Program for the Advancement of Malaria Outcomes (PAMO) Malaria Health Systems Gap Analysis Report

PMI/Program for the Advancement of Malaria Outcomes (PAMO) - PATH Mikwala House Stand 11059 Off Brentwood Lane Longarces, Post.Net Box 370, Pvt. Bag E10| Lusaka, Zambia

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Table of contents List of Abbreviations ...... 5 Executive Summary ...... 6 Introduction ...... 8 Background ...... 9 Justification for the gap analysis ...... 10 Objectives of the gap analysis ...... 11 Specific objectives ...... 11 Focus and methodological approach ...... 11 Geographical coverage ...... 11 Thematic coverage ...... 11 Data collection ...... 11 Data cleaning and Analysis ...... 11 Presentation and discussion of findings ...... 11 Objective 1: To establish the status of PAMO supported provinces and districts with regard to implementation of proven malaria interventions...... 12 ITN distribution in target districts ...... 12 IRS coverage in target provinces ...... 16 Improve access to and quality of malaria case management at public health facilities and community level to ensure prompt, accurate diagnosis and appropriate treatment of malaria ...... 19 Delivery of Intermittent Preventive Treatment to pregnant women (IPTp) using Sulphadoxine-Pyrimethamine (SP) as part of an integrated package of antenatal services ...... 23 Civil society and community-based organizations implementing malaria control activities ...... 27 Objective 2: To assess and document management capacities of provincial and district MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions ...... 27 Management capacity ...... 28 Tailored capacity-building plan ...... 29 Quality HMIS data reporting ...... 30 Technical/material assistance to DMOs, health facilities, and communities to assist with training for the roll out of DHIS2 in the targeted provinces and districts ...... 31 Capacity building for DMOs and health facilities to improve supply chain management for malaria drugs and related commodities in the targeted provinces and districts ...... 32 Objective 3: To establish the levels of malaria health care financing with focus on financing sources and trends ...... 33 Funding of Malaria Activities ...... 33 Sources of Funding ...... 34 Funding Challenges ...... 34 Major Gaps in Malaria Prevention and Treatment...... 35 Conclusion and Recommendations ...... 35 Annex ...... 37

Malaria health systems gap analysis task team

Principal Investigator: Maurice Pengele, BSW, HMP, MCD, AHMP - M&E Technical Specialist – PAMO/PMI – PATH

Co-Principal investigators: Godfrey Biemba, MBCHB, M.Sc. - Country Director – ZCAHRD Shadrick Chembe, MCD, B.Phil., M&E Cert. - Consultant

List of Abbreviations

ANC Antenatal care BCC Behavior change communication BRITE BroadReach Institute for Training & Education CBO Community-based organizations CCP Johns Hopkins University Center for Communication Programs CD Continuous distribution CHA Community Health Assistant CHAZ Churches Health Association of Zambia CHW Community Health Worker COP Chief of Party CSO Civil society organization DMO District Medical Office DHIS2 District Health Information System 2 DHS Demographic Health Survey EPI Expanded Program on Immunization GRZ Government of the Republic of Zambia HMIS Health Management Information System iCCM Integrated community case management IEC Information, education, and communication IPTp Intermittent preventive treatment in pregnancy IRS Indoor residual spraying ITN Insecticide-treated net MACEPA Malaria Control and Elimination Partnership in Africa M&E Monitoring and evaluation MIP Malaria in pregnancy MIS Malaria Indicator Survey MOH Ministry of Health NHC Neighborhood Health Committee NMCC National Malaria Control Center NMCP National Malaria Control Program NMSP National Malaria Strategic Plan OCA Organization Capacity Assessments OR Operations Research OTSS Outreach Training and Support Supervision PAMO Program for the Advancement of Malaria Outcomes PMI President’s Malaria Initiative PMO Provincial Medical Office PMP Performance Monitoring Plan SBCC Social and behavior change communication SMAG Safe Motherhood Action Groups TWG Technical working group WHO World Health Organisation ZMLA Zambia Management and Leadership Academy ZCAHRD Zambian Center for Applied Research and Development Executive Summary With support from the American Government through the President’s Malaria Initiative (PMI), the Program for the Advancement of Malaria Outcomes (PAMO) has been designed with the principal aim of reducing illness and mortality due to malaria by addressing key challenges in malaria prevention and treatment. PAMO contributes to USAID and the President’s Malaria Initiative’s (PMI) goals of strengthening the capacity of Zambia’s Ministry of Health (MOH) to implement the National Malaria Strategic Plans at provincial, district, and community levels. Zambia has made impressive gains in controlling malaria in the last decade due to robust malaria control policies, committed governmental leadership, and strong international partnerships, technical support, and financing. Even so, the PAMO target provinces - Muchinga, Luapula, Eastern, and Northern - require focused interventions to achieve the country’s goal of being free of malaria by 2030. The rural nature of the provinces, which have an estimated total combined population of five million, makes this effort particularly challenging.

PAMO specific objectives are to support proven malaria interventions in line with the National Malaria Control Program (NMCP), strengthen management capacity of provincial and district personnel to provide oversight of interventions, and strengthen information systems at provincial and district levels to improve data reporting, analysis, and use for decision-making. Selected strategies include strengthening school- based distribution, looking at multiple distribution channels for ITNs, using technology to examine net coverage and improve use, strengthening capacities of practitioners in diagnosis and case management, strengthening linkages for supply chain management, updating training curricula and guidelines, and working with community leaders to tailor our efforts to specific needs in each target catchment area.

Before commencing the implementation of PAMO activities, a malaria health systems gap analysis was conducted in order to identify programmatic requirements needed to sufficiently plan and fully implement the program. This report, is therefore, an outcome of the assessment. In comprises the introduction, background, methodology, findings, conclusion and recommendations. The essence of a gap analysis was to identify programmatic requirements needed to sufficiently plan and fully implement a program.

