medicines were collected by the SS team and surrendered to the NIC Quantification of Clinics were encouraged Health facility Ongoing NIC VHW commodity to report early needs for requirements VHWs to avoid stock outs Some clinics Pharmacy managers to Health facility Ongoing District pharmacy holding more conduct thorough manager RDTs and ACTs assessment of stocks on while others are hand at the health facilities experiencing stock and community to enable outs redistribution to where there is need Male VHWs DNOs to consider training Health facility On going DNOs recommended to of male VHWs to provide support to gold panners
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support CCM of where female VHWs are gold panners1 not welcome More outbreaks VHWs to intensify health Community Ongoing District Health anticipated due to promotion regarding Promotion Officers increased malaria prevention and VHWs commissioning of control especially in dams communities near these dams. Malaria Threshold All clinics to have updated Health facility Ongoing NIC Limit Value charts Threshold Limit Value EHT not updated charts at all times
In Year 4, supportive supervision visits to the districts will follow up on the above recommendations.
3.2.4 AVAILABILITY OF COMMODITIES During the supportive supervision visits, the team assessed availability of RDTs and malaria medicines. Generally, all the districts had limited stocks of both RDTs and ACTs with facilities holding stocks below their minimum stocks level. This resulted in VHWs not getting constant supplies of commodities and thus referring all patients to the clinic for most of the year. In addition, there were no other medicines (paracetamol, ORS and zinc) at the community level. During the supportive supervision visits conducted at the end of the third quarter (June 2018), the clinics were receiving malaria commodities including rectal artesunate; but the supplies were still below recommended minimum stock quantities. The health facility staff indicated that they would distribute the commodities to VHWs as soon as the malaria season starts in November.
VHW commodity tracker is a tool that records RDT, medicines, gloves and cotton wool given to VHWs. Facilities were not properly documenting commodities given to each VHWs; hence ZAPIM designed this tool to address the gaps in proper tracking of commodities supplied to VHWs from the facility. During the supervisory visits, VHWs and health facilities were using the tool to track movement of commodities between a health facility and the community.
ZAPIM commended the health facilities for tracking the commodities, as this will strengthen VHW accountability. During the supportive supervision visits, the team learned that the tool was also very helpful in tracking quantities and the state of the commodities given to each VHW. The tool is also useful during support visits to health workers by National Pharmaceuticals.
1 Panners are informal artisanal miners.
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The tool may need improvement to track the commodities that VHWs return to the facility and the state of returned products. Some VHWs return the commodities after they have expired while others bring them before expiration; however, the tool is unable to capture this.
Figure 8: VHW commodity tracker
3.3 LONG LASTING INSECTICIDE TREATED NETS
In 2016, the MoHCC adopted a targeted vector control policy separating IRS and LLINs starting from the ward level. Hence, while districts can use the two interventions, they should not deploy them in the same ward. The rationale is to optimize the use of limited resources available while increasing protection for the population at risk. Currently, LLINs are distributed in 35 of the 47 districts with low and moderate malaria transmission. Furthermore, starting in 2011, the country adopted the LLIN universal coverage approach. This approach targets one net for every sleeping place or a net for every two people unlike the previous approach, which targeted only the vulnerable groups like pregnant women and children under five. Between 2010 and 2016, the country has undertaken four major campaigns to maintain universal LLIN coverage. In addition, the country has established CD of LLINs to sustain the net coverage. In Year 3, ZAPIM’s main focus was to support the NMCP to continue the roll out CD of nets in 11 out of the 35 districts.
3.3.1 LLIN CONTINUOUS DISTRIBUTION CHANNELS In October 2017, with support from USAID/PMI, the NMCP launched a nationwide LLIN CD campaign for the first time. This followed the success of the two-year CD pilot project in Makonde, Hurungwe, Mt Darwin and Mazowe Districts. Three of the four distribution channels (Figure 9), ante-natal care (ANC), Expanded Program on Immunization (EPI) and the community, were used. The school-based channel was put on hold as the country assessed the implementation of the other three channels in terms of demand and supply. This was to avoid an oversupply of LLINs in the community. NMCP intends to distribute LLINs through the school channel only in areas where the other three channels are inadequate to meet the demand.
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Figure 9: LLIN continuous distribution channels used in Zimbabwe, October 2017 – September 2018
3.3.2 CONTINUOUS DISTRIBUTION PROCUREMENT AND SUPPLY PMI supported the NMCP with the procurement and provision of LLINs for the nationwide CD campaign. PMI procured a total of 889,950 rectangular LLINs for the country and 807,700 (90.8%) were delivered to 39 districts (35 Districts for CD and 4 Districts for Outbreak Response) (Table 13). The nets were for both CD and Mass Distribution in areas were IRS was scaled back and as response intervention to malaria outbreaks. The areas where IRS has been scaled back are supported by Plan International, which is a malaria sub-recipient of the Global Fund. For the list of LLINs delivered by district during October 2017 – September 2018, please see Annex A. Global Fund through Plan International supported the distribution of nets supplied to non-ZAPIM- supported districts. PMI provided 807,700 LLINs to ZAPIM and Plan International. To start the roll out, ZAPIM and Plan International supplied an initial 234,300 LLINs to the 33 CD targeted districts for the first six months under the push system. Thereafter, ZAPIM developed a pull system for health facilities to request LLINs through an ordering system. ZAPIM delivered the LLINs to the districts between October and November 2017. According to the implementation plan, districts received a six-month supply of their annual requirement and subsequently delivered a three- month supply to the health facilities. The districts retained the remaining three months’ supply to resupply health facilities under the pull system when health facilities request for additional LLINs as needed. Five ZAPIM-supported districts commenced CD of LLINs in November 2017 with the remaining six starting in January 2018. This brought the number of districts conducting continuous distribution in Mashonaland Central and Mashonaland East to 11. In Year 3, ZAPIM distributed LLINs in 144 wards in the 11 districts. The districts are Bindura, Centenary, Guruve, Mazowe, Mt Darwin, Mbire, Rushinga, Shamva, Murewa, Goromonzi and Hwedza. The districts distributed the nets through 98 health facilities. Shamva, Bindura, Mt Darwin and Centenary Districts distributed nets through EPI/Community LLINs outreach points located in villages. An outreach point is a place located in a village used as a site which offers health services, such as schools and village/ward centers. It is usually located more than 10 km from the nearest health facility and is visited once a month by a team of health workers to offer health care services to the population of that locality. The outreach points brought the nets closer to the people as some communities reside far away from the health facilities. Table 13 below shows the number of wards and health facilities which participated in the CD of LLINs by district.
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Table 13: ZAPIM Distribution of Wards and Health Facilities of CD LLINS by District, October 2017 - September 2018 3
Province District Number of Wards in a Number of Wards Health Facilities in LLINs District that Received Wards LLINs Mashonaland Central Bindura 18 10 8 Centenary 29 15 6 Guruve 19 14 12 Mazowe 34 28 21 Mt Darwin 40 16 9 Rushinga 19 1 1 Mbire 19 4 4 Shamva 23 14 6 Mashonaland East Goromonzi 25 21 13 Murewa 34 17 13 Hwedza 19 4 5 Total 279 144 98
In Year 3, 114,132(Table 14, Figure 10) rectangular nets were distributed to the communities through the three CD channels. Quarter 2 had the highest number of nets distributed at 53,141 (49.5%) since October 2017. Of the 114,132 nets distributed, 84,391 (74%) were distributed through the community channel, followed by ANC with16, 895 (15%) and EPI with 12,846 (11%). There was a high uptake of nets for outdoor use in Mbire, Centenary, Mazowe, Guruve and Mt Darwin. The main challenges were the lack of adequate storage capacity at the health facility level and lack of transport for supportive supervision and for supplying health facilities with nets.
Table 14: ZAPIM-supported Distribution of LLINs in 11 Districts by Channel, October 2017 - September 2018
Channel of Number Distributed Total Distributed Distribution Oct-Dec Jan-Mar 2018 Apr-Jun 2018 July-Sept 2018 Total LLINs % Distributed 2017 Distributed ANC 2,753 6,934 3,476 3,626 16,895 15%
EPI 1,852 5,434 3,096 2,420 12,846 11%
Community 5,621 40,773 22,966 14,912 84,391 74%
Total 10,226 53,141 29,538 20,958 114,132 100%
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120,000
100,000
80,000
60,000
40,000
TotalLLINs distributed 20,000
0 Oct-Dec 2017 Jan-Mar 2018 Apr-Jun 2018 July-Sept 2018 Total LLINs Distributed
ANC EPI Community
Figure 10: ZAPIM continuous distribution routes of LLINs 11 districts, October 2018 - September 2018
Table 15 shows the LLIN distribution by districts. The top three districts were Mazowe District with 24,423 (21%), Mt Darwin with 17,562 (15%) and Centenary District with 14,918 (13%) nets distributed. Table 15: LLIN Distribution Channels by District, October 2017 - September 2018
District/Channel EPI ANC Community Total Bindura 294 465 4,187 4,946 Centenary 1,346 1,040 12,532 14,918 Guruve 1,132 1,182 7,075 9,389 Mazowe 3,833 4,993 15,597 24,423 Mbire 163 145 2,372 2,680 Mt Darwin 1,896 2,578 13,088 17,562 Rushinga 6 46 254 306 Shamva 480 663 3,843 4,986 Goromonzi 866 1,193 7,468 9,527 Murewa 184 669 6,720 7,573 **Hwedza 11 20 9,712 9,743 *Hurungwe 1,440 2,303 232 3,975 *Makonde 1,195 1,598 1,311 4,104 Total 12,846 16,895 84,391 114,132 *The distribution of nets in these districts in Mashonaland West Province was handed over to Plan International in April 2018. **The Hwedza District is not supported by ZAPIM for other activities except for nets.
In Year 3, ZAPIM delivered an additional 4,000 LLINs in response to reported malaria outbreaks in Binga (2,200), Beitbridge (1,500) and Chipinge (300) districts.
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3.3.3 TRAINING ON USE OF RECTANGULAR NETS In Year 3, ZAPIM embarked on an extensive training program of health workers and sensitization of community leaders and the community itself on the use of rectangular nets. Previously NMCP distributed rectangular LLINs to some communities without any form of training or education. This resulted in relatively lower utilization as people did not know how to hang them, preferring the easier to hang conical LLINs. Training of personnel involved in LLINs distribution to promote rectangular LLIN use is central to the successful implementation of the program. The main focus of CD training was to equip health workers and VHWs with knowledge and skills for CD and on multiple strategies for hanging rectangular nets. The training adopted a cluster approach and total/full coverage approach. All health workers and VHWs involved in LLIN distribution received training on CD of LLINs. ZAPIM conducted the training under the “My Net My Life” campaign slogan. ZAPIM taught participants various methods to hang a rectangular net. These included the manufacturer’s method, ring methods, use of droppers, center roof tie, winnowing basket, goal posts and cross methods. In all, trainers taught participants 12 ways of hanging rectangular LLINs for use inside houses and outside/field structures. The trainings were hands-on as they used demonstrations as part of the training methodology. ZAPIM provided further modifications and innovations to the methods of hanging the rectangular LLINs including transformations into the much-preferred conical shape. All the methods use familiar, locally available materials. During training under the “My Net My Life” campaign, ZAPIM shared key messages on promoting high net usage. The training also emphasized key messages summarized using the SEFUS acronym: Nets are safe (S) Nets are effective (E) in preventing malaria Nets are free (F) Nets should be used (U) every night, all the time Nets are strong (S) and flexible Nets should cover all sleeping spaces – indoors and outdoors ZAPIM trained participants on how to conduct household/community net follow-up visits and use of the assessment tool/form to record findings. Table 16 shows the number of health workers trained per district by gender. Table 16: ZAPIM Training of Health Workers in the Use of Rectangular Nets by District, October 2017 - September 2018
District Male Female Total Mbire 4 2 6 Centenary 9 11 20 Guruve 15 13 28 Bindura 15 10 25 Shamva 15 11 26 Rushinga 4 1 5 Mazowe 27 34 61 Mt Darwin 1st Group 27 21 48
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Goromonzi 16 21 37 Murewa 15 28 43 Hwedza 14 19 33 Mt Darwin 2nd Group 23 22 45 Total 184 193 377
A total of 377 (118%, target of 320) health workers from 99 HFs were trained on CD of LLINs in the 11 ZAPIM-target districts. Gender equity considerations were applied as there were 184 (49%) males and 193 (51%) females. ZAPIM adopted a cluster approach for the training of VHWs. The cluster involved bringing together VHWs from three to five HFs depending on the numbers and distances to travel. The maximum per cluster was 45 VHWs. Table 17 show the number of VHWs trained by district and by gender from the 144 wards in the 11 CD targeted districts. Table 17: ZAPIM Training of VHWs in the Use of Rectangular Nets by District, October 2017 - September 2018
District Male Female Total Centenary 15 100 115 Goromonzi 9 49 58 Hwedza 11 40 51 Mazowe 27 249 276 Mbire 27 28 55 Mt Darwin 37 101 138 Rushinga 1 6 7 Shamva 1 28 29 Total 128 601 729
ZAPIM trained 729 VHWs out of a target of 770 (95%) in CD of LLINs. This target was based on the total number of VHWs in wards earmarked for LLIN distribution. The approach was to train all VHWs in the targeted wards. By gender, 128 (17.6%) males and 601(82.4%) females were trained. Of the targeted VHWs, 41 could not attend due to inability to travel away from their homes, miscommunication, or other commitments at the time of training.
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Figure 11: VHW demonstrating the ring method of hanging a rectangular LLIN
Figure 12: CD participants showing different household items that could be used to deploy nets, Mvurwi, July 13, 2018
3.3.4 ASSESSMENT OF OWNERSHIP AND UTILIZATION OF LLINS During the trainings in Mazowe and Mt Darwin Districts, which were the CD pilot Districts, ZAPIM conducted some assessments eliciting responses from the participants on ownership and utilization of LLINs. ZAPIM collected further information on LLIN successes, challenges and solutions. This information proved to be very useful in LLINs programing. Table 18 below shows the results of the assessments. This assessment was carried out in June 2018 (winter season). From the results in Mazowe District, LLIN ownership was high at 95%, however slightly over half (46%) of respondents used an LLIN the night before the survey. Mt Darwin had 92% LLIN ownership of LLINs and a utilization rate of 77%.
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Table 18: Assessment of Net Ownership and Utilization among Health Workers in Mazowe and Mt Darwin Districts, Zimbabwe, June 4-15, 2018
District Site Net ownership Net Utilization Mazowe Yes No Total Slept under Did not sleep Total net previous under net night previous night Tsungubvi Clinic 17 1 18 5 12 17 Concession 29 5 34 15 14 29 Hospital Henderson 40 0 40 24 16 40 Research HQ Holme Eden 25 1 26 16 9 25 Farm Health Donje Clinic 29 1 30 16 13 29 Total 140 8 148 76 64 140 (94.6%) (5.4%) (100%) (54.3%) (45.7%) (100%) Mt Darwin Mutwa 30 2 32 20 10 30 Tsakare 22 1 23 12 10 22 Matope 41 2 43 38 3 41 Mt. Darwin- 11 0 11 9 2 11 Kandeya Mt. Darwin 28 6 34 23 5 28 Total 132 11 143 102 30 132 (92.3%) (7.7%) (100%) (77.3%) (22.7%) (100%)
The participants indicated through secret ballot their net ownership and use. In Mazowe District, 94.6% of participants had at least one net, and in Mt. Darwin District the figure was 92.3%. Those without nets were mostly new to the area. In Mazowe District, 76 (54.3%) of those with nets said they slept under an LLIN the night before the meeting, while 102 (77.3%) reported the same in Mt. Darwin District. Mazowe District is a low transmission area, and people sometimes ignore the need to sleep under a net at all times throughout the year. Hence, there are relatively low net utilization rates. The utilization rate is well below the national target of 85%. The outcome of this assessment mirrors data obtained from similar assessments at the community level. ZAPIM and MoHCC intensified health education efforts on the importance of using a net every night, year-round for every sleeping space. ZAPIM asked respondents why they slept or did not sleep under a net the night before. Table 19 below shows the reasons for use and non-use of a net. Table 19: Motivation for Use of LLINs and Reasons for Non-use, Mt. Darwin District, June 4-8, 2018
Motivation for use of LLINs Reasons given for non-use of LLINs
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Slept under net to prevent mosquito biting to No mosquitoes in my house avoid getting malaria Never been bitten by mosquitoes Mosquito nets also prevent other insects from Feel restricted when under the net disturbing my sleep Feel too hot when under the net My child was infected with malaria, so I have made Just complacency it a habit of using the net all the time No mosquitoes because of low temperatures Reside close to the Mazowe River, where there Did not sleep at home are lots of mosquitoes Have difficulty breathing if I sleep under mosquito Mosquitoes are still present and biting people net The area has disused sewage ponds and uncovered Religious objectors sewerage/drains, which act as breeding sites for Old nets no longer usable mosquitoes (culicines) Did not know how to hang the rectangular net The net is treated and kills mosquitoes Not malaria season Feel responsible enough to protect myself and my Just do not want to sleep under the net family from getting malaria Itchiness
ZAPIM and the participants discussed the reasons for non-use. ZAPIM advised non-users to learn from the net users and urged non-users to use the net year-round to avoid getting malaria. ZAPIM trained the participants on how to address these issues when they subsequently engage communities during LLIN visits and at other meetings. The training also included discussions on the successes and challenges and solutions to the challenges in LLIN promotion at all levels – district and community. Table 20: ZAPIM-Collected Successes, Challenges and Solutions for CD of LLINS in Mazowe District, June 2018
Category/Level Successes Challenges Solutions Community Reduced malaria cases Long distances to health EHTs to conduct LLIN outreach Short queues at health facilities programs facilities People are now Rash among children Proper aeration of nets knowledgeable about Itchiness of nets Health education on net aeration malaria Free nets (we used to buy nets) Lack of concern about Continue educating the people on No more mosquito getting malaria the importance of using the net all bites year round Happy and very grateful Lack of knowledge of how Continue education and training on about getting nets to hang the net how to hang nets. Cultural practices Engage the traditional leaders and demystify the cultural beliefs.
Inadequate space to hang This cannot be solved unless the all the nets homeowner expands the size of their house.
Collection of more nets VHWs to use the assessment tool than is needed as trained.
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VHWs/CHWs Malaria has declined Few or a shortage of Give enough coupons to health Pregnant women coupons facilities and VHWs booking early Some people not using nets Continuous education People are using nets Misuse of nets Community policing Program has been highly accepted Itchiness Health education on net aeration Long distances to health VHWs should be provided with facilities bicycles and spares Facility-based Health Malaria trend on the Misuse of nets Community policing Workers decline Non-use of nets Continuous education Antenatal care (ANC) and Expanded Program Some community People should get nets regardless of on Immunization (EPI) beneficiaries have no whether they have identification coverages have identification cards cards or not improved VHWs have no means of Provide bicycles and spares People are getting nets transport People are now Some VHWs and HWs are Orient all health workers on net knowledgeable about not yet trained on CD for distribution processes the benefits of using a LLINs Train all VHWs on LLIN net distribution
ZAPIM spent time addressing the challenges and ways to implement suggested solutions. At the end, there was general agreement that all parties involved in LLIN distribution should play their part for the smooth implementation of the CD activity. The parties also agreed that regular interaction with the communities and continuous engagement is critical to increasing net utilization. In order to address the issue of itchiness, ZAPIM developed Standard Operating Procedures (SOP) on net aeration. The SOP is in English, and ZAPIM will translate it into Shona and Ndebele in Year 4. The SOP will be one of the materials ZAPIM, health workers, and VHWs will use at LLINs community engagement meetings.
3.3.5 FOCUS ON HWEDZA DISTRICT Malaria has been on the increase for the last three years in Hwedza District. The malaria problem in Hwedza is not widespread but is confined to areas bordering with Buhera and Makoni Districts of Manicaland. There are four wards: 11, 12, 13, and14 which are primarily affected. These four wards are serviced by five health facilities; Goneso, Mukamba, Mukarara, Chikurumadzviva, and Zvidhuri. The district has 14 health facilities in total. These areas started experiencing malaria problems in 2015, and in 2017, they had an outbreak with one institutional death. One of the affected health facilities, Makarara, treated 65 cases between January and June 2017 when compared to 15 cases over the same period in 2016.The Provincial Medical director of Mashonaland East Province through the NMCP requested ZAPIM to support the district with LLIN distribution. The ZAPIM Team, accompanied by the DEHO, conducted a geographical reconnaissance of the targeted areas during the month of January 2018. The purpose of the visit was to gain an appreciation of the targeted areas, the configuration of the communities, and the type of structures and road network. The ZAPIM team also sought to review records at the HFs in order to gather more information on the malaria situation and to discuss suggested points for mass distribution with the HWs and tailored training activities for the VHWs.
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Given the low levels of transmission, it is possible for Hwedza District to eliminate malaria. In addition to deploying universal vector control via LLINs in the four wards primarily affected, it is necessary to establish a strong surveillance system coupled with rapid response to identify and address any malaria foci.
3.3.5.1 TRAINING OF HEALTH WORKERS ON MASS DISTRIBUTION OF LLINS Nurses, EHTs from the targeted HFs, staff from the District Office based at Hwedza Hospital, and members of the DHE attended the training. The trainings covered the following: the NMCP’s goal, vision, and objectives regarding malaria; the role of LLINs in malaria prevention and control; the way nets work; and how to address the problems of itchiness. Health workers saw demonstrations on the various ways of hanging rectangular nets. Health workers went over the setup of a distribution point to ensure uniformity and well-structured and well-functioning distribution points. Participants worked in pairs and groups to gain from each other’s experiences, all to ensure that they had a better understanding of the work ahead. ZAPIM shared key communication messages and the participants identified potential barriers to effective implementation and use of LLINs, including discussing potential solutions. The participants categorized potential barriers into consumer and service, with the former referring to beneficiaries and the latter referring to the health workers and institutions. Table 21 below depicts the identified barriers and solutions to LLIN use. Table 21: Barriers and Solutions to LLIN Promotion in Hwedza District, February 2018
Barrier Solution Misuse of LLINs Local and traditional leaders addressed this potential problem during the LLINs sensitization meetings. They pushed messages about desired use of LLINs and discouraged misuse. Use LLINs to protect each sleeping space. Misuse of nets can be unsafe and will not be tolerated by local leaders. Repurpose old nets no longer suitable for sleeping spaces (with too many holes) as screens for windows or doors. Politicization of the LLINs HWs were in charge of the distribution and ensured fairness in issuing the nets based on need and not political or social affiliations. The distribution targeted every sleeping space indoors and outdoors. Challenges in hanging the nets HWs and VHWs demonstrated how to hang the LLINs at all gatherings and made random follow-up visits 2 weeks after distribution. VHWs conducted home visits to ensure that beneficiaries were hanging and using their nets and to offer practical assistance to those who had challenges. Itching of the nets (important fears) Trainers explained the three-stage way of reducing itchiness. HWs and VHWs explained these techniques to beneficiaries at meetings and during net follow-up visits. Collecting excess nets HWs used registers to distribute nets. EHTs collected excess LLINs. The district used the excess nets to roll out CD. Low uptake due to long distances Static and mobile distribution centers were set up, as needed to get LLINs close to beneficiaries. This was managed by the EHTs.
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Table 22: Service Barriers and Solutions in Hwedza District, February 2018
Barrier Solution Bad attitudes/Low motivation HWs carried on with their work as per the training. Tokens of appreciation to be given of HWs to those who participated and implemented the distribution with high quality. Supportive supervision is also essential in motivating HWs Favoritism LLINs were distributed fairly without any favoritism. Storage HWs identified storage facilities at their institutions suitable for LLINs observing safety rules. For example, storing LLINs away from medicines and far from patients.) Lack of knowledge among Trainers gave HWs information on LLINs, their use, importance, universal coverage, its Health Workers challenges and solutions. Difficulty in educating all HW HWs were advised to give adequate information to their colleagues who remained at the and VHWs HFs and to nominate one of them to attend the VHWs training sessions. Inadequate resources The district, province and ZAPIM ensured that all the necessary resources were available for the smooth implementation of this activity. ZAPIM determined that every meeting yielded an action plan, and the relevant meeting/workshop conveners conducted follow-up visits.
3.3.5.2 HWEDZA DISTRICT MINI MASS DISTRIBUTION The Hwedza District established five static and four mobile centers. The district distributed the nets over a five-day period using 86 HWs that included nurses, EHTs, nurse aids, and security guards. The district received 11,000 LLINs and 9,458 LLINs were distributed. The balance of 1,658 nets were used to start the roll out of the CD program in the 4 wards. Table 23 shows the LLIN distribution by ward. Table 23: LLIN Mass Distribution in Hwedza District, Zimbabwe, March 2018
% Target H/Hs Target Population LLINs Ward Population Distributed H/Hs Covered Pop Protected Protected 11 1114 1114 4494 4494 2711 100 12 1300 1297 5437 5425 3019 100 13 600 610 2473 2588 1924 105 14 537 537 2532 2532 1804 100 Total 3,551 3,558 14,936 15,039 9,458 101 More people were protected than the targeted population, as some who were not available during household registration later turned up during the distribution. The exercise was successful, and the CD program was rolled out immediately after the mass distribution. The key achievements or successes of this LLIN mass distribution were that members of the apostolic churches who normally shun health facility services came in large numbers to collect the nets and nets were distributed in a non-partisan manner. ZAPIM and NMCP trained health workers and VHWs on the CD program after the review of the mass distribution campaign. The CD program covered people who were missed or were not available during the mass campaign, and households who had new sleeping places after the mass campaign. The timing coincided with the malaria transmission period and the objective was to ensure that people have easy and immediate access to free nets during the peak transmission period. Table 24 lists the challenges and solutions for the Hwedza mass distribution campaign for LLINs.
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Table 24: Challenges and Solutions of LLIN Mass Distribution Campaign in Hwedza District, Zimbabwe, March 2018
Challenges Solutions Some VHWs had registered bedrooms instead of sleeping HWs made adjustments on the day of distribution places. nets. Some VHWs used Village Heads’ secretaries or records for LLINs registration. Climatic conditions (heavy rains and flooded rivers) prevented These villages were served whenever they came some villages from collecting the nets on designated days. to collect the nets. Net aeration was also affected due to rain. People were advised to use sheds or house verandas to hang their nets for aeration. Some households double registered. These were identified by the VHWs and no double allocation occurred. VHWs forgot to write their LLINs requirements. VHWs were advised to register and get nets from the HFs. Some people did not want to listen to the LLIN educational Distribution personnel educated recipients on the talks. All they wanted was to get the net and go. importance of nets. It is necessary to develop appropriate messaging/ strategies for different groups. These will include flyers or leaflets. ZAPIM will develop these in Year 4.
3.3.5.3 COMMUNITY PARTICIPATION IN HWEDZA DISTRICT The participation of communities and their leaders is central to the success of the program. Village Heads, Kraal Heads, Chiefs and Church Elders play a pivotal role in developmental programs. The district introduced the CD program of rectangular nets under the “My Net, My Life” campaign. This was the first time for most communities to hear about CD; to see and use rectangular nets. The district’s use of the existing channels, the adoption of innovative ways of using the people’s beliefs and reinforcing the “My Net, My Life” campaign message, led to acceptance of the program by the community. Councilors, Kraal/village heads, village chairpersons, HCC members and VHWs attended community sensitization meetings. The meetings had the following objectives: Increase uptake and utilization of LLINs Improve knowledge of the participants on their roles and responsibilities and their eventual ownership of the program Increase numbers of those educated on the various ways of hanging the net under the “My Net, My Life” campaign. During the interactive sessions, the Community Leaders highlighted the challenges they faced and came up with suggested solutions. Table 25 summarizes the challenges and recommendations.
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Table 25: Challenges and Recommendations from the Community Leaders' Meetings, Hwedza District March 2018
Challenges Recommendations Some community members disrespected The chief should caution, punish or take other disciplinary actions leaders against villagers who disrespect the leaders or fail to heed the Village Head’s instructions. Refusing to attend development meetings Leaders will take action to address these challenges through the community policing framework. Misuse of LLINs Leaders committed to come up with some form of community policing measures for LLIN misuse. Village Heads will educate the villagers on the importance of using an LLIN and will lead by example. Village heads will give VHWs time to talk about malaria and LLINs at village meetings and will make a show of support for them. Old LLINs still usable or unusable These were to be washed, repaired if torn, and stored for future use especially when there are visitors. Those not usable could be cut and made into window screens/curtains and also used to cover open eaves of houses. Not holding ward meetings Councilors will hold ward meetings. Itchiness of nets The LLIN aeration and washing stages were explained to address itchiness. Further explanations were given on how to properly hang the net and sleep in it with minimum contact.