To assert it as a proactive platform for planning PAMO activities, the gap analysis followed an evidence- based approach to planning and programing based upon the targets and strategies outlined in the National Malaria Control Program (NMCP), upon which the design elements of PAMO hinge.

The principal objective of the gap analysis was to identify programmatic requirements needed to fully plan and implement PAMO activities in line with the National Malaria Strategic Plan. The information obtained would be helpful in designing work plans by intervention provinces and consortium partners. The specific objectives were:

1. To establish the status of PAMO supported provinces and districts with regard to implementation of proven malaria interventions. 2. To assess and document management capacities of provincial and district MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions 3. To establish the levels of malaria health care financing with focus on financing sources and trends.

The assessment covered all the 36 districts in the four PAMO supported provinces. Therefore, it was comprehensive enough to have the results of the analysis generalized to the rest of the designated geographical reach of PAMO. The analysis was guided by the key intervention areas of malaria programming based on the National Malaria Control Program and the PAMO M&E results framework.

Data collection involved documentary reviews and key informant conversational sessions with relevant district health staff. Predominantly, desk review was performed. Further interviews were conducted with relevant provincial and national health staff to complete gaps from district data sources and to address policy related and other high levels information pieces. SPSS was used for data processing and analysis and results were transferred to excel spreadsheets in The assessment tracked many indicators related to PAMO’s three objectives. While performance across districts was varied from indicator to indicator, the following are the major issues that were identified:  Low percentage of districts with distribution and supervision plans to develop and implement them.  Low ITN coverage for under-five, ANC and mass distribution in most of PAMO districts.  Few facilities with at least a staff trained in performing RDTs.  Inadequate provincial supervision of district level staff in a number of areas such as iCCM, MIP and IPTp-SP.  Low adherence to the MIP policy of ensuring that all women who attend ANC clinics receive at least two doses of IPTp against malaria.  Small proportion of PAMO districts with staff trained in MIP.  Lack of MIP data review by most districts.  There is need for the project to ensure that all districts develop management capacity building plans.  Few districts with improved management processes aligned with capacity building plans.  Inadequate HMIS data management skills and practices.  Insufficient staff trained in supply chain and logistics management.

In view of the findings, the following recommendations are proposed:

 There is need to develop strategies that will contribute to closing the gaps that have been identified by the assessment.  Subsequent assessments should ensure the use of standard data collection tools and right measurements for indicators to be more meaningful in aiding decision making.  PAMO should explore ways of helping districts to adhere to the MIP policy of ensuring that all women who attend ANC clinics receive at least two doses of IPTp against malaria.  There is need for capacity building in HMIS data management.

Introduction With support from the American Government through the President’s Malaria Initiative (PMI), the Program for the Advancement of Malaria Outcomes (PAMO) has been designed with the principal aim of reducing illness and mortality due to malaria by addressing key challenges in malaria prevention and treatment. PAMO contributes to USAID and the President’s Malaria Initiative’s (PMI) goals of strengthening the capacity of Zambia’s Ministry of Health (MOH) to implement the National Malaria Strategic Plans at provincial, district, and community levels. Zambia has made impressive gains in controlling malaria in the last decade due to robust malaria control policies, committed governmental leadership, and strong international partnerships, technical support, and financing. Even so, the PAMO target provinces - Muchinga, Luapula, Eastern, and Northern - require focused interventions to achieve the country’s goal of being free of malaria by 2030. The rural nature of the provinces, which have an estimated total combined population of five million, makes this effort particularly challenging.

PAMO is a consortium of various expert organizations with PATH as the prime. Others are Johns Hopkins Center for Communication Programs (CCP), Jhpiego, BRITE and ZCAHRD and will all work closely with the National Malaria Control Centre and the provincial and district authorities in the four selected provinces to achieve PAMO objectives. Led by PATH, the partners will have distinct roles and responsibilities. PATH will manage the PAMO team, ensuring maximum responsiveness and connectivity across the program’s objectives and geographic focus areas, and leveraging the unique expertise and experience of each partner in the PATH-led consortium. PATH will also provide technical and programmatic leadership in support of objectives two and three, building capacity of provincial and district partners in malaria program management; and improving quality and timely reporting of HMIS/DHIS2 data, and using these data for program decision making.

Jhpiego will provide technical and programmatic leadership to support effective malaria in pregnancy (MIP) and, in coordination with PATH, support improved case management including effective scale up of Integrated Community Case Management (iCCM). They will also lead PAMO implementation in Luapula province. JHU-CCP will provide technical and programmatic leadership to support effective campaign and continuous distribution of Insecticide Treated Nets (ITNs) and support effective BCC in target Provinces. ZCAHRD will provide technical and programmatic leadership to support priority Operations Research for PAMO. BRITE will support in identification of malaria program management capacity development needs across malaria control interventions with a focus on improving linkages between facility and community levels.

Background Malaria, though preventable and curable, remains a public health problem in Zambia. It remains one of the leading causes of morbidity and mortality. It also still remains among the top ten major causes of visitation to health facilities; accounting for over 40 percent of all health facility visitations in Zambia. The disease poses a severe social and economic burden on communities living in endemic areas (MoH, 2011). Children under age 5, pregnant women, and individuals whose immune systems are compromised are the most vulnerable populations at risk for malaria. Malaria is endemic in all the ten provinces of Zambia both in urban and rural areas (CSO et al. 2014).