ZAPIM will continue to engage and empower communities so that the use of LLINs becomes part of the culture and a net is viewed as a very special and prized possession. Regular and continuous engagement of the community is key to malaria prevention and control activities.
3.3.6 NET DURABILITY STUDY ZAPIM carried out the 24-month NDS assessment in November 2017. A two-day orientation training of 40 research assistants (RAs), 10 team leaders, and one provincial supervisor was held on November 20- 22, 2017. The training focused on research ethics, interviewing techniques, quality data collection using smart phones, and counting of holes and repairs on LLINs. The distribution of the research personnel was according to the sample size per district as shown in Table 26.
Table 26: Distribution of Research Assistants for the 24 Month NDS Assessment, Mashonaland Central and West Provinces, Zimbabwe, November 2017
Province District Number of Health Workers Trained Mashonaland Central Bindura 6 Centenary 4 Guruve 3 Mazowe 5 Mt Darwin 3 Rushinga 1 Shamva 3 Mbire 2 Mashonaland West Hurungwe 5
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Kariba 1 Makonde 4 Zvimba 3 Grand total 40 The number of RAs was reduced from 45 at 18 months to 40 at 24 months, in line with the reduced sample size. Of the 40 RAs, six were new; and of the 10 team leaders, only one was new. The trainers were drawn from NMCP (1), NIHR (2), and ZAPIM (2). The trainers also served as supervisors for the field data collection.
3.3.6.1 FIELD DATA COLLECTION Field data collection started with a one-day sensitization of provincial-, district- and ward-level stakeholders. This was conducted on the same day in all the 12 participating districts. Field data collection started on November 25 and ended on December 5, 2017. The target was for each RA to cover at least three to four households per day. Ten districts completed the study within the stipulated 10 days, with Shamva and Zvimba having to extend the study by two additional days due to heavy rains. During the field work, team leaders used a standardized checklist to supervise the RAs. They monitored for adherence to the protocol, ethics compliance, interviewing techniques, use of smart phones in recording the responses, performance of smart phones and software, and care of study equipment and materials.
The team leaders reported daily to the coordinator on key indicators using short message system (SMS). These indicators were numbers of: HHs visited, HHs interviewed, HHs which refused, HHs revisited, all LLINs seen, study nets seen, and nets retrieved for laboratory analysis, and challenges. National coordinators were apprised of the field situation daily. From the daily data submitted, a total of 1,586 HHs were visited with 1,120 successfully having been interviewed and only 39 refusals. A total of 1,862 LLINs were seen. The major challenge was that people were absent from their homes due to working in their fields, away at work, and/or relocated, and about 258 revisits had to be scheduled. A total of 97 LLINs (DawaPlus [45] and DuraNet [52]) were retrieved for laboratory analysis. These nets were retrieved from the mining, farming, rural and peri-urban sectors.
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Figure 13: Research assistants and a household member counting holes in Hurungwe District
3.3.6.2 LABORATORY ANALYSIS OF NET SAMPLES In order to avoid delays experienced during the six-month assessment, a residential session for the cutting of the nets was held immediately after the completion of the field data collection. Seven net cutters from NIHR were engaged in the cutting of the 101 LLINs. They verified the net code, manufacturer’s label, and date of manufacture; inspected the net to see if it was the correct net with the correct number of panels; counted the holes and number of repairs done; and then cut the net for the laboratory bio-chemical analysis. The nets were then packed into three categories for bioassays (NIHR), chemical analysis at Walloon Agricultural Centre in Belgium, and stored for backup (ZAPIM). The samples for chemical analysis were sent to Belgium in December 2017 and results received in May 2018. The bioassays were completed in March 2018.
3.3.7 LESSONS LEARNED There have been great lessons learnt in CD implementation, which are: o Cost savings: o The use of appropriate field-based training venues like hospital board rooms, hospital dining halls, community halls, HFs Out Patient Department waiting areas and appropriate open-air venues resulted in great cost savings. o Use of the cluster approach brought the trainings closer to the people and reduced distance, days and cost o Distribution of LLINs by using GHSC and MoHCC provincial trucks at minimal cost to ZAPIM
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o Joint/shared hosting of meetings between ZAPIM and Plan International for the Vector Control Subcommittee review and planning meetings and inter departmental joint implementation and cost sharing of activities o Focused training - focus on strategy, methods/tools which brought the best results o Working with highly motivated lower level health workers and VHWs who put work first before incentives was central to program implementation. Use of research findings, meeting discussions and observations to inform programming is key to achieving program objectives e.g. addressing challenges on net itchiness to increase net use, adoption of village-based distribution model to increase ownership and access and adoption of captivating approaches to the introduction of rectangular nets.
3.4 SOCIAL AND BEHAVIORAL CHANGE COMMUNICATION ZAPIM SBCC implemented Year 3 activities guided by the country’s malaria communications-related vision stated in the Zimbabwe Malaria Communication Strategy 2016–2020: “To have a malaria free Zimbabwe through empowered communities who have knowledge and skills to protect themselves from malaria.” Overall, ZAPIM’s SBCC interventions in Year 3 provided financial and technical resources to develop communication material and strengthen efforts aimed at increasing demand and use of malaria interventions through increasing malaria related knowledge. ZAPIM channeled some resources to investigate the knowledge, attitudes, practices and behaviors of malaria-affected communities in order to understand the social and environmental determinants of behaviors among various communities and sectors with a view to tailor-made appropriate interventions. The project conducted the work in districts selected from the 15 ZAPIM targeted districts. ZAPIM also focused on building the technical capacity for SBCC within the NMCP. The project engaged communities in high-burden malaria areas to empower them in the adoption of effective malaria prevention and care seeking behaviors. Figures 13 and 14 depict some instances of community engagement.
Figure 14: Communities engage in focus group discussion in Angwa Ward, Mbire District
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Figure 15: Community members learn how to identify mosquito breeding sites along the Msengezi River in Chidodo Ward, Mbire District
3.4.1 CHIKUNDA LANGUAGE MALARIA CONTROL AUDIO BOOK In a concerted effort to provide tailored behavior change communication materials, ZAPIM developed materials in the Chikunda language mainly spoken in Chapoto Ward of the high-burden malaria district of Mbire. ZAPIM continued work from Year 2 to develop and finalize the Chikunda language malaria audio book for communities located at the border area of Kanyemba where Zimbabwe shares a border with Zambia and Mozambique. The language is trans-national as people living in border areas of these countries speak it. Chikunda language is the lingua franca of the Doma people, a minority group of Zimbabweans in Chapoto Ward who have not been reached by previous malaria messages in the main Zimbabwean languages – Shona and Ndebele. Minority and harder-to-reach groups such as the Doma are mostly illiterate and cannot effectively access malaria information from fliers, posters, dialogues, or radio broadcast messages. ZAPIM worked with the district team to develop a malaria audio book in Chikunda to communicate messages and increase knowledge on the malaria epidemics that frequently occur in the area. ZAPIM facilitated the development process of this behavior change tool by collaborating with the local people, including VHWs, artists, and writers. Mbire District health personnel provided the necessary guidance. ZAPIM developed the Chikunda language malaria control audio book in a series of stages over a period of 9 months as Figure 15 illustrates.
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Conducted consultation meetings on content development with Launched and Rollout of the Ministry of Health developed a dissemination plan at and Child Care at dissemination plan for community level National, Provincial the audio book and District levels
Finalized the script Pre-tested and Conduct a post- rollout and casting of finalized the audio rapid assessment of the community based dissemination and book artistes analyze results
Conducted script Procured media rehearsals and services and recording production consultant
Carried out the post- Procured and production of purchased the audio recorded work gadgets
Figure 16: Key stages of developing the Chikunda language audio book
Two months after the launch of the audio book, ZAPIM conducted a rapid assessment of its implementation. Notable results are as follows:
High levels of acceptability of the audio book in Chapoto Ward community was observed and documented
A dissemination plan targeting at least 4,000 community members was developed. Over the period, from rollout to the assessment, about 1011 community members were reached showing enthusiasm by both community members and facilitators
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The Doma ethnic community of Chapoto registered appreciation of audio format as opposed to written messages. (See text box “Most of us in the Doma community cannot read or write but with Dipa quotation.) (audiobook) we feel educated too because we can listen and understand. We even Use of audio only format without visuals was not feel confident to mix and discuss issues a barrier to information retention as previously with those who can read and write”- An thought excited community member during rapid assessment in Chapoto Ward. Communities were calling for more copies to be distributed
Figure 17: Sentiments from Chapoto community member on the Chikunda audio book, interviewed during the rapid assessment
3.4.2 ASSESSMENT OF DRIVERS OF CONTINUING MALARIA TRANSMISSION IN ANGWA WARD, MBIRE DISTRICT, MASHONALAND CENTRAL PROVINCE, ZIMBABWE
Malaria-related social behavior change can be attained in an environment where there is support for holistic malaria services. In Year 3, the ZAPIM SBCC team invested in a detailed investigation of the malaria services in Angwa Ward of Mbire District. As with its northern neighbor, Chapoto Ward discussed above, Angwa Ward also has a perennially high burden of malaria cases. ZAPIM worked with Mashonaland Central Province and Mbire District staff to carry out an assessment of the drivers of the documented, consistently high transmission levels of malaria despite reported high coverages of IRS and LLINs. The objectives of the assessment were to:
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Describe malaria incidence trends in Angwa Ward for the period 2012-2017 Describe the health care system in Angwa Ward Estimate the current coverage, quality, access, and use of malaria prevention interventions in Angwa Ward, including personal protection outdoors Characterize the presence of malaria vectors and describe vector bionomics and insecticide resistance patterns in Angwa Ward Assess the knowledge, attitudes, practices and perceptions of malaria and malaria risk Describe the type, quantity and timing of outdoor activities in Angwa Ward
The hypotheses for the continued high malaria transmission were: Inadequate coverage of the recommended interventions High coverage of interventions, but with poor/ineffective quality High coverage of high-quality interventions but with concomitant, ongoing, high malaria transmission
Further, if coverage of traditional control interventions is adequate in Angwa, are there other drivers of malaria transmission that the NMCP needs to identify and address? Alternatively, although coverage of traditional malaria control measures appears to be adequate from administrative records, are the actual coverage, access, and consistent use of malaria prevention interventions in Angwa Ward sufficient to control malaria transmission? Finally, are there unidentified aspects of the lifestyles and/or livelihoods of this community that increase malaria risk/exposure and result in persistently high burden of disease?
The main phases of the assessment were as follows: Concept note development Protocol and detailed implementation plan development Protocol review and approval process by the Medical Research Council of Zimbabwe Assessment implementation Logistics planning and resource mobilization (data collectors, transportation) Training of data collection teams Field work for data collection through household surveys and entomological data collection Data analysis and entomological analysis of vector specimens Report writing Due to the large volume of vector specimens for the laboratory to analyze, the report is still under development and ZAPIM will publish results in the first quarter of Year 4. Figure I5 shows data collectors during the assessment.
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Figure 18: Angwa assessment data collection teams prepare to embark on data collection
Figure 19: Data collector chats to a family to learn their livelihood patterns
3.4.3 COMMEMORATIONS AND EVENTS Effective malaria advocacy is a strategy the NMCP adopted to mobilize support from policy level structures and to show solidarity with national and global agendas. ZAPIM consistently supports the MoHCC/NMCP to organize and provide material for commemorative events. In Year 3, ZAPIM planned to support the following events: National level Southern African Development Community Malaria Day commemorations: The NMCP postponed the commemorations indefinitely due to a politically motivated high-alert situation in the country. ZAPIM had developed commemoration advocacy materials in the form of 50 hot/cold flasks for distribution to leaders and decision makers who are influential in provision of resources for malaria National level World Malaria Day commemorations: ZAPIM participated in the development and
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publishing of a newspaper supplement under the theme “Ready to Beat Malaria”. The supplement reached the public in all provinces in the country (circulation 75,000 copies). The supplement highlighted the key malaria control efforts in the country and the commitment by the MoHCC and partners to close the gap in malaria programming ZAPIM supported a provincial level World Malaria Day commemoration event in Mashonaland Central by providing SBCC materials for distribution to the public and logistical support for the district level MoHCC
3.4.4 SBCC TECHNICAL & PLANNING ACTIVITIES As a key malaria implementing partner, ZAPIM participated in and financially supported one SBCC Subcommittee meeting. The 2014 version of the terms of reference was revised at the Subcommittee meeting. The committee elected ZAPIM as the Chair for the Subcommittee. ZAPIM also supported the rebranding initiatives of the NMCP. The NMCP has summarized the rebranding rationale as follows: “Repositioning the NMCP brand is a strategic process to change the way people think about the organization in response to changes in the program towards the elimination agenda. To start the repositioning journey, there is need to craft a long-term organization wide positioning statement to capture what the organization stands for, define its intended beneficiaries and the core benefit of the brand that makes it singularly unique. Once the positioning statement has been captured, it will act as a hook upon which all the activities of the organization will be aligned and hung upon” ZAPIM is the key partner supporting this process to continue in Year 4.
3.4.5 COMMUNITY ACTION CYCLE IN HIGH-BURDEN MALARIA WARDS The focus of technical support in Year 3 was to train 84 HCCs in high-burden malaria wards in Mashonaland East and Mashonaland Central through the CAC ‘Act Together’ phase. The CAC Act Together phase is the 5th phase in the cycle. The phase involves assessing the capacity of HCCs to implement their malaria plans developed in earlier stages of the process and training on the gaps identified (see Figure 19 below). ZAPIM supported eight districts to conduct post-training follow-up visits on “Explore Health Issues and Setting Priorities” the third phase to some of the HCCs before training on the CAC Act Together. ZAPIM did this to check their understanding, progress, challenges and to give appropriate guidance to the district facilitators and HCC ZAPIM SBCC has been focusing on eight districts which were selected on the basis of being the most malaria high burdened districts considering resources available.
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Figure 20: Community Action Cycle
3.4.5.1 FOLLOW-UP FINDINGS FROM POST CAC “EXPLORE HEALTH ISSUES AND SET PRIORITIES” TRAINING ZAPIM supported eight districts, Mudzi, Mutoko, Goromonzi, Mbire, Centenary, Bindura, Mt. Darwin, and Shamva, to conduct the follow-ups. Table 27 below highlights the number of HCCs supported per District. Table 27: HCCs Followed-up by District, October 2017- September 2018
Province District HCCs trained HCCs followed Audience reached in CAC up Mashonaland Goromonzi 10 2 173 East Mutoko 11 5 243 Mudzi 14 5 190 Mashonaland Mbire 7 5 177 Central Centenary 13 5 245 Shamva 13 5 262 Bindura 8 4 219 Mt Darwin 8 5 236 Total 84 36 1,509
Facilitators impressed on the HCCs to institutionalize the practice of analyzing facility and community- level data related to the key areas namely: LLINs received and distributed through Community, EPI and ANC; and constant review of barriers to use of LLINs, including assessing whether the intervention was making a difference.