The Zambian Government is aware of the social and economic challenges that malaria poses and has hence identified malaria control as one of the main public health priorities. This is evidenced in National Development Plans and National Health Strategic Plans. For example, the Ministry of Health (MOH), through the National Malaria Control Centre (NMCC), developed a National Malaria Strategic Plan (NMSP) 2011–2015, aimed at significantly sustaining the gains achieved during initial scale-up efforts of malaria control interventions toward the achievement of the national vision of ‘a malaria-free Zambia’ (MoH, 2012).

The NMSP was reviewed in 2013 resulting into a one year extension to 2016. The theme of the NMCP (2011-2016) is to consolidate malaria control gains for higher impact while the vision is a malaria-free Zambia by 2030. Its mission is to facilitate equity of access to quality-assured, cost-effective malaria prevention and control interventions, close to the household. The plan has four goals which are: 1) To reduce malaria incidence by 75% of the 2010 baseline by 2015; 2) To reduce malaria deaths to near zero by 2015; 3) To reduce all-cause child mortality by 20% of the 2010 baseline by 2015; and 4) To establish and maintain five “malaria-free areas” in Zambia by 2015.

Zambia’s twofold effort to fight malaria focuses on prevention and control. Prevention of malaria transmission is achieved through two primary means which are use of ITNs and IRS. Additionally, there are specific complementary interventions for pregnant women through provision of free-of-charge ITNs to beneficiaries at antenatal clinics (ANCs) as well as the provision of IPT with sulfadoxinepyrimethamine (SP). On the other hand, malaria control focuses on selected interventions which include provision of prompt and effective treatment with artemether-lumefantrine (ART-LUM) within 24 hours of symptom onset (MoH, 2012).

Malaria prevention and control interventions are implemented within a framework of a clearly established health system delivery structure anchored on two ministries: MoH and MCDMCH. (Zambia Malaria Operational Plan FY 2016). At national Level, the MOH Headquarters in Lusaka is responsible for overall coordination and management of the health sector. Provincial Health Offices (PHOs) are responsible for coordinating health service delivery in their respective provinces while District Health Offices (DHOs) are responsible for coordinating health service delivery at district level. At community level, Neighbourhood Health Committees (NHCs) have been established to facilitate linkages between the communities and the health system (MOH, 2011). The MoH is responsible for planning, providing health policy guidelines, surveillance, monitoring and evaluation, allocation of funds, and sourcing key health inputs such as drugs and equipment for service delivery. The MOH, through the National Malaria Control Centre (NMCC), also provides technical support but not operational assistance. On the other hand, the MCDMCH provides technical oversight for the implementation of health activities at district, health center, health post, and community levels. MCDMCH, through the DHOs that are responsible for

implementing activities such as IRS, ITN distribution and malaria case management at level 1 hospitals, health centers and community levels (Zambia Malaria Operational Plan FY 2016).

Malaria control and prevention efforts, however, cannot be sustained without effective and efficient systems that allow for collection, analysis and sharing of information in order to aid timely decision making across all the levels from community to national level. According to the World Health Organisation (WHO) (2015), malaria predominates in countries with weaker health systems. In light of this, a number of partners have worked with the MoH to establish and strengthen malaria health systems. For example, the MoH has been supported by MACEPA to design and introduce a rapid reporting system that records specific points of malaria data each week. The data is then sent to a central server by mobile phone. This allows program managers to focus interventions on specific needs based on the information which is readily available at district, provincial, and national levels (PATH (2010-2016).

Suffice to note that Zambia has made impressive gains in controlling malaria in the last decade due to robust malaria control policies, committed governmental leadership, and strong international partnerships, technical support, and financing. However, a number of challenges still need to be dealt with if Zambia is to continue recording significant progress towards a ‘malaria-free Zambia’. One of the challenges is limited availability of funds to carry out activities at the district and community levels. For example, MCDMCH recently recruited and filled a number of key positions at the central level to avert the staffing challenges. Nevertheless, availability of operational funds for the recruited staff to perform their respective tasks which include regular supportive supervision to the districts remains a major challenge. Furthermore, Zambia’s heavy dependence on external funding poses another challenge for malaria prevention and control especially in light of decreasing donor funding. For example, the shift of DIFD resources away from malaria control activities leaves a major gap in the procurement of ITNs, RDTs, ACTs and essential medicines and supporting IRS (Zambia Malaria Operational Plan FY 2016).

Moreover, Zambia has a large cadre of community health workers providing treatment for malaria at community level particularly in rural areas. However, the treatment data from CHW is generally not reported in the national HMIS. According to a 2014 PMI-supported review, data challenges were the main reasons for the mismatch between reported cases in HMIS and antimalarial and RDT consumption data. As a result, the real annual malaria burden is higher than that reported in the HMIS. This poses a great challenge in combatting malaria especially in Zone 3 (Eastern, Luapula, Muchinga, Northern, and North- Western Provinces where progress) in malaria control has been achieved but not sustained leading to lapses.

Justification for the gap analysis The essence of a gap analysis was to identify programmatic requirements needed to sufficiently plan and fully implement a program. The assessment covered key malaria control interventions, which include vector control Long Lasting Insecticidal Nets (LLINs), Indoor Residual Spraying (IRS)), case management (diagnostic testing and treatment), preventive chemotherapy (Intermittent preventive treatment in pregnancy (IPTp), Intermittent Preventive Treatment in infancy (IPTi), and seasonal malaria chemoprevention (SMC). It also covered supportive activities needed to effectively deploy and monitor these interventions such as management capacity, training, Behavior Change Communication (BCC), Monitoring and Evaluation (M&E)/HMIS and malaria health care financing.

Objectives of the gap analysis The principal objective of the gap analysis was to identify programmatic requirements needed to fully plan and implement PAMO activities in line with the National Malaria Strategic Plan. The information obtained would be helpful in designing work plans by intervention provinces and consortium partners. Specific objectives 4. To establish the status of PAMO supported provinces and districts with regard to implementation of proven malaria interventions. 5. To assess and document management capacities of provincial and district MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions 6. To establish the levels of malaria health care financing with focus on financing sources and trends.

Focus and methodological approach This section is a description of the focus and methodological approach used to conduct the assessment. It consists of the geographical and thematic coverage, data collection, cleaning and analysis.

Geographical coverage The assessment covered all the 36 districts in the four PAMO supported provinces. Therefore, it was comprehensive enough to have the results of the analysis generalized to the rest of the designated geographical reach of PAMO.

Thematic coverage To ensure systematic implementation and alignment of the exercise to concerted national efforts, the malaria health systems gap analysis was guided by the key intervention areas of malaria programming based on the National Malaria Control Program and the PAMO M&E results framework.

Data collection Data collection involved documentary reviews and key informant conversational sessions with relevant district health staff. Predominantly, desk review was performed. Further interviews were conducted with relevant provincial and national health staff to complete gaps from district data sources and to address policy related and other high levels information pieces. Data collection instruments were formulated at national level with the involvement of national and provincial officers from both PAMO and government staff. Thereafter, PAMO and government staff at provincial level piloted the data collection instrument. Once the instruments were finalized, data collectors in each province were recruited and orientated in data collection. Under the supervision of provincial coordinators and provincial capacity development officers as well as provincial level government staff, data collectors went into the field to collect data.

Data cleaning and Analysis To ensure data quality, the data entered in SPSS were run to identify unusual cases which were then corrected by referring back to the respective questionnaires. Then, data analysis was done using Statistical Package for Social Sciences (SPSS). After analysis, results were transferred to excel spreadsheets in order to generate composite figures. Presentation and discussion of findings This section presents findings of the assessment. The findings are organized by objective and thematic area. Presentation and discussion of findings under each of the three objectives are preceded by a brief

11 summary of indicators that guided data collection and analysis. The indicators are grouped under thematic areas which are presented as subtitles.

Objective 1: To establish the status of PAMO supported provinces and districts with regard to implementation of proven malaria interventions. There are four thematic areas that were covered under objective one. These were: 1) ITN distribution in target districts; 2) improved access to and quality of malaria case management at public health facilities and community level to ensure prompt, accurate diagnosis and appropriate treatment of malaria; 3) delivery of Intermittent Preventive Treatment to pregnant women (IPTp) using Sulphadoxine-Pyrimethamine (SP) as part of an integrated package of antenatal services; and 4) Social and Behavioral Change Communication (SBCC) implementation for malaria at health facility and community levels through community mobilization and dialogues. Each of the thematic areas has indicators which were tracked in order to establish the status of the target provinces with regard to the implementation of proven malaria interventions.

ITN distribution in target districts Six indicators were covered under ITN distribution. The first one looked at the percentage of DHOs with district ITN distribution and supervision plans. Figure 1: Percentage of districts with district ITN Findings, presented in distribution and supervision plans per province Figure 1, show that 61.1% (22) of PAMO districts 9 reported to have ITN 9 distribution and 8 supervision plans. Luapula 7 6 had the largest number (9) of districts with the 6 5 plans followed by 5 Muchinga (6) and 4 Northern (5). Eastern 3 2 province had only two 2 districts that reported having an ITN 1 distribution and 0 supervision plan. Luapula Muchinga Northern Eastern Distribution and supervision plans are important in ensuring that proven malaria interventions are implemented. It is only through planning that a district would be able to distribute ITNs in response to what obtains on the ground. Moreover, having distribution and supervision plans can enable efficient and effective use of the already limited resources in malaria prevention. While planning is important, it may only serve the intended purpose if it is reinforced by supervision to ensure that implantation is in line with predefined objectives. Therefore, having 40% of PAMO districts without distribution and supervision plans makes it difficult for these districts to implement proven malaria interventions.

The second indicator looked at ANC ITN coverage which was analysed by calculating the percentage of actual ITN distribution against targets in 2015. 20 (56%) of the 36 PAMO districts had both targets and actual distribution figures. The rest (16) had targets but did not distribute any ITN for reasons presented under the indicator on challenges in ITN distribution with an exception of Mporokoso district which did not have any target for 2015 but distributed some ITNs. As shown by Figure 2, 3 of the 20 districts distributed ITNs ANC beyond their respective targets with Nakonde having the highest percentage of ANCT ITN coverage at 514.4%. Further, findings show that the ITN coverage for 10 districts was above

50% while that of the other 10 was below 50% with Lunga district recording the lowest coverage at only 9.1%. Further analysis revealed that 18 out of the 20 districts that recorded some ITN coverage also reported having ITN distribution and supervision plans. Only two districts, that is, Luwingu and Chilubi, did not report having ITN distribution and supervision plans and yet recorded 54.5% and 49.8% ANC ITN coverage respectively.

2015 ANC ITN coverage

Nakonde 514.4% Mafinga 168.7% Chipata 113.0% Mbala 88.7% Mwense 83.1% Mansa 75.3% Milenge 69.0% Chinsali 66.6% Luwingu 54.5% Mpika 51.3% Chilubi 49.8% Mpulungu 48.3% Chama 41.7% Kasama 41.2% Samfya 33.5% Katete 32.6% Chiengi 29.9% Nsama 28.1% Nchelenge 9.8% Lunga 9.1%

0.0% 100.0% 200.0% 300.0% 400.0% 500.0% 600.0%

The third indicator was based on 2015 coverage of ITNs for under-five and the results are summarized in Figure 3. 18 out of 36 PAMO target districts reported some level of coverage with Chama of Northern province recording the highest at 99.2% followed by Mwense of Luapula province at 97.7% and Mbala onf Northern province at 80.8%. Chiengi district of Luapula province reported the lowest percentage coverage at 2.2%. Similar to an earlier observation, only two (Luwingu and Chilubi) out of the 18 districts that recorded some ITN coverage did not report having ITN distribution and supervision plans. Further, 7 districts (38.9%) reported more than 50% of ITN coverage while the rest (11 districts) were below 50% of ITNs coverage for under-five.