Regularly assess ANC bookings to determine the proportion of mothers booking late instead of booking early, and to understand the barriers.
Monitor increase or decrease in malaria cases and try to identify most affected villages, target group and exposure factor.
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Review community actions towards scaling up IRS acceptance.
Facilitator conducted practical demonstrations on identification of mosquito larvae where possible. Figure 20 shows EHT, Mr. Julius Chimonyo, explaining to HCC members the features of mosquito larvae, and breeding habits in Mutoko, Kawere area. The village heads took turns to identify the mosquito larvae.
Figure 21: Training HCCs to identify mosquito larvae in Mutoko, Kawere Eliminating mosquito breeding sites has potential to reduce risk of malaria transmission if done on large scale by entire communities. Communities should be empowered to identify and eliminate mosquito breeding sites. During the trainings, initially only few community members could identify mosquito larvae. Participants were very grateful for the demonstrations. They testified that they often saw the larvae but never associated them with mosquitoes. They had instead associated mosquito larvae with “germs” which cause stomach problems if one drinks such water. Local EHTs were encouraged the share knowledge on mosquito breeding habitats and feeding habits with HCC members who can in turn share the knowledge with their communities. Table 28 below shows the status of HCCs and the challenges they experience, established from the feedback with HCCs members and district facilitators during the follow-up visits.
Table 28: Status of Eight ZAPIM-Supported HCCs, Challenges and Proposed Solutions for the Remaining Period of the Project
Status of HCCs Challenges Solutions At the time of visit only HCCs in Unavailability of box files for securing ZAPIM provided box files for Goromonzi, Bindura and Mt Darwin reports for HCCs securing all documentation on CAC had not finalized their malaria plans activities at province, district and for each facility trained on CAC All the district facilitators in the 8 They cited transport, fuel and Proposed to support the district and districts acknowledged that they had competing programs as challenges. province with fuel to ensure that at not conducted supportive visits to More so, other programs such as least they provide optimal support the HCCs nutrition, TB, or HIV and AIDS come and supervision to HCC activities. with a full package of support. HCCs were conducting community The Secretariat of the HCC who are Through the district facilitators the education sessions at village, ward, the local EHT and NIC were not EHT and NIC will document
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and at social gatherings promoting prioritizing documenting activities community -based activities including use of LLINs, IRS, ANC booking and conducted in the community. They resources mobilized early treatment. were used to recording only Results- Based-Funds (RBF) issues. Some HCCs played a catalytic role in Absence of local field staff who would There is need to provide timely establishing hygiene clubs that constantly remind the clubs to address reminders to hygiene clubs to address broad range of health malaria issues. These clubs will put address malaria issues. problems including malaria more attention to issues that they are constantly supported/reminded hence for example there are field based officers who promote issues of HIV testing and these are the issues you will find they will concentrate on and report more often. Facilitated establishment of drama These groups lack material support like groups that ensured diversification of T-shirts, resources and adequate dissemination channels of malaria information on malaria. information. Effecting community policing against Some of the traditional leaders who are There is need for regular advocacy misuse of nets or against refusal of supposed to enforce the community meetings with traditional leaders, spraying. policy against misuse are reluctant to religious objectors and other special enforce. groups. Mobilizing food for spray operators, The effort needs to be up scaled and and community guides. sustained. Some HCCs initially evolved from a The effort needs to be up scaled and focus on playing an oversight role on sustained. use of RBF (infrastructure development) to now taking a public health approach. Today some are discussing outbreaks, health statistics and are now going to communities to conduct education sessions. Creating an enabling environment for VHWs to conduct community education sessions.
3.4.5.2 CAC REFRESHER COURSE TRAINING A total of 35 provincial and district facilitators from Mashonaland Central and Mashonaland East attended a two-day refresher course on 2-3 May and 4-5 April for Mashonaland East and Mashonaland Central respectively. This was also a platform to prepare and re-equip district facilitators on application of the CAC Act Together, Evaluate Together and Prepare to scale up phases. The following were objectives of the refresher course: Share experiences on implementation of the CAC “Explore and Setting Priorities” and “Plan Together” phases. Share knowledge and skills on how to implement the CAC “Act Together”, “Evaluate Together” and “Prepare to Scale Up” phases. (The remaining CAC Phases) Strengthen methods and skills for effective participatory facilitation. Make recommendations on gaps identified.
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The major highlight from these two-day refresher courses was reaffirmation of observations on HCCs listed in the table above and adoption of the same recommendations.
3.4.5.3 CAC ACT TOGETHER TRAININGS IN MASHONALAND EAST AND MASHONALAND CENTRAL The CAC “Act Together” seeks to assess the capacity of the HCC to implement their malaria plans. In Year 3 this was the core CAC activity to be supported in the eight districts covering 84 HCCs spread throughout Mashonaland East and Mashonaland Central. ZAPIM used an assessment matrix and 18 questions to guide the assessment process. The questions covered areas of resource mobilization skills, proposal development skills, financial resources management skills, group maintenance skills and skills in monitoring community actions. The capacity assessment matrix was guided by the following; proposed activity (derived from malaria plans), knowledge, skills and resources needed, availability or non-availability of the required knowledge, skills and resources in the community, how to develop this capacity, by whom, and where/where not available. Additional questions were used to assess other dimensions including: ability to mobilize resources, experience with running income generating projects, training in proposal development, previous funding sources, and demonstrated ability to manage financial resources. Table 29 shows the coverage of HCC Assessments.
Table 29: ZAPIM HCCs Assessed and Audience Reached by District, October 2017- September 2018 District HCC assessed Audience reached Mudzi 14 83 Goromonzi 10 75 Mutoko 11 95 Centenary 12 98 Mbire 4 84 Mt Darwin 8 69 Bindura 8 45 Shamva 14 65 Total 67 549
The following were some of the capacity assessment findings:
Misconceptions about the causes of severe malaria symptoms. For example, it is believed that convulsions are associated with bewitching attacks leading to treatment-seeking from faith healers (contributes to the first delay). Majority of all the participants could not identify mosquito larvae, did not know breeding or feeding habits for mosquitoes. Knowledge on LLINs was generally good in most sessions. HCCs were mobilizing local resources such as bricks, building sand, and labor mainly for infrastructure development although with no formal training in resource mobilization. The expectation is that HCCs should have skills in resource mobilization in order for them to address health issues in their context. Majority of HCCs in Mutoko, Goromonzi, and Centenary have viable income generating projects not present in the other districts. Some HCCs generated income ranging from as little as $80.00
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to $3,000 in the past year funding other community-based activities which are not covered by RBF. Without financial sustainability the activities of these groups cannot be sustained All HCCs have not been trained in proposal development. All HCCs reported having clear roles for every member of the group. However, as they represent various constituents such as village heads, schools, youth, faith healers, traditional healers, business community and VHWs they were not regularly reporting back.
One important implication of these findings is that there is need to invest time to ensure that HCCs are capacitated. The overall goal of applying the CAC approach is to build the capacity of HCCs so that they are able to assess their situation, have the capacity to plan health interventions, can mobilize resources to implement the interventions and have the skills to monitor the effectiveness of their health actions. The current half-day phased trainings are inadequate. HCCs are a joint committee of members selected from community and they differ widely in level of comprehension of health and SBCC concepts. This is the reason why participatory facilitation skills are critical. However, this training approach requires time and is very difficult to achieve with the current half day trainings. It also means that they require regular reminders and reinforcement to ensure retention.
As part of their achievements, HCCs have participated in conducting community education sessions that address some behavioral determinants underlying key, undesirable malaria behaviors, like low IRS coverage, low LLIN utilization, late ANC booking and delays in seeking treatment. Some specific examples of activities conducted by the HCCs in this regard include: Nyaure HCC in Goromonzi District conducted four cluster community meetings that promoted LLINs utilization and provided malaria prevention and treatment information. These meetings reached total of 174 adults from 22 villages.
Chiwenga HCC in Centenary District conducted seven cluster meetings covering 28 villages for pre- IRS sensitization.
Machaya HCC conducted three meetings, Dambakurima four meetings whilst Muzarabani conducted four cluster meetings reaching 15 villages. All are in Centenary District.
Muonwe HCC in Bindura District conducted net hang up campaigns in the community and in schools and they have made breakthroughs in persuading one of the Apostolic sects that shun utilizing health services, including using nets, to change. Some of the members are now collecting nets.
Nyava HCC in Bindura District conducted 20 village meetings promoting utilization of nets whilst Chiriseri conducted ten village meetings.
Muzarabani HCC in Centenary District mobilized 28 community guides who assisted spray operators contributing to an increase in its IRS coverage from 64% to 93%.
These examples illustrate the whole concept of CAC in which small groups of people are trained and expected to act and diffuse the messages repeatedly to the broader community using interpersonal communication. Figure 21 shows some typical community SBCC sessions in Suswe and Nyamakoho in Mudzi.
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Figure 22: Community SBCC session in Suswe, Mudzi District
Figure 23: Community SBCC session in Nyamakoho, Mudzi District
The following are a few more notable achievements: HCCs have established community drama groups and hygiene clubs as a way of disseminating malaria information for example Dendera and Suswe HCCs.
HCCs participated in selecting community guides who accompany spray operators.
Some HCCs mobilized food for spray operators.
Some HCCs are now regularly putting malaria on their monthly meetings agenda reviewing malaria cases, uptake of LLINs and ANC bookings. Previously, these committees predominantly discussed issues to do with infrastructure development at the clinics.
Some HCCs are effectively policing against the misuse of nets for example at David Nelson Clinic the HCC apprehended two men who were misusing nets (fishing). As per the community’s constitution, offenders are sentenced to perform community work in activities that promote health. In this instance they were asked to fill in mosquito breeding sites. After this experience, the incidences of reported misuse of nets declined.
One of the barriers to net use has been reports of itchiness of the skin resulting from failure to follow instructions on aeration of nets before use. HCC communication interventions aimed to address this. Reported incidences of itchiness are declining as observed during the CAC Act Together trainings.
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Other centers also reported a decline in late ANC bookings.
3.4.5.4 INCEPTION OF CAC IN MATABELELAND NORTH PROVINCE ZAPIM conducted a 5-day inception training for 10 provincial and district staff from Matabeleland North Province. District staff were drawn from Binga and Hwange Districts. The participation of the PEDCO, PEHO, Provincial Health Promotion Officer (PHPO) and a representative from the PNO office was very positive in several ways namely: The provincial team acknowledged that they were not paying much attention to how SBCC was being conducted and that it was not guided by any theoretical framework.
Participants recognized that by applying the CAC process, the province can improve malaria outcomes. The PEDCO, PEHO, PHPO and representative from the PNO’s office agreed to incorporate SBCC variables into the provincial malaria support and supervision checklist. Previously SBCC variables were not included in the checklist.
The province recommended ZAPIM to train ward health teams on the CAC process.
3.4.5.5 MATABELELAND NORTH CAC DISTRICT SENSITIZATION (BINGA AND HWANGE) ZAPIM supported Binga and Hwange Districts to conduct a two-day CAC sensitization training targeting 12 DHE members and 38 staff from health facilities drawn from high-burden malaria wards. Binga and Hwange reported that majority of facilities in the two districts have annual plans though they did not use any framework for developing those plans. Failing to use a framework may lead to failing to address the real issues. Some facilities reported achieving success in reducing the number of home deliveries through working with communities especially the ward health teams (WHTs). The CAC process can leverage on these successes. Furthermore, Hwange was conducting an assessment on ANC late bookings and the results could be used as baseline.
3.4.5.6 SENSITIZATION MEETINGS FOR EHT AND VHWS A total of 109 EHTs and VHWs were sensitized on the barriers that prevent consistent use of LLINs, content of message on malaria among participants, platforms being used to share information in the community, and on interpersonal communication skills. Some of the barriers that were consistently cited include: Itchiness of skin when in contact with net
Inadequate knowledge on benefits of using nets
No mosquito seen
No knowledge on how to hang a net
Communication aimed at decreasing experiences of skin itchiness, increasing awareness on benefits of using nets, and developing a high index of suspicion that mosquitoes are always present even though we might not see them were considered as the key issues that are most likely to have the largest impact on increased use of nets. Demonstrations were used to show how to aerate and hang nets.
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3.4.6 COMMUNITY ADVOCACY MEETINGS The project supported four clinics namely Chapoto, Masoka, Angwa and Chidodo in Mbire District to conduct community advocacy meetings with 52 traditional leaders, 17 church leaders, 35 HCC members, 54 VHWs, and 29 other community members. The meetings’ purpose was to ensure that influential community leaders appreciate the contribution of malaria disease burden in the community and create an enabling environment for VHWs to educate community.
Villages in the Chapoto area, namely Nyarupuru, Chanzatu, and Chiramba, have established drama groups that disseminate malaria messages through song, dance and drama. Village heads spoke strongly about the need to have additional products like repellents. One the village heads, Mr. Abenia Mawachi, testified that he consistently uses his net and it is now the norm for him. Such testimonies go a long way in the community.
3.4.7 LLIN UTILIZATION PROMOTION IN GOROMONZI AND HWEDZA DISTRICTS These LLIN utilization activities were conducted in collaboration with ZAPIM LLINs and SBCC specialists. ZAPIM used the meetings to orient health workers, VHWs and village heads on the continuous distribution of LLINs. Communication can effectively improve utilization of LLINs provided health workers understand key communication concepts and how to apply the SBCC concepts to create successful communication interventions. These sessions were guided by the barrier analysis theoretical framework which seeks to identify the barriers that prevent adoption of correct malaria behaviors; isolate barriers that can be addressed through communication; and target the messages through the most appropriate channels to reach audiences. Following this analysis, the barriers that emerged as most amenable to communication interventions include: inadequate knowledge on how to hang nets, skin itchiness, long distances to travel to collect nets, and lacking confidence on effectiveness of nets to prevent mosquito bites and malaria in general. Understanding of this information is very useful when HCCs members, VHWs and village heads conduct community education meetings and when they want to monitor changes in behavior, as these will be used as proxy indicators to utilization of nets for example.