Figure 3: 2015 ITNs for under-five coverage

Chama 99.2% Mwense 97.7% Mbala 80.8% Samfya 74.1% Chinsali 72.0% Mpika 59.2% Milenge 55.4% Luwingu 49.8% Kasama 45.3% Chilubi 42.6% Mansa 36.0% Katete 34.1% Mpulungu 30.8% Chipata 22.6% Lunga 20.0% Nsama 10.3% Nchelenge 9.0% Chiengi 2.2%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

The fourth indicator measured the 2015 ITNs for mass distribution coverage. As shown in Table 1, only one district, Chiengi of Luapula province, had both target and actual distribution figures translating into 95.5% coverage. The remaining 35 districts did not distribute any ITNs for mass distribution because they did not receive any supplies for 2015. The remaining 25 PAMO districts reported having neither targets nor actual distribution. It should be noted that use of ITNs is one of the primary means of achieving malaria prevention. This can only happen with adequate ITN coverage. However, the results on ITN coverage show that there is a significant gap between ‘what should be’ and ‘’what is’. For example, having only 7 districts reporting above 50% of coverage of ITNs for ANC implies that there are still many pregnant mothers that do not access

14 an ITN. The inadequate access to INTs does not only end at pregnant women but also affects children as coverage of ITNs for under-five was equally low in most districts. This shows that there is still a lot that needs to be done to increase access to ITNs. Challenges regarding ITN distribution Respondents were asked to indicate challenges Figure 4: Perceptions of challenges associated associated with with ITN distribution distribution of ITN for ANC, under-five and mass distribution. Since 42.1% the question was open- Transport from DHO to health facility ended, allowing Inadequate supply, misuse and 18.4% respondents to mention inadequate BCC on proper of ITNs as many challenges as they Stock-outs 18.4% faced, responses were grouped in sets as shown Transportation to homes 10.5% in Figure 4. 42.1% of respondents cited Stock-outs, no trained malaria agents 5.3% and ITN distribution not done annually transportation of ITNs Stock-outs and communication 2.6% from DHO to health challenges facilities as the most Stock-outs and transport from DHO to 2.6% common challenge health facility followed by a set of 0.0 10.0 20.0 30.0 40.0 50.0 challenges which included inadequate supply, misuse of ITNs by recipients and inadequate Behaviour Change Communication (BCC) on proper use of ITNs and stock-outs. It is noted that transport is again cited as a challenge by 10.5% of respondents except this time it is transportation of ITNs from health facilities to households or homes. The other challenges that were mentioned included stock-outs, lack of trained malaria agents and communication.

Some challenges seemed to fall within what the PAMO project could address such as misuse of ITNs and lack of trained malaria agents. These can be dealt with directly through capacity building in identified weak areas. Others, however, such as inadequate transport and stock-outs require provision of resources to close the gaps. Nevertheless, resource provision on its own may not be sustainable as the problem resurfaces the moment supply is terminated. Therefore, even challenges relating to inadequate resources could also be treated partly as gaps in certain capacity domains. For example, proper planning can minimize the challenge of inadequate transport in the sent that transportation of ITNs can be integrated with transportation of other medical supplies.

Solutions to improve ITN coverage and usage

Figure 5 shows respondents suggestions Figure 5: Suggested solutions to improve ITN coverage on how to deal with the and usage identified challenges in order to improve ITN Improve transport and timely supply 30.8% coverage. The majority of respondents Routine supply of ITNs 17.9% recommended the need To have adequate stocks and transport to 12.8% to improve transport communities and timely supply. This Acquire transport 7.7% was followed by 17.9% who suggested that there Adequate supply and good data collection 7.7% should be routine supply Adequate supply, sensitisation of proper 7.7% of ITNs. Other solutions usage and formulate laws to prevent misuse included the need for Improve coordination among communities, 7.7% adequate ITN stocks and staff and DHO available transport, Routine supply of ITNs and stakeholder 5.1% improving data involvement Routine supply of ITNs and training malaria collection, sensitisation 2.6% agents of communities on proper use of ITNs coupled with formulation of laws to prevent misuse, improved coordination among community members (users), health facility staff and DHOs and training of malaria agents in ITN distribution.

Some of the proposed solutions indicate that proper planning is required to deal with some of the challenges. Improving transpoort and timely supply suggest to some extent that ITNs are supplied at some point but not on time. Whle untimely supply can easily be blamed on inadequate transport, and true in some cases, it is also possible to have transport and yet not supply ITNs on time due to other reasons such as lack of proper planning. Therefore, each of the solutions needs to be interogated during implementation in order to deal with root causes of the identified challenges.

IRS coverage in target provinces Results on IRS coverage are organized under three items: i) IRS coverage itself measured by the percentage of structures sprayed against target in 2015; ii) challenges affecting IRS coverage; and (iii) perceived solutions to deal with the challenges in (ii). Figure 6 is a summary of results on IRS coverage in 2015 in terms of the percentage of structures that were sprayed in 2015 against district targets. At least 85% of the structures that were targeted in 2015 in the 25 districts that reported IRS coverage were sprayed. Nine out of the 25 districts that reported coverage had either 100% or more structures sprayed against target. Widest coverage (124%) was reported in Chinsali district of Muchinga province followed by Chipata district (112%) of Eastern province and Mporokoso district (107%) of Northern province.

Figure 6: Percentage of structures sprayed against target in 2015

Chinsali 124% Chipata 112% Mporokoso 107% Nakonde 106% Lundazi 106% Samfya 103% Mbala 103% Kaputa 102.8% Chama 100% Sinda 99.4% Kawambwa 97.3% Mpulungu 97% Milenge 97% Nchelenge 96% Mafinga 96% Kasama 96% Isoka 95.9% Mwense 94.5% Mpika 94% Mansa 94% Chiengi 94% Mwansabombwe 93% Katete 90.8% Nsama 87.2% Luwingu 85% 0 20 40 60 80 100 120 140

Table 2 shows the actual number of structures sprayed in 2015 per district. Chipata district had the largest number (53,153) of structures sprayed followed by Samfya district (31,711) and Lundazi (27,667). On the other hand, Chama recorded the smallest number (1,200) of structures that were sprayed. Districts performed better on IRS coverage that ITN distribution coverage. The assessment did not establish what could have led to such differences in coverage between ITN and IRS. This, however, could be important to find out during implementation. The lessons learnt from IRS coverage could be useful in improving ITN coverage. Even so, there is still a gap in IRS coverage that needs to be dealt with to ensure that all households are sprayed.

Challenges on IRS coverage Respondents were asked about the challenges that affect IRS coverage in their respective districts. Their responses were then grouped into categories and coded as shown in Figure 7. The majority (31.3%) said that some places were very difficult to reach due to poor state of roads Figure 7: Challenges affecting IRS coverage and long distance from health facilities. In this category, the other Hard to reach areas and refusal by 31.3% challenge was that community community members members refused to have their Few structures considered for IRS 25% structures sprayed. The other challenge that was given by 25% of Poor community involvement 15.6% the respondents was that only few Inadequate chemicals and spray 9.4% structures were considered for IRS operators which in other words means limited Long distance to sites and bad 9.4% coverage on the basis of available roads Inadequate community 6.3% supplies. Other challenges cited sensitisation include poor community involvement Misconceptions that chemicals do 3.1% (15.6%), inadequate chemicals and not work spray operators (9.4%) and 0.0 5.0 10.015.020.025.030.035.0 misconceptions that chemicals used in IRS do not work.

Solutions to deal with Figure 8: Solutions to deal with identified challenges challenges in IRS coverage IRS Respondents that mentioned challenges were also asked to suggest solutions to those Intensify sensitization and provide 33.5% adequate resources challenges. The solutions were 18.5% also grouped according to Scale up use of IEC and BCC categories in which they were Increase bases to shorten distance to 11% operating areas given as presented in Figure 8. % 33.5% recommended the need Enhance community involvement 9.2 to intensify sensitization and Consider all eligible structures 6.9% provide adequate resources. Assess whether IRS is 6.9% Sensitization was suggested as a environmentally friendly way of countering refusal by Provide transport for distribution 4% community members to have their structures sprayed and Employ more SOPs 3.5% also clear misconceptions Improve road network 2.9% regarding the effectiveness of Use local NHCs for IRS and form 2.3% IRS. 18.5% suggested the need team of IRS operators based on the… to scale up use of IEC and BCC. Increase supply 1.2% This is also related to the earlier suggestion of intensifying 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 sensitization and the rationale

18 for doing so. 11% said that there was need to increase bases to reduce distances to operating areas. This suggestion is related to a subsequent suggestion recommending the use of local NHCs for IRS. Since the NHCs live in the community and can serve as a link between health facilities and the community, their involvement could significantly contribute to reducing the challenges of transport and distance. The other suggested solution was the need to enhance community involvement (9.2%). This again is related to the recommended use of NHCs and increasing bases for IRS. Other perceived solutions were the need to: consider all eligible structures for IRS (6.9%); assess whether IRS is environmentally friendly (6.5%); provide transport (4%); employ more SOPs (3.5%); improve road network (2.9%); use local NHCs for IRS and form teams of IRS operators based on the facility (2.3%); and increase supply (1.2%).

It is clear that some of the solutions that were mentioned such as providing transport, employing more SOPs and improving road network are beyond PAMO objectives and therefore not feasible within the PAMO project framework. However, capacity building for staff management could avert some of the identified challenges as districts would become better equipped to deal with the available financial, material and human resources. Moreover, solutions bordering on enhancing community involvement could also significantly contribute to reducing some of the challenges in IRS coverage. Further, suggestions such as the need to assess whether IRS is environmentally friendly are indications of knowledge gaps even among some health staff which if not dealt with could worsen misconceptions among community members.

Improve access to and quality of malaria case management at public health facilities and community level to ensure prompt, accurate diagnosis and appropriate treatment of malaria Under this thematic area, nine indicators were assessed. The indicators were: 1) malaria diagnosis; 2) iCCM training for health workers; 3) malaria case management; 4) health facilities with at least one health worker trained in performing RDTs for malaria; 5) provincial supervision of district level mentors in iCCM; 6) districts provision of mentorship to facilities in Figure 9: percentage of malaria cases reported to the HMIS iCCM; 7) districts review of in the past 12 months that were confirmed with an RDT or malaria case data; 8) quality microscopy control; and 9) training in supply chain management for 200 essential drugs. 180 160 Malaria diagnosis 140 92 83 Prompt and accurate diagnosis 120 46 14 of malaria is critical to realizing 0 100 5 0 the vision of a malaria-free 87 0 0 0 0 0 80 5 0 0 0 6 0 Zambia by 2030. For this 60 96 98 98 reason, it is one of the key 92 83 90 93 88 88 88 84 83 40 67 73 76 74 74 68 pillars of PAMO’s first 20 40 objective of supporting proven 0

malaria interventions in line

Isoka

Sinda Lunga

with the NMCP. To assess the Mbala

Mpika

Mansa

Katete

Chama

Chilubi

Mafinga

Chiengi

Kasama

Milenge Chipata

status of malaria diagnosis in Nakonde

Mpulungu Nchelenge PAMO districts, respondents Kawambwa

were asked to indicate the Mwansabombwe percentage of malaria cases reported to the HMIS in the % malaria cases confirmed with microscopy past 12 months that were % malaria cases confirmed with an RDT