3.4.8 GOROMONZI MALARIA OUTBREAK SBCC SUPPORT Goromonzi District in Mashonaland East experienced a malaria outbreak in January 2018 in wards 13, 14 and 16. These wards received nets, distributed with support from ZAPIM. The district requested support for SBCC activities from ZAPIM through NMCP. The following activities were supported: Consulted on the results of entomology surveillance activities conducted in the affected wards by the VectorLink Project. The entomological results showed a high density of A. funestus which has an indoor biting preference which suggested that most patients were bitten whilst indoors.
Conducted a number of interviews with people who were recently treated for malaria in farms that experienced high incidence of treated cases to elicit information on their knowledge of malaria, travel history, ownership of nets, utilization patterns, their risk perception to getting malaria, and social and economic activities they engaged in that could possibly be exposure factors.
Based on an analysis of all these aspects; the project developed messages focusing on increasing awareness on the existence of the malaria outbreak, explaining transmission, risk factors, signs and symptoms of simple versus severe malaria, effects of malaria at individual, family, community, and national levels,
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prevention options, identifying mosquito larvae, and demonstrating how to hang nets. Analysis also identified possible drivers of the outbreak which were: I. High influx of vulnerable gold panners in the area who did not have access to any malaria prevention interventions. Some thus slept in the open.
II. A significant number of farms which were the epi-center of the outbreak namely Goromonzi Rural District Compound, Alderly farm, Pleasant valley and Warrendale had not been issued with nets despite the nets being available at Kubatsirana Clinic (the holding center).
A total of 28 community education sessions were conducted reaching an audience of 821.
Figure 24: Community education session at Kubatsirana Clinic
3.5 MONITORING & EVALUATION/OPERATIONS RESEARCH
3.5.1 CASE/DRUG CONSUMPTION STUDY ZAPIM could not finalize the Case/Drug Consumption Study report during the year because of NMCP’s data access restrictions. Although there was continued engagement with the NMCP Director discussing the possibility; this did not yield the desired results. ZAPIM and PMI agreed to use the available data to finalize as much of the report as possible as a draft. ZAPIM and PMI reviewed a second version of the draft of the report and finalization of the draft has since been moved to end of October 2018. Thus, in Year 4, ZAPIM will support NMCP to review the final findings and take action on the areas that need improvement. Despite the unavailability of some of the data, the recommendations of the assessment are expected to help strengthen the Health Management Information System (HMIS) and Logistics Management Information System (LMIS), thus improving the quality of data reported on malaria.
3.5.2 NATIONAL MALARIA SM&E PLAN ZAPIM made a commitment to support the development of an SM&E Plan for the National Malaria Strategy, 2016–2020 in Year 3. The support was received with appreciation, and discussions to initiate the process began in Quarter One. A five-day stakeholders’ meeting was held to develop the National Malaria
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SM&E Plan. ZAPIM continued to encourage NMCP to facilitate the finalization of the malaria SM&E Plan. The document was finalized in the last quarter of the year and submitted to PMI for further review.
The M&E Plan provides a comprehensive tracking system that enables transparent and effective management of information on malaria control program activities. The plan clearly articulates the goal, objectives and the strategies to achieve such objectives. It also highlights, in detail, the indicator matrix with core indicators for impact, outcome, and output measurements towards malaria control efforts in Zimbabwe for 2016-2020. Baseline, targets, data sources and frequency of reporting on the indicators have been captured in the framework to guide reporting. ZAPIM and other malaria partners will continue to contribute to the achievement of these targets. Other key components in the M&E Plan include;
Routine and non-routine data collection and reporting processes Data flow, analysis, information products and dissemination Data quality assurance mechanisms and related supportive supervision M&E action plan, sources of funding and funding gaps Research agenda and the plan to develop one for the country
3.5.3 EPIDEMIC PREPAREDNESS AND RESPONSE GUIDELINES The national malaria EPR guidelines currently in use were developed in 2011 and do not provide sufficient details to be useful in preparing the health system to respond to an epidemic. The epidemiology of malaria in the country has since changed; thus, there was a need to review and update the EPR guidelines to make them relevant to the current situation. The new EPR guidelines should strengthen epidemic preparedness, detection, response, and reporting. ZAPIM, NMCP, and PMI agreed to review the guidelines. Besides providing financial and logistical support, ZAPIM also worked with other partners such as the WHO and Clinton Health Access Initiative to ensure that the country has current, detailed, useful EPR guidelines.
During the year, ZAPIM supported the NMCP to revise the EPR guidelines through a national stakeholder meeting. ZAPIM is currently in the process of finalizing the document. NMCP has made a commitment to mobilize resources for training of trainers in all the provinces on the revised EPR guidelines. ZAPIM intends to support printing, dissemination, and training of health workers in its three supported provinces.
3.5.4 M&E TRAINING OF HEALTH WORKERS In Year 3, ZAPIM supported the training of health workers in M&E in Mashonaland East and Matabeleland North Provinces. A total of 101 out of a target of 102 health workers were trained. The training focused on M&E fundamentals: data management, data quality issues, detection, notification, response to malaria outbreaks and using the District Health Information System 2 (DHIS2). Trainers placed special emphasis on the need to verify the data from the community (VHW) and facility levels before submitting it to the district office. Table 30 shows the distribution of health workers trained per province, cadre, and by gender. Table 30: Distribution of ZAPIM-supported Health Workers Trained in M&E by Province, Cadre and Gender, October 2017 – September 2018
District Profession Male Female Total Mashonaland East Nurse (district and health facility) 5 22 27
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District Profession Male Female Total Laboratory Staff 2 1 3 Pharmacy Staff 0 1 1 Environmental Health Staff 9 3 12 Health Information Staff 2 1 3 Other 2 3 5 Total 20 31 51 Mashonaland North Nurse (district and health facility) 15 18 33 Laboratory Staff 3 0 3 Pharmacy Staff 1 0 1 Environmental Health Staff 9 3 12 Health Information Staff 0 1 1 Total 28 22 50 Grand Total 48 53 101
3.5.5 DATA QUALITY ASSESSMENTS During the year, ZAPIM supported three provinces to conduct DQAs at selected health facilities in the districts. A total of 47 health facilities: Binga (7), Hwange (2), Murehwa (12), Goromonzi (12), Mbire (7) and Guruve (7) participated in the DQAs. The main objectives of the DQA were to: Conduct onsite data verification of selected malaria indicators at sampled health facilities in various districts Verify indicator data against primary source documents, document the reasons for variance and ensure that the data is updated Assess whether the selected health facilities have adequate data collection and reporting tools Assess whether some of the facilities are still in malaria outbreak status Assess the availability of updated outbreak thresholds at health facilities Establish whether death investigations are conducted at health facilities and district level. The DQAs were conducted together with the provincial and district staff. The team members used this platform to provide on-the-job coaching and mentoring. Table 31 highlights some of the key findings and recommendations. Table 31: DQA Findings and Recommendations
Key Findings Recommendations Facilities were using improvised T12 and RDT Need to revise or develop standard registers and also registers. Furthermore, facilities were not using a ensure they are printed, made available, and properly standard register as the primary source document to used by health facilities. compile the T5 monthly summary form. Some of the
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facilities were using T12 and IMNCI register whereas Follow up with all the health facilities that were requested others were using the RDT register. The to resubmit monthly return forms for selected months recommended primary source documents for compiling T5 are the T12 and IMNCI registers. As a result, discrepancies were noted on reported data on suspected cases, suspected cases tested, confirmed cases, and confirmed cases given ACTs. Two malaria indicators on the T5 have been Update the malaria indicators in T5 and ensure that they incorrectly described, resulting in a source of have standard definitions. NMCP M&E department should confusion for some of the nurses not trained in M&E. work with National Health Information department and The indicators are described as: “suspected cases ensure that the malaria indicators are updated on T5. treated but not tested” instead of “number of suspected cases” and “suspected cases treated by RDT or blood slide” instead of “number of suspected cases tested”. No RDT columns in T12, making it difficult to verify Need to put RDT columns in T12 the data Incorrect interpretation of indicators such as “number Ensure that all the facilities have a dictionary of all the of cases given ACTs” has resulted in over-reporting. malaria indicators Some facilities were reporting the number of tablets dispensed to clients as opposed to the number of Refresher training of health facility staff on data collection treatment courses. Thus, there was variance between and reporting tools the confirmed cases and ACTs consumed. Majority of the trained VHWs were testing, but not Proper quantification of commodities for both health treating because of shortage of commodities. facility and VHWs at the health facility level to avoid shortage of commodities. Early treatment of confirmed cases can be strengthened by giving VHWs testing and treatment commodities. This can also avoid pseudo- outbreaks No mechanisms for follow up of clients referred by Need to institute follow-up mechanisms and ensure that health facilities or VHWs clients referred by health facilities to VHWs or vice versa are tested and treated.- EHTs can do this as part of their routine work No clear communication on reporting by VHWs VHWs should submit data at the end of each month, but the data should be disaggregated by week Cases of patients with symptoms of malaria such as All patients that present with signs and symptoms of fever, headache, and dizziness were not tested for malaria should be tested to avoid missing some of the malaria. There is a possibility that some of the suspected cases suspected cases were missed or received late treatment. Supply chain management challenges- e.g. Clients given Improve supply chain management to ensure constant quinine instead of ACTs because the latter was out availability of ACTs through support and supervision as stock well as clinical mentorship All VHW data were not yet included in thresholds- yet Include VHW data when calculating threshold limit values in some instances there were more cases in the and updating thresholds. community compared to the health facility Almost all the facilities were not updating the T3 (tally Streamline the data collection tools to avoid sheet), resulting in data not tallying with T12 and overburdening the health workers IMNCI data. The staff indicated that they did not have time to update the T3 because of the pressure of work.
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The DQA team requested facilities to resubmit the statistics for the affected months to the district office as corrective measures for large variances. All the other anomalies noted were discussed with the health facility workers who were requested to take corrective measures. It was also recommended to have regular DQAs on a quarterly basis to improve data quality.
3.5.6 SURVEILLANCE, M&E SUBCOMMITTEE MEETING Only one Surveillance M&E Subcommittee meeting was conducted during the year. ZAPIM participated in the meeting in August 2018. The meeting discussions centered on the need to develop a malaria research agenda, a roadmap for the HMIS Strategic Plan, a malaria elimination capacity assessment and guidance to transform malaria technical subcommittees.
3.5.7 PROVINCIAL MALARIA REVIEW MEETINGS ZAPIM provided both financial and technical support to the three provinces to undertake malaria review meetings. A total of 143 participants (119% of target) attended the meetings. The malaria review meeting for Matabeleland North was combined with the malaria death audit meeting and therefore had more participants as compared to the other two provinces. Participants drawn from the PMD’s Offices, DHEs, and health facilities in the three provinces attended the meetings. Participants were encouraged to review the malaria situation in the districts and share progress in the implementation of malaria interventions. They also discussed the quality of data generated at both community and facility levels, shared best practices, and identified implementation challenges and possible solutions. ZAPIM used this opportunity to share and discuss Year 2 achievements, activities that the project is supporting, and findings and recommendations of the Data Quality Assessments conducted in selected districts from the three provinces.
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4. GENDER AND CHILD SAFEGUARDING
ZAPIM implemented the Year 3 activities in full consideration of gender issues with an emphasis on the protection of its employees from sexual harassment. There was no reported incidence of any form of discrimination based on sexual orientation. The project allowed equal participation of women and men in all the trainings conducted across the thematic areas. LLINs were distributed to both women and men. All activities were implemented in a gender sensitive manner. During the development of SBCC materials, both men and women were engaged under equal contractual terms. Language used in the trainings and on all materials developed was gender sensitive. During Year 3, both women and men undertook the practice and perception of malaria key interventions. Pregnant women were given LLINs during antenatal visits and counseled to regularly sleep under an LLIN to protect her and the unborn child. Women played a leading role in making sure that their children slept under nets, and they were typically the frontline caregivers, who sought treatment for their children. All proposed SBCC interventions were designed to align with gender norms in the community while focusing on empowering women to carry out the recommended behaviors for malaria treatment, prevention, control, and elimination. In Year 3, the program continued to be vigilant in all activities related to the existing child safeguarding policy and ensured child safety in implementation of all program activities. The program oriented all staff in compliance with the child safeguarding policy. No incidents of child violations or child rights violations were reported during this reporting period. The program made deliberate efforts to ensure that activity schedules and venues considered suitable travel times for parents and child minders travelling to and from the ZAPIM–related activity and allowed time to care for children. Mothers brought their infants to the short community-based workshops. Furthermore, breaks were established throughout the activities to enable mothers to breastfeed their babies at suitable times. In the case of residential workshops, mothers who needed to bring babies did so and provided a childminder. The safety and welfare of children was of utmost importance. Children remained important beneficiaries for ZAPIM-led malaria prevention services. The LLINs continuous distribution systems continued to ensure children’s sleeping spaces were covered and LLIN distribution for children remained a priority.
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5. ENVIRONMENTAL COMPLIANCE
Health programs, including those supported by ZAPIM, may have negative environmental effects. To ensure the optimal environmental protection, USAID-funded projects, programs, and activities must have measures in place to mitigate any anticipated environmental effects. ZAPIM focus areas that could have potential negative effects on the environment include the following: Generation of medical waste at both health facility and community levels Disposal of LLIN solid and liquid waste Management of public health medicines and commodities
5.1 MEDICAL WASTE If medical waste generated from health facility and community case management is not properly handled, stored, and disposed there is risk of disease transmission. As with the previous years, in Year 3, ZAPIM technical staff supported health facilities and community health workers in infection prevention. Through case management trainings, ZAPIM trained health workers on infection prevention using measures such as wearing gloves when handling medical waste, avoiding recapping of sharps, proper disposal of sharps into puncture proof sharps containers, and disaggregation of medical waste in color coded bins. At community levels, the program also trained VHWs on proper handling of medical waste as they are expected to bring medical waste to health facilities for proper disposal every month. Apart from trainings, the program uses supportive supervision visits to mitigate identified gaps in handling and disposal of medical waste and to ensure implementation of suggested measures. In the future, ZAPIM will integrate environmental compliance into quarterly data quality assessments.