19 confirmed with an RDT or microscopy. As shown in Figure 9, 52.8% (19) of PAMO districts recorded at least a case confirmed with an RDT in the 12 months preceding the study. Kawambwa and Mpulungu recorded the highest percentage of cases (98% each) confirmed with an RDT followed by Mafinga at 96%. However, only 22.2% (eight) recorded a malaria case confirmed with microscopy in the past 12 months with Isoka reporting the highest percentage (92%) followed by Mbala (87%) and Katete (83%). The percentage of malaria cases confirmed with microscopy was in the range between 92% and 5%. iCCM training for health workers The training of health workers in iCCM is at two levels. At the first level, health workers are trained as trainers in iCCM while the second level is simply a training of staff in iCCM. The status of PAMO district with regard to the two levels of training is presented in figures 10 and 11. Figure 10 shows that 61.1% of the districts reported having at least one staff that had successfully completed iCCM training of trainers. Katete had the highest number of staff (20) followed by Kaputa (12) and Mporokoso (10). Overall, more male (61.7%) than female (38.3%) staff had successfully completed iCCM training of trainers.

On the other hand, 58.3% of the districts Figure 10: Number of staff that have completed iCCM training of trainers by district reported having at least one staff that had 40 35 successfully completed 30 20 iCCM training (Figure 25 20 12 10 11). Mwansabombwe 15 8 10 6 6 5 5 5 4 4 4 4 4 4 4 had the highest 5 3 2 2 0 1 1 1

number of staff (47)

Isoka

Sinda

Lunga

Mbala Mpika

followed by Kasama Mansa

Katete

Samfya

Nsama

Chama

Kaputa

Chilubi

Chiengi

Kasama

Milenge

Chinsali

Mwense Nakonde

(31) and Mpika (27). Mpulungu

Kawambwa Mporokoso Overall, more male Mwansabom… (73.3%) than female (26.7%) staff had Male health workers Female health workers successfully completed iCCM training of trainers.

Figure 11: Number of staff that have completed iCCM training

100 90 80 70 47 60 50 31 40 27 30 21 20 16 16 15 15 20 13 11 10 10 10 10 10 10 8 8 10 6 4 0

No. male health staff No. female staff Total No. staff

It should be noted that the value of the numbers of staff trained in iCCM do not truly reflect a discernible reality in the absence of the total number of staff in the district. For example, knowing that Katete had 20 staff trained in iCCM may in itself not mean much until the total number of staff in Katete is established. Such information would therefore be required for the PAMO project to make meaningful use of data on iCCM training.

The other observation is that results do not show any relationship between the number of staff trained as trainers in iCCM and those simply trained in iCCM. It is logical to assume that staff were trained as trainers in order to train their fellow staff. If that were the case, one would expect positive correlation between those trained as trainers and those simply trained. However, this is not the case with the data presented in Figures 10 and 11. For example, 20 staff were trained as trainers in Katete and 20 other staff were trained in the same district and yet Mwansabombwe which had only six staff trained as trainers had 47 staff trained in iCCM. It is, therefore, important to explore the relevance of the training of trainers for cost effectiveness.

Malaria case management Training of health workers in case management empowers the workers to diagnose common childhood illnesses such as pneumonia; malaria; diarrhoea; cough; malnutrition and HIV/AIDS. Figure 12 shows that 77.8% of the PAMO districts reported Figure 12: Number of health workers trained in case management per district having at least one staff trained in case Lundazi 192 management. Sinda 100 Lundazi had the Isoka 91 highest number of Kasama 39 Mansa 30 staff (192) followed Lunga 23 by Sinda (100) and Mwansabombwe 19 Isoka (91). Overall, Milenge 16 Mbala 16 more male (72.6%) Kawambwa 16 than female (27.4%) Chiengi 15 staff were reported Nakonde 14 12 to have been trained Kaputa Mpulungu 11 in case management. Mafinga 11 However, these Samfya 10 10 numbers would Chilubi Nsama 9 have been more Mporokoso 8 useful if measured Katete 3 1 against other Chama variables such as 0 50 100 150 200 250 300 350 400 total number of staff No. male staff No. female staff Total No. of staff per district and the population of service users in a district.

Health facilities with at least one health worker trained in performing RDTs for malaria RDTs are an important tool that enables health workers to diagnose and treat malaria in the community. In the absence of RDTs, health workers would not be able to diagnose and treat malaria. RDTs also enable health workers to confirm malaria cases. Figure 13 shows the status of health facilities in PAMO districts with regard to having staff trained in performing RDTs. 24 (66.7%) districts reported that all their facilities (100%) had at least one health worker trained in performing RDTs for malaria. An additional 3 districts reported that they had 50%, 22% and 1% of their facilities with at least one health worker trained in performing RDTs for malaria. The remaining nine districts did not report having any of their facilities with staff trained in performing RDTs. As earlier stated, it would not be possible to control malaria if diagnosis is not up to the required standard. This is because provision of prompt and effective treatment requires that every case of malaria is diagnose. Therefore, all facilities should have staff trained in performing RDTs. As such, training of staff in performing RDTs should be extended to all facilities in all districts.