5.2 LIQUID AND SOLID LLIN WASTE The distribution of LLINs generates solid waste from LLIN packages. Considering the high volume of nets the program distributes, there is potential harm to the environment if proper disposal procedures are not followed. Washing of nets at the household level may also lead to contamination of water sources if communities are not taught the proper disposal of water from LLIN washing. To mitigate the negative environmental effects of liquid and solid waste VHWs and health workers are trained on proper disposal of waste from LLINs. LLIN packaging is cut into small pieces and buried in a pit 50-100 cm deep, away from water bodies. Nets should not be washed in rivers or dams but should be washed in a dish and water should be disposed in a pit. The program gives this information to community members during LLIN distribution.
5.3 MANAGEMENT OF PUBLIC HEALTH MEDICINES AND COMMODITIES ZAPIM supports activities at both the health facility and community level where medicines and commodities such as malaria medicines, testing kits, syringes, gloves, etc. are distributed. There is a risk of children ingesting improperly secured medicines. Medicines may also expire; and using expired
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medicines may result in poor treatment outcomes. It is therefore necessary to have good medicines and commodities management practices in place. Through malaria trainings and supportive supervision, health workers are taught proper storage of medicines, ways of avoiding drug expiration (e.g., quantification of stocks and proper handling of expired drugs). During supportive supervisions for VHWs, ZAPIM assisted with the identification and return of expired medicines from the VHWs to the health facilities for supervised destruction by the health care staff.
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6. ADMINISTRATIVE ACTIVITIES
6.1 STAFFING AND MANAGEMENT In Year 3, ZAPIM continued to build on the established decentralized management approach and implemented activities with high quality through careful planning and strong communication. ZAPIM worked through existing MoHCC provincial and district-level staff and structures to continue building capacity within the government and ensure that project activities consider local context and respond to local needs. All levels of the NMCP received this approach with great appreciation and this strengthened coordination and collaboration in project implementation. ZAPIM will leverage on established relationships throughout the remaining life span of the project. During Year 3, ZAPIM experienced a number of staffing changes including key personnel transitions. Dr. John Bosco Rwakimari, Technical Director/Malaria Specialist transitioned to another Abt project in February 2018. This position was filled by an internal candidate within ZAPIM – Dr. Anthony Chisada, who replaced Dr. Rwakimari in July 2018. Another internal candidate, Dr. Gilson Mandigo, filled Dr. Chisada’s previous position of Senior Case Management Specialist in August 2018. It is anticipated that Dr. Mandigo’s previous position of Case Management Specialist will be filled in Year 4. Internal recruitment allowed continued smooth program implementation since the incumbents already possessed a broad understanding of the project and context hence reducing the learning curves of the new positions. Other recruitments in Year 3 include the Community CM Specialist that was filled by Mrs. Florence Rondozai in December 2017, the Data Quality & Reporting Officer filled in April 2018 by Mr. Wonder Sithole, and the Administrative Coordinator position by Ms. Mazvita Kanoyangwa to replace Ms. Grace Chivandikwa who left the organization in April 2018. To maintain cost-effectiveness, ZAPIM and VectorLink continue to share the Administrative Coordinator and IT Specialist positions. In Year 3, ZAPIM benefitted from several short-term, technical assistance assignments from Abt Associates, Save the Children and Liverpool School of Tropical Medicine. Details of these visits and remote support are in Appendix A.
6.2 CONFERENCES, RETREATS, TRAININGS AND MEETINGS ZAPIM staff participated in the following trainings and meetings in addition to the routine partner meetings throughout the year under review. The following are key meetings held in Year 3: Evaluation Methods of Malaria Programs: The ZAPIM M&E/OR Manager attended a five-day training at the University of Ghana from June 18-22, 2018. The training covered basic and statistical concepts, process evaluation, impact evaluation, and designing evaluations for malaria programs. Ten participants drawn from Angola, Burundi, Ghana, Kenya, Malawi, Mozambique, Zambia and Zimbabwe attended the training. The training involved plenary sessions, discussions, group work and hands on experience. Elimination TOT: The Senior Case Management Specialist attended the training organized by NMCP in Mutare from on June 14 and 15, 2018. The training laid a good foundation as ZAPIM intends
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to start elimination work in year 4. The NMCP shared results of capacity assessment for elimination carried out in 10 districts in 2018 that added eight new districts to the elimination list. In Mashonaland East Province, Chikomba, Seke and Marondera Districts are now elimination districts and Wedza District is now a buffer district. The training topics included malaria cases and entomological surveillance, CM in elimination, SBCC and community participation in malaria elimination, and use of DHIS2 Tracker in elimination districts. Multilateral Initiative on Malaria (MIM) Conference April 15- 18, 2018: ZAPIM had two abstracts presented at the conference in Dakar, Senegal. The LLIN Specialist presented an abstract on the results of the LLIN mass distribution Endline survey and the other on Case Drug Consumption Survey was presented by the Logistics Coordinator in the Department of Pharmaceutical Services (DPS) in the MOHCC. Pan Africa Mosquito Control Annual (PAMCA) Conference September 24-26, 2018: ZAPIM participated in this regional conference which held in Victoria Falls. The conference discussions included latest scientific evidence to better implement Integrated Vector Management programs and strengthen entomological surveillance. Africa University researchers supported by ZAPIM presented three articles at the conference. Roll Back Malaria SBCC Working Group Annual General Meeting September 25-27, 2018: ZAPIM presented a poster on Chikunda language audio book at the conference in Lusaka, Zambia and received the second runner-up award. National Malaria Vector Control Planning and Review Meeting: The ZAPIM LLINs Specialist participated in this important meeting in Mutare from April 22 to 27, 2018. The meeting reviewed vector control in the country including LLINs. Review of the LLIN Mass Distribution Campaign Plan for 2018: ZAPIM supported and participated in the review that was held in Gweru on May 30 and 31, 2018 Matabeleland Provincial Health Team Meeting: ZAPIM presented project achievements to date and upcoming planned activities for the province. PMI Partner Meetings: ZAPIM participated in the quarterly PMI implementing partner meetings and shared progress on project implementation and some key interventions such as CM mentorship and Chikunda audio book. Year 4 Work Plan Development Meetings: ZAPIM met with the three provinces to gather their views on the priorities for Year 4. NMCP endorsed the proposed priorities. The project made it clear to the provinces and NMCP that the final activities to implement in Year 4 depend on the available budget and PMI approval. The project presented the consolidated work plan to NMCP before submitting to PMI. USAID Partners Meeting: ZAPIM attended the USAID partners meetings, which focused on the current economic situation in the country and the 2018 presidential and parliamentary elections. The facilitator on the elections presented three presidential election outcome scenarios to partners followed by discussions on potential effects on partner implementation activities. NMCP Subcommittee Meetings: ZAPIM attended the Case Management, SBCC, Vector Control and Surveillance, and M&E sub-committee meetings. ZAPIM/NMCP Meetings: ZAPIM held regular meetings with NMCP leadership to give updates on the implementation of ZAPIM-supported activities and discuss program achievements and challenges. Some of the issues discussed included: shortages of commodities at facilities and VHWs homesteads, slow progress on finalization of the revised EPR Guidelines, and delays in finalizing the new SM&E plan. This platform allowed for dicsussion of possible solutions to the challenges.
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7. CHALLENGES, LESSONS LEARNED AND RECOMMENDATIONS
7.1 CHALLENGES The following were key challenges experienced during Year 3: Knowledge and skills decay in management of malaria cases: The most important contributor to knowledge retention is putting what one has learned into practice. It is against this background that health workers in low-burden malaria areas tend to lose knowledge and skills in management of malaria because they do not treat malaria patients often. This results in loss of the awareness and alertness of malaria and associated symptoms, increasing the risk of missing malaria cases. Delays in malaria diagnosis lead to increased risk of severe malaria resulting in deaths in these low burden areas. Stock out and expiration of medicines at community and facility levels: Frequent malaria commodity stock outs can lead to adverse outcomes for patients and negatively affects health facility and VHW ability to provide quality care. Stock-out occurs in high-burden areas where demand often surpasses supply. In these circumstances, health facilities that are hardest hit tend to hold on to the little available stocks of RDTs and ACTs and do not supply VHWs. There are some VHWs that received training during the year but could not treat people due to stock outs of commodities since health facilities received less than the minimum stock level. The lack of commodities at VHWs levels leads to delays in treatment, especially in communities located far from health facilities. Stock outs of pre-referral treatment at VHWs and lower level facilities lead to delays in initiation of treatment in severe cases. Patient referral at the VHW level to higher levels of care can involve long travel and waiting times affecting patient outcomes. In the long term, stock outs of commodities lead to loss of competencies for VHWs resulting from none or infrequent practice.
On the other hand other health facilities and VHWs experienced stock expiration. This is more common in low-burden areas due to low demand and inconsistent monitoring of the commodities. For example, expiration of SP in Matabeleland North was noticed during the ZAPIM supportive supervision visits in the province. Both expiration and stock outs of SP are associated with low IPTp coverage.
Lack of supportive supervision of VHWs by the local health facility staff: This is due to nurses being overwhelmed with their routine work and emergencies at the facility and lack of transportation to conduct the activity. Most rural health centers are under staffed and do not have adequate staff to allow for some nurses to travel to conduct VHWs supportive supervision, as their absence would mean the health facilities remain with little or no qualified staff to attend to other duties. Incomplete documentation of registers by VHWs and lack of standard T12 registers at HF: VHWs have multiple registers that they use to document the work they are doing at community level. ZAPIM has supported the VHWs with the registers such as the RDT/Malaria medicines registers and the sick child registers. All the columns and sections in these registers should be filled in correctly and completely to enable the VHW to compile their monthly reporting
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form. During supportive supervision visits these registers are reviewed and gaps have been identified. The gaps are mostly related to VHWs not following the step by step process of using the registers (especially the sick child register). In the RDT/medicines register major gaps are on recording the opening and closing stocks making it difficult to trace the commodities given, used and remaining balance. This gap affects the calculation of commodity requirements for RDTs and medicines to be given to each VHW. There are no printed standard T12 registers at HFs. This leads to use of improvised registers which in some instances do not collect all the relevant data elements. There is need for standard printed T12 registers at HFs to ensure standardized consistent data collection.
Delay in quarterly Malaria Sub-Committee Meetings: Delay in NMCP technical sub- committee meetings hampered progress in moving the malaria agenda forward. This lack of partner technical consultation and discussion has led to delayed resolution of pertinent and timely issues which need to be handled at such fora, for example, the National Malaria M&E Plan and EPR Guidelines.
Inadequate knowledge on how to hang rectangular nets: Lack of knowledge by HWs and VHWs on how to hang rectangular nets may contribute to low utilization of LLINs. Many people including HWs did not have the knowledge and skills on how to hang rectangular nets as it was the first time that rectangular LLINs were being distributed on a large scale in the country. Previously the NMCP and partners used to distribute conical LLINs.
Limited storage facilities for LLINs: Inadequate storage facilities or no space at all at district and health facility levels is disruptive to the LLIN distribution system. District and health facility levels must have a supply of LLINs ready to cover new sleeping spaces and/or replace old/retiring nets.
Distribution of LLINs: There was a delay in transporting LLINs to distribution facilities because districts had no vehicles to transport the LLINs.
Follow up on the HCC activities: In all the districts supported, the district facilitators did not follow up on the HCC activities because of transportation challenges and other competing priorities. For example in Mutoko, ZAPIM supported the district with fuel coupons to ensure that the district facilitators can make follow up on HCC activities. They had not been able to do this activity, as they had not been allocated a vehicle from the few vehicles available.
Inadequate motivation for positive malaria behavior change: Despite concerted efforts to educate communities on behaviors to adopt in order to prevent and control malaria, it has been observed such practices remain very low. This situation calls for geared up efforts to motivate communities to use preventive measures such as using LLINS that they already possess for children and pregnant mothers consistently.
Data on training gaps: ZAPIM has faced difficulties in gathering the necessary information from provinces to understand the full need for CM, M&E trainings, and supportive supervision. This is due in part to the lack of clarity on the denominator of all health worker cadres, staff movements, new recruitments and their training status and the availability of Global Fund support for these same activities which might lead to duplicative efforts. This lack of information limits ZAPIM’s ability to determine if additional support is needed to ensure full coverage.
Delays in finalizing the review of the EPR Guidelines and development of Malaria M&E Plan: NMCP delayed confirming dates for meetings necessary to undertake these two activities,
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resulting in delays. WHO, the key facilitators for the review of the EPR guidelines did not continue in its leadership role after the initial consultative meeting.
7.2 LESSONS LEARNED AND RECOMMENDATIONS In light of the above challenges, ZAPIM also learned some lessons which the team will consider for future programming. The following are possible recommendations. • Knowledge and skills decay in management of malaria cases: Workers in such areas need constant reminders during supportive supervision visits so that they are able to deal with cases of malaria when they come across them. Mentorship, refresher trainings, production of severe malaria video, simulations to address lack of knowledge on management of severe malaria cases can also be used. • Expiration of medicines: Tracking of medicine expiration dates and redistribution of excess medicines when stock is above maximum stock. The ideal situation is that VHWs should hand over all short-dated stock of medicines and commodities to the facilities before they expire. In the event of expiration occurring at the VHWs level, all such expired medicine should be handed over to the health facilities. All expired medicines should be recorded properly in the VHWs and health facility records. During supportive supervision visits, ZAPIM assisted with medicine redistribution or hand over of expired medicines from VHWs to the health facilities. • Shortage of ACTs and RDTS at community level: ZAPIM will participate in key national coordination meetings and engage stakeholders in the supply chain management to discuss VHW logistics and support to ensure VHWs have the necessary commodities to provide quality CCM activities. • Lack of supportive supervision of the VHWs by the local health facility staff with the resultant poor documentation and recording by VHWs: In year 4 ZAPIM will have a representative at provincial level to provide coordination of supportive supervision of VHWs which will focus on VHW documentation of registers and monitoring of expiry dates of commodities at community level. ZAPIM will support EHTs with logistical support, fuel, tools and orientation in VHW supportive supervision to capacitate them to provide the supportive supervision. • Incomplete documentation of registers by VHWs and lack of standard T12 registers at HF: ZAPIM provided all trained VHWs with the relevant registered and trained both VHWs and HWs on the documentation of information in the registered. SS of VHWs and VHW review meeting continue to strengthen the use of the registers to ensure complete documentation. In Year 3 ZAPIM led the review and standardization of the T12 registers. The MOHCC will commence printing and dissemination of the standardized registers in 2019. In Year 4 ZAPIM will support the printing and distribution of the standard T12 registers in the supported districts. Once the standard T12 registers are in use, ZAPIM will support HWs to use the registers consistently and correctly through trainings, mentorship and supportive supervision. • Malaria Sub-Committee Meetings: Continue engagement of NMCP and highlight the importance of conducting the meetings. Offer to assist in financial support and secretariat functions to make the meetings happen regularly. • Knowledge to hang rectangular nets by health workers and VHWs: Target more health workers and VHWs to train them on hanging of rectangular nets. These trained cadres will train communities. • Need to motivate communities for positive malaria behavior change: Support the NMCP to develop and implement a malaria communication brand and messages that will rally communities and motivate them towards increased malaria prevention behavior change.
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• Storage facilities for LLINs: Districts and health facilities to create space for storage of minimum stocks of LLINs. Target at least 6 months stock of CD LLINs at district level and 3 months stock at health facility level. • Distribution of LLINs: DEHOs to lobby for district transport to avoid delays in transportation of LLINs to distribution facilities. They should also provide a monthly LLINs distribution list to the transport officer, the DHSA and Community Nursing Department who control vehicle use by different programs. ZAPIM will continue to support districts with fuel and stationery for the distribution. LLINs SS not prioritized during the integrated SS by District Health Executives and Provincial Health Executives: DHEs and PHEs to include LLINs on their supervisory checklists and schedules. In Year 4 ZAPIM will assist DHEs and PHEs in developing checklists that include LLINs. • Follow up on the HCC activities: Set aside a budget to support follow up visits by district facilitators. In Year 4 ZAPIM will provide fuel and logistical support for these. • Data on training gaps: The project will use provincial and district review meetings, supportive supervision visits, mentorship visits and other forums to gather and update the data. • Delays in finalization of the review of the EPR Guidelines and development of Malaria M&E Plan: The program learned that continued engagement with NMCP on the importance of reviewing and developing such key documents can help NMCP to understand how such efforts can eventually benefit the national malaria control program. ZAPIM had to assume the role of lead facilitators on the EPR guidelines to ensure the finalization of the documents. These approaches succeeded in moving forward the preparation of the two documents. The documents have now been finalized.
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ANNEX A: LLINS DELIVERED BY DISTRICT, OCTOBER 2017 – SEPTEMBER 2018
District LLINs Delivered Bindura 7,950 Centenary 20,800 Guruve 11,800 Mazowe 24,700 Mt Darwin 34,400 Rushinga 2,600 Shamva 10,900 Mbire 4,450 Goromonzi 24,450 Murewa 16,600 Mangwe 7,900 Lupane 5,750 Matobo 4,350 Mhondoro- Ngezi 9,600 Tsholotsho 49,850 Mutoko 5,100 Chiredzi 43,150 Mberengwa 30,450 Kwekwe 2,250 Gokwe South 118,000 Bubi 29,450 Umguza 22,950 Gwanda 42,750 Makonde 9,150 Hurungwe 15,850 Zvimba 14,250 Chegutu 9,500 Masvingo 109,850
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District LLINs Delivered Bikita 8,450 Zaka 9,750 Gokwe North 8,400 Nkayi 4,500 Bulilima 4,250 Lupane 64,200 Matobo 4,350 Binga 2,200 Hwedza 11,000 Beitbridge 1,500 Chipinge 300 Total 807,700
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ANNEX B: SHORT-TERM TECHNICAL ASSISTANCE
Project staff provided the following STTA during Year 3:
Name Position Dates Scope of Work William Vargas Consultant, LSTM February 3 – 10, 2018 Provide technical assistance in the protocol development of the Assessment of drivers of continuing malaria transmission in Angwa Ward. Ekpenyong Ekanem ZAPIM M&E Specialist, January 28 – February Provide technical Abt Associates 10, 2018 assistance in the National M&E Plan development and additional analysis and writing of the Case/Drug Consumption study Catherine Thompson ZAPIM Regional May 28 – June 2, 2018 Provide technical and Managing Director, East, administrative support Central and Southern to the project and Africa and Portfolio introduce Rebecca Manager, Abt Bronheim as new Associates ZAPIM Portfolio Manager, Abt Associates. Rebecca Bronheim ZAPIM Portfolio May 28 – June 13, Provide technical and Manager, Abt 2018 administrative support Associates (new) to the project, including Year 4 work-plan development. Nicole de Gier ZAPIM Technical April 22 – May 4, 2018 Provide technical and Manager, Abt administrative support Associates to the project. Simon Gould Consultant, LSTM June 24 – 30, 2018 Assist with the writing of the Assessment of the drivers of continuing malaria transmission in Angwa Ward.
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Name Position Dates Scope of Work Carla Sanchez Save the Children August 26 – 31, 2018 Support Community Senior Specialist, SBCC CAC trainings SBCC/Community (Act Together phase). Capacity-Strengthening
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ANNEX C: PMP INDICATOR/YEAR 3 MILESTONE MATRIX
Key: PMP Impact-level Indicator PMP Life-of-project-level Indicator and Year 3 Milestone/Indicator
Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps CM Number of malaria PMP 392 N/A 290 290 Not The baseline and results Scale up malaria deaths (HMIS applicable are national. The majority interventions and also 2016) (N/A) of the cases were continue to support reported in Q2 and Q3 malaria death which is usually the investigations in the malaria peak period. The affected provinces. two quarters had 82 deaths 7 deaths respectively. Of these (22.0%) were reported in three ZAPIM-supported provinces, Mashonaland East (30), Mashonaland Central (26) and Matabeleland North (8).
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps The completeness rate was 95.5% CM Incidence of PMP 17/1,000 N/A 10.5/1,0 10.5/1,000 N/A In ZAPIM-supported ZAPIM continues to malaria (HMIS 00 (HMIS/DHIS2 provinces, The most priotize high impact 2016) ) affected districts were interventions to Mudzi, Goromonzi Mt contribute to the Darwin, Mbire, Bindura, reduction of malaria Centenary, and Mutoko. districts experiencing These districts were malaria outbreaks will suspected to be continue to be experiencing malaria prioritized. outbreak. The completeness rate was 95.5% CM Proportion of PMP 35% N/A 37% 37% N/A The figure of 37% is MCHIP carried out an women who (MIS according to the 2016 assessment in received two 2012) MIS. Manicaland to or more doses of determine the causes Intermittent for the low uptake of Preventive IPTp. ZAPIM continues Treatment of to ride on the findings Malaria in and recommendations Pregnancy during of the assessment to ANC improve the program CM Proportion of PMP 68.8% N/A 50% 50% N/A The figure of 50% is The indicator is not well under-five children (MIS according to the 2015 reported in the 2016 who sought 2012) ZDHS. The new National MIS preliminary report treatment within Malaria Strategic Plan is and therefore the 2015 ZDHS report has been
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps 24 hours of onset still being costed and will used as reliable source of fever inform the targets. document. CM Percentage of PMP 99.8% 100% 96.8% 96.8% 95.5% There was a shortage of The health facilities and suspected malaria (HMIS RDT kits in the Country. community- based cases that receive a 2016) Hence some cases were health workers should parasitological test not tested for malaria. continue to exhibit high The completeness rate compliance and was 95.5% acceptable practices. CBHWs are adhering to the guidelines and this is a good practice. CM Percentage PMP 93% 100% 84% 84% 84% The indicator only The results show that of confirmed (HMIS captures ACT’s given and the level of access to malaria cases that 2016) other anti malaria given to treatment of deserving receive first-line complicated cases are not cases for first-line antimalarial documented in the DHIS2 treatment decreased in treatment system. The completeness the year. according to rate was 95.5% national policy CM Number of health PMP 896 (Year 670 663 663 99.% A total of 304 facility The trainings will be workers including 1 ZAPIM based health workers scaled up in Year 4 VHWs, trained in Annual from the three provinces since there are still malaria case Report) were trained in CM and training gaps. management MIP mashonaland East (ACTs, MIP/IPTp, (79) , Mashonaland central RDTs, Microscopy, (155) and Matabeleland Medicines North (70). VHWs were management) trained in CCM in Matebeleland North
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps (200), including 40 trainers in the same province and Mashonaland East (119) CM Number of planned PMP 0 3 2 2 66.6% A total of 36 health Supportive supervision malaria-related facilities from visits were done in Year supportive Matabeleland North 3 targeting trained supervision of (Binga, Hwange) and health workers. These health facility Mashonaland East (Mudzi were chosen based on workers conducted and Uzumba Maramba malaria burden and Pfungwe(UMP)) were history of malaria reached. outbreaks CM Number of PMP 0 15 15 15 100% All the districts plans feed As part of the outbreak districts with into the provincial plans. response initiative, outbreak response ZAPIM will continue to plans support all the districts during the year to ensure they have robust plans to quickly respond to any outbreaks. ZAPIM supported the revision of the EPR guidelines. In Year 4 ZAPIM will support the training of provincial and district staff. It is anticipated that this will go a long way in improving the quality of
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps the outbreak response plans. CM Functional training Year 3 0 1 1 1 N/A The training database was A functional database milesto set up through I-TECH TrainSMART database is (TrainSMART) for ne and NMCP support. All now in place. All the current the provinces were training events that take trainings and future trained in TrainSMART. place are expected to trainings be entered in TrainSMART. ZAPIM will monitor this process. CM Training database Year 3 0 1 1 1 N/A All the outstanding Now that the training configured with milesto training events were database is functional, transfer of cleaned ne entered into the ZAPIM will continue to data from existing TrainSMART data base. work with will all the systems. provinces and ensure that data entry of all the training events is up to date. CM Number of Year 3 0 30 22 22 73.3% The participants included The trained personnel mentors trained milesto doctors, nurses, pharmacy will continue to provide for the pilot ne and laboratory personnel. mentorship to other mentorship Matabeleland North (10), health personnel in Year program Mashonaland East (8) and 4 Masgonaland Central (4) CM NMCP CM/MIP Year 3 1 2 1 1 50% The other meeting was ZAPIM will continue to subcommittee milesto not conducted because of engage NMCP so that quarterly meetings ne competing activities subcommittee meetings supported
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps are held on a regular basis. CM Assessment of Year 3 0 1 1 1 N/A The draft report is Report writing is malaria case and milesto available. There was delay ongoing, with the final consumption data ne in the finalization of the report expected in the conducted report because of data Q1 of Year 4. sharing issues. CM Number of staff Year 3 0 300 304 304 101% SMS reminder information The SMS will continue trained in CM/MIP milesto was sent to all health care to be sent out again in reached with SMS ne workers trained since Year 4. information Year 1. reminders and quizzes CM Supportive Year 3 0 500 500 500 100% These were reviewed Already used for the supervision tools milesto together with the mentorship training and and job aids ne mentorship guides will continue to be used reviewed and for mentorship visits updated with NCMP CM Number of on the Year 3 0 5 5 5 100% Initiated malaria clinical ZAPIM will engage the job mentorship milesto mentorship visits in 5 PEDCO and DMO to visits to six ne priority districts covering find a lasting solution to districts conducted 25 health facilities. this problem. Between mid-July to mid- August districts suspended activities because of the national elections. Binga has been lagging behind because of
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps unavailability of a vehicle for mentorship visits. Number of malaria Year 3 2 (Year 1 3 3 3 100% These death audit ZAPIM needs to death investigation/ milesto ZAPIM meetings were conducted continue supporting malaria death audit ne Annual in Matabeleland North (2) these critical meetings meetings with Report) and Mashonaland central and see how to support NMCP, hospitals (1) provinces. The teams provinces to address and PMDs, DMOs, audited the deaths to major issues from the and Matrons in determine the main death audit meetings. attendance causes of malaria deaths, Mashonaland East the system and meeting was management challenges rescheduled to resulting in these deaths, October/November identify avoidable causes 2018 of deaths, and plan ways of curbing the avoidable deaths. CM Number of facility- Year 3 0 50 48 48 96% A total of 48 health The orientation is based health milesto workers from Binga and expected to strengthen workers oriented ne Hwange Districts were malaria community case on supportive oriented. management programs. supervision process and tools CM Number of Year 3 0 319 214 214 67% The assessment focused ZAPIM will continue to potential VHW milesto on patient assessment, support the health peer supervisors ne RDT testing, and waste facility staff to conduct followed up (post- management, medicine post training follow-ups training follow-up) dosage and storage, in Year 4. documentation and
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps reporting. The other targeted VHWs could not be found at home at the time of the visits. CM Number of training Year 3 0 1,800 1,800 1,800 100% All training manuals and Supportive supervision manuals and job milesto job aids were printed, and DQAs will be used aids (facilitators ne resulting in smooth to assess whether the and participant running of the trainings tools are being used. manuals, medicine supply and accountability register, RDT job aid and monthly reporting book) printed CM Number of bi- Year 3 0 8 4 4 50% Four districts- Shamva, Need to work with annual district milesto Mutoko, Bindura, and district and health staff VHW review ne Mudzi. A total of 159 out to ensure that any meetings of a target of 160 VHW issues identified during conducted (eight representatives attended post training follow-up districts) the meetings. of VHWs are addressed. CM Number of items Year 3 0 2,233 2,233 2,233 100% The items were procured The items continue to procured for the milesto and distributed , some of incentivize the VHWs VHWs (T-shirts, ne them have continued to and also help them to timers, rain coats, be used for training. perform their duties bags and salter diligently. Items were scales) distributed to Mudzi, UMP, Hwange and Binga
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps CM Number of EHTs Year 3 0 60 0 0 0% The activity will no longer Scheduled for Year 4 and nurses milesto be conducted this year. supported to ne There is need to come up conduct VHW with systems to account supportive for fuel and allowances supervision given to the health workers before supporting the initiative CM Number of District Year 3 0 16 7 7 44% A total of eight districts Engagement of ZAPIM VHW supportive milesto were supposed to receive provincial coordinantors supervision visits ne two visits each. Only one in Year 4 will facilitate conducted round of supportive the support to the supervision visits was districts to ensure done to seven districts VHWs receive the due to competing desired support activities LLIN Proportion of PMP 49% (MIS N/A 54% 54% N/A The figure of 54% is The indicator is not population that 2012) according to the MIS reported every quarter slept under an 2016. or year.. insecticide treated net the previous night LLIN Proportion of PMP 8% N/A 17.5% 17.5% N/A It is important to note the There is need to scale children under-five (ZDHS (ZDHS (ZDHS 2015) different methologies used up the interventions who slept under an 2010-11) 2015) for MIS and ZDHS. which promote net LLIN the previous 49.6% usage among children. night (MIS 33% 33% (MIS The new National 2012) (MIS 2016) Malaria Strategic Plan is 2016)
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps still being costed and will inform the targets. LLIN Proportion of PMP 49.1% N/A 36% 36% (MIS N/A Only 36% of women slept There is need to scale women of child (MIS (MIS 2016) under an LLIN the up the interventions bearing age who 2012) 2016) previous night, which was which promote net slept under an a substantial decrease usage among women LLIN the previous compared to the 49% in aged 15-49 years. The night the 2012 MIS. new National Malaria Strategic Plan is still being costed and will inform the targets. LLIN Proportion of PMP 46.4% N/A 58% 58% (MIS N/A The baseline and results The National Malaria households in (MIS (MIS 2016) are national. M&E Plan is being ZAPIM target 2012) 2016) finalized and will inform districts with one the targets. or more LLINs LLIN LLIN Continuous PMP 10 (Year 1 12 9 9 75% LLIN Continuous Distribution of CD of distribution system ZAPIM distribution system was LLINs commenced in rolled out in Annual rolled out in Bindura, Quarter 1 of Year 3. ZAPIM target Report) Centenary, Guruve, districts Mazowe, Mt Darwin, Rushinga, Shamva, Goromonzi and Murehwa. LLIN Net durability PMP 0 1 1 1 N/A Data collection and Month 36 is the last study findings analysis for the 18 and 24- durability monitoring produced and month study were assessment. This is recommendations completed. Study reports scheduled for Q1 of adopted for future to be finalised in October Year 4 2018
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps distribution planning LLIN Number of trainers PMP 0 320 377 377 118% Different approach was The training approach is trained on used. Instead of cost effective and helps continuous LLIN conducting provincial to cascade the training distribution TOT, health facility staff to the community were trained as trainers. cadres. The approach The health facility staff should be continued in cascaded the training to Year 4 and subsequent the VHWs. years. LLINs Number of Year 3 0 6 6 6 100% Meetings were conducted Scale up LLIN community milesto to sensitize community distribution Leaders’ meetings ne leaders on LLIN on LLINs distribution conducted LLIN Number of people PMP 1,358 770 728 728 94.5% The cadres were trained Now that the cadres (LLIN Distributors) (Year 1 in use of rectangular nets have been capacitated in trained in LLIN ZAPIM use of rectangular nets, routine/continuous Annual this will go a long way in distribution Report) scaling up LLIN continuous distribution LLIN Number of LLINs PMP 573,950 889,950 807,700 807,700 90.7% These were distributed by Remaining LLINs will distributed (Year 1 ZAPIM and PMI continue to be ZAPIM distributed as per need Annual Report) LLIN Number of ANC PMP TBD 98 98 98 100% 98 health facilities in 11 Effort will be made to clinics districts are involved in ensure that all the ANC CD of LLINs clinics in 10 districts
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps implementing LLIN implement LLIN routine routine distribution dstribution. LLIN Number of existing Year 3 1 (Year 1 1 1 1 1 SOP on net aearation was If effectively used, the guidelines, milesto ZAPIM produced SOP will improve net implementation ne Annual usage tools and status of Report) malaria vector control reviewed to inform the development of vector control policy LLIN Number of vector Year 3 1 (Year 1 2 1 1 50% The other meeting was ZAPIM will continue to control milesto ZAPIM not conducted becaues of engage NMCP so that subcommittee ne Annual competing activities subcommittee meetings meetings Report) are held on a regular supported basis. LLIN Establishment of Year 3 0 1 1 1 N/A ZAPIM continued to Implementation is Entomology milesto support the training expected to go ahead as Training at AU ne centre soon after its planned. supported establishment. SBCC SBCC repository PMP 0 1 0 0 0 This falls under the ZAPIM will no longer (on-line data base) portfolio of the support the activity. of malaria mainstream MOHCC. messages and delivery methods established
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps SBCC Number of PMP 1066 696 696 696 100% These were trained from Follow up visits to persons trained in (Year 1 84 HCCs HCCs to be intensified SBCC ZAPIM in Year 4 Annual Report) SBCC Rapid assessment- PMP 0 1 1 1 100% NMCP, with ZAPIM The report is currently Knowledge, support, conducted an under develppment and Attitude and assessment to the results will be used Practice Surveys of systematically identify the to provide evidence for the Mbire drivers of high malaria implementing required community transmission in Angwa programmatic decisions completed Ward despite reported and for improving high levels of intervention similar situations in coverage. other areas of the country and beyond. SBCC Commemoration Year 3 0 1 0 0 0 Due to a politically ZAPIM will continue to of the SADC milesto motivated high- alert support future Community Malaria ne situation in the country commemorations. Day supported the event was indefinitely postponed SBCC World Malaria Day Year 3 3 3 1 1 33% One provincial level ZAPIM will continue to Campaign milesto World Malaria Day support future supported in 3 ne commemorations was commemorations.. provinces done in Mashonaland Central and supported with provision of BCC material for distribution
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps SBCC SBCC materials Year 3 0 450 400 400 89% This include 350 Tonga These were printed and and tools, malaria milesto copies tool kit and 50 Chikunda distributed. Rapid calendar and ne Talking Book assessments required to talking book for see if these are making hard to reach any change in the communities communities. printed and disseminated SBCC VHW SBCC Year 3 0 500 500 500 100% All material distributed Need for continued facilitator tools milesto copies review of the tools reviewed and ne where necessary printed SBCC National level Year 3 0 1 1 1 N/A ZAPIM also supported the ZAPIM will be a key malaria branding milesto rebranding initiatives of partner supporting this initiative to ne the NMCP process to continue in operationalize Year 4. strategy 7 of Malaria Communication Strategy SBCC Number of Year 3 0 3 1 1 33% No budget for this ZAPIM will support the provincial cross- milesto activity. However, ZAPIM provinces in Year 4 border ne participated in the collaboration development of ZAM/ZIM meetings on SBCC terms of reference for the community change steering committee. SBCC Number of Year 3 0 500 500 500 100% All the materials were Monitor the use of promotional milesto printed and distributed materials ne
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps materials procured for HCC members SBCC Number of HCCs Year 3 0 86 84 84 97.8% Bindura and Mt Darwin These will be supported followed up (post- milesto hospitals not doing the in Year 4 training follow-up ne follow up because of visits) conducted budgetary constraints SBCC Number of radio Year 3 0 2 0 0 0 Radio spots production to All media campaigns to spots produced for milesto commence in Year 4 commence in Year 4 sensitization on ne LLINS campaign SBCC Number of radio Year 3 0 2 0 0 0 Radio spots production All media campaigns to spots produced for milesto to commence in Year 4 commence in Year 4 sensitization on IRS ne campaign SBCC Number of Year 3 0 86 84 84 97.8% Districts not following up Follow up with advocacy meetings milesto because of resources community stakeholders with community ne on LLIN use stakeholders on LLIN use conducted SBCC Number of SBCC Year 3 1 2 1 1 50% The meetings were ZAPIM will continue to Sub-Committee milesto coordinated by NMCP. engage NMCP so that meetings ne These were platforms at subcommittee meetings conducted which malaria SBCC are held on a regular implementation by all basis. MOHCC structures are reviewed and reports from provincial and district levels presented
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps SBCC ZAPIM Website Year 3 0 1 0 0 0 On hold; home office On hold until further developed and milesto considering budget notice from home office populated ne M&E Number of PMP 10 (Year 1 144 101 101 70%% The trainings were There is still a big districts and health ZAPIM conducted in Mashonaland training gap and Year 4 facility staff trained Annual East and Matabeleland budget is anticipated to in M&E, supportive Report) North Provinces. Training cover part of the supervision, in Mashonaland Central deficit. epidemic alert was not done because of protocols competing activities (EPR/IDSR) M&E ZAPIM M&E Year 3 0 1 1 1 N/A The M&E Database was M&E Database will database updated milesto updated on a regular continue to be updated ne basis. in Year 4 and used to monitor the performance of the project. M&E Number of Year 3 0 6 4 4 67%% ZAPIM supported the DQAs provide a national, provincial milesto three provinces to platform for onsite and district data ne conduct DQAs at mentorship and has quality assessments selected health facilities in proven to be a strategic (DQAs) conducted the districts. A total of 47 mechanism for health facilities: Binga (7), enhancing the quality of Hwange (2), Murehwa routine data. ZAPIM will (12), Goromonzi (12), continue to support Mbire (7) and Guruve (7) regular DQAs in Year 4. participated in the DQAs
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Targets/ Benchmarks Results
Indicator/ Baseline* Year 3 Oct YR 3 Year 3 Percentage of Milestone for 2017 – Results Cumulative Annual Target Comments/ # Year 2 Activity Type Sept 2018 Results Achieved Problems Encountered Next Steps M&E Number of Year 3 0 6 4 4 66.7% ZAPIM provided both ZAPIM will continue to provincial and milesto financial and technical finance and provide district planning ne support to the three technical support to the and review provinces to undertake three provinces to meetings the malaria review undertake malaria conducted meetings Two bi-annual review meetings in Year meetings were conducted 4 in Matabeleland North. The budget was not sufficient to conduct two meetings in the other provinces. M&E Number of Year 3 0 2 1 1 50% The meeting are ZAPIM will continue to Surveillance, M&E milesto coordinated by NMCP. engage NMCP so that and OR Sub- ne Only one Surveillance, subcommittee meetings Committee M&E Subcommittee are held on a regular meetings meeting was conducted basis. supported during the year.
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ANNEX D: ADDENDUM ON THE ECONOMIC SITUATION IN ZIMBABWE
Following the close of FY18, recent economic developments that have direct impact on project implementation in FY19 have necessitated the write-up of this addendum. The purpose of the addendum is to highlight economic challenges, the impact on ZAPIM project implementation and possible mitigating solutions.
Zimbabwe’s economic challenges continue to escalate and the government frantically attempts to solve the problems as they deepen by introducing new policies. New monetary and fiscal policy statements were announced on September 29 and October 1, 2018 by the Reserve Bank of Zimbabwe Governor and the Minister of Finance and Economic Development respectively. In summary two key measures that impact project implementation were introduced; 1. Monetary – Operationalization of the February 2018 ring-fencing policy on Nostro foreign currency accounts (FCAs) which seeks to separate foreign currency accounts into two categories, namely Nostro FCAs and Real Time Gross Settlement (RTGS) FCAs by October 15, 2018. 2. Fiscal – The Intermediated Money Transfer Tax was reviewed upwards from 5 cents per transaction to 2 cents per dollar transacted effective October 1, 2018.
Since the announcements, the economic situation in Zimbabwe has further deteriorated. Prices of goods and services have increased drastically in line with USD black market exchange rate. Some basic commodities such as cooking oil, flour, bread and sugar have disappeared from the market and long winding queues have emerged for fuel. Vendors have created three prices based upon method of payment- - the USD cash price, which is much cheaper, more realistic and the preferred payment option for vendors, the higher prices associated with bond cash, and the electronic payments, such as Ecocash (payment through mobile vendor) and bank transfers.
The situation described above has presented the following problems for the project: More rapid than expected depletion of project budget due to increased costs. Delays and deferment of some project activities. Vendors and service providers insisting on cash payments posing security risks on project staff. Unavailability of fuel has made project travel difficult. Public transport fare increases have negatively impacted staff movements to and from work as well as partner personnel attendance to project meetings, trainings and interventions. Current per diem for participants and staff has become inadequate. Staff absence at post due to fuel shortage and looking for vital commodities/drugs. Staff salaries erosion as cost of living continues to escalate. Health insurance has been suspended in some cases. Medicines not readily available due to foreign currency shortages. Non-availability of safe drinking water, with bottled water becoming increasingly scarce.
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To date, some activities that require field travel and grouping people together have had to be postponed in part due to lodging and conferencing costs that have doubled or tripled in some cases and the possible delay in the release of FY19 funding for ZAPIM. Below is a list of affected activities; 1. Case management trainings 2. Deaths audit meetings 3. M&E review meetings 4. Community action cycle meetings 5. Community case management trainings and follow-up visits.
ZAPIM explored options to mitigate the impact of the problems and identified the following possible short to medium term solutions and benefits. Recommended solutions Benefits of the recommended solution Minimize amount of funds kept in the local project Splitting the monthly remittances into tranches accounts by splitting the monthly wire transfer will ensure that only minimum funds will be kept into two tranches. in the local project bank accounts, thereby safeguarding USG funds and reducing the risk of loss of large amounts of funds to possible government policy changes and shifts. Purchase pre-paid fuel in USD for project Purchasing fuel in USD will ensure smooth activities. continuation of project activities as there will be guaranteed access to fuel from designated service stations in major cities and towns. Make cash payments to vendors when absolutely Making cash payments whenever reasonable and necessary and practical to do so to maintain feasible will ensure that project budgets will not be reasonable prices. depleted before time. ZAPIM will be able to undertake all previously budgeted for activities as per approved work-plans thereby submit promised deliverables to PMI. However, safety precautions will take precedence over other factors. Encourage regular vendors to open Nostro FCAs. The opening of Nostro FCAs will be critical for vendors as this will help retain USD value, allow access to hard cash and will not require a departure from ZAPIM established financial management processes. Review the current ZAPIM approved lower than An upward review of the per diems will motivate established USAID per diem policy staff as well as participants and ensure that adequate financial resources are availed while on field mission. Continue to pay part of the staff salaries through Current WU arrangement has greatly motivated the Western Union (WU) arrangement and staff as they access 50% of their salary in cash. The ensure staff has functional Nostro FCAs. opening of Nostro FCAs will be critical for staff as this will help retain USD value, allow access to hard cash and will not require a departure from ZAPIM established financial management processes.
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Staff to utilize the Abt Zimbabwe WhatsApp group Both formal and informal communication is highly to alert and inform each other where basic essential in volatile situations to manage security commodities are available in-country or in case of and psychological effects on staff that have impact insecurity. on staff as they perform their daily duties. Staff encouraged to further explore options of While this option may involve travel to buying basic commodities from neighboring neighboring countries, staff would be guaranteed countries. of accessing basic commodities. However, staff would have to take vacation time and coordinate this option outside project time.
All proposed solutions do not anticipate additional costs to the project. Additional, unforeseen challenges and solutions may emerge over time.
ZAPIM will continue to monitor the economic situation and ensure safe custody of USG funding. While waiting for stabilization of the context, the project will focus on documentation of best practices and continue to prioritize time-sensitive activities. The activities will be implemented using safe cost-effective measures that result in value for money output yet still deliver quality deliverables stated in the approved work-plan.
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