Figure 13: Districts with health facilities with at least one health worker trained in performing RDTs for malaria

1 1 1

Districts with all health facilities with atleast one health worker trained Districts with half of the health facilities with atleast one health worker trained Districts with 22% of health facilities with atleast one health worker trained Districts with1% of health facilities with atleast one health worker trained

Provincial supervision of district level mentors in iCCM Findings revealed that the majority of PAMO districts do not receive mentorship from the province in iCCM. Figure 14 shows that only 39% (14) of the districts reported that there was provincial supervision of district level mentors in iCCM according to national guidelines. The composition of these districts covers the four provinces.

Provincial Health Offices are responsible for coordinating health service deliver in their respective provinces. Coordination includes supervision and mentorship so that health services are delivered in line with national guidelines. Lack of supervision would make it difficult for PHOs to perform quality control in service delivery. Moreover, it would be difficult to implement proven malaria interventions because of the gap that could be created between provincial and district level structures due to lack of supervision. So, the reported low levels of supervision could impact negatively on the quality of services in malaria prevention and control.

Figure 14: Provincial supervision of Figure 15: District mentorship of district level mentors in iCCM facilities in iCCM

Receive supervision 56% 39% 61% Do not receive 44% supervision Districts that mentor facilities in iCCM

Districts that do not mentor facilities in iCCM As shown by Figure 15, 44.4% (16) districts reported that they provided mentorship of facilities in iCCM according to national guidelines. It was observed that most (71.4%) of the districts in which district level mentors were supervised in iCCM also provided mentorship of facilities.

Delivery of Intermittent Preventive Treatment to pregnant women (IPTp) using Sulphadoxine- Pyrimethamine (SP) as part of an integrated package of antenatal services This thematic area was analysed by looking at five indicators: 1) % of pregnant women receiving two or more doses of IPTp while attending antenatal care in the past 12 months; 2) Number of ANC health workers that received MIP training during the past 24 months; 3) provincial supervision of district level mentors in MIP and IPTp-SP; 4) district mentorship of health facility staff in MIP and IPTp-SP; and 5) Number of districts reviewing MIP data at monthly DMO meetings.

Pregnant women receiving two or more doses of IPTp while attending antenatal care in the past 12 months Figure 16: % pregnant women receiving two or The provision of free IPTp with at more doses of IPTp while attending antenatal least three doses of SP during care in the past 12 months pregnancy is one of the preventive measures highlighted in the Malaria in Kasama 300.3% Pregnancy (MIP) policy. The expected Isoka 160.1% outcome is that all pregnant women Chama 100% attending ANC clinics should receive Mporokoso 99.3% Mansa 83.7% at least two doses of IPTp against Kawambwa 79.7% malaria. However, only three districts Chinsali 77.3% reported that 100% of pregnant Chiengi 77.2% women attending ANC clinics Mpulungu 72.8% received at least two doses of IPTp Nchelenge 65.4% against malaria while attending Katete 64.2% antennal care in the past 12 months Nsama 64.0% 62.4% (Figure 16). 16 districts are in the Mpika Nakonde 57.4% range 99.3% and 2% of pregnant Lunga 53.6% women attending ANC clinics that Chilubi 50% received at least two doses of IPTp Milenge 37.6% against malaria while attending Mafinga 4.2% antennal care in the past 12 months Sinda 2% while the remaining 17 did not report 0% 50% 100% 150% 200% 250% 300% 350% any percentage. It is obvious that there is a huge gap between the MIP policy and implementation. The vision of a malaria-free Zambia by 2030 cannot be attained if such gaps are not addressed.

Number of ANC health workers that received MIP training during the past 24 months Figure 17 shows that only eight districts reported having at least a health worker trained in MIP during the past 24 months. Mansa reported the highest number of staff (26) trained in MIP followed by Lunga (21). The number of districts with staff that received training in MIP is too low to be ignored. Effective MIP cannot be achieved without trained staff.

Figure 17: Number of health workers trained in MIP during the past 24 months

Mansa, 26

Lunga, 21

Nsama, 6 Mafinga, 5

Samfya, 1 Sinda, 1

Mwense, 2 Mporokoso, 2

Provincial supervision of district level mentors and district mentorship of facilities in MIP and IPTp-SP Figure 18 shows that 15 districts reported that the province provided supervision of district level mentors in MIP and IPTp-SP according to national guidelines. Similarly, 15 districts reported that they provided mentorship of facilities in MIP and IPTp-SP according to national guidelines (Figure 19). Further analysis revealed that 93.3% of the districts in which district level mentors were supervised in MIP and IPTp-SP also provided mentorship of facilities in MIP and IPTp-SP. The results show that improved provincial supervision of districts is positively correlated to district supervision of facilities.

Figure 18: Provincial supervision of Figure 19: District mentorship of district level mentors in MIP and facilities in MIP and IPTp-SP IPTp-SP

No. of districts that provide mentorship 15 No. of districts in which 15 mentors are supervised by to facilities in MIP the province in MIP and and IPTp-SP IPTp-SP

21 No. of district that No. of districts in which 21 mentors ARE NOT DO NOT provide supervised by the province mentorship to in MIP and IPTp-SP facilities in MIP and IPTp-SP

District review of MIP data at monthly DMO meetings Regular review of MIP data is important in ensuring that implementation of key Figure 20: District review of MIP data at malaria interventions is in line with policies monthly DMO meetings and guidelines. Moreover, regular reviews are critical to responsive and timely decision making. In view of this, the assessment gathered information on the 22 districts 14 districts do not review status of MIP data review at district level. review MIP MIP data As shown in Figure 20, only 38.9% (14) of data PAMO districts review MIP data at monthly DMO meetings. The small proportion of districts in which there is review of MIP data poses a threat to the success of the fight against malaria. In those districts where data is not reviewed, it is difficult to plan because data should form the basis for good plans. In the absence of good planning, it would be difficult to ascertain whether implantation is in line with existing polices and guideline. Moreover, decisions made may not be in line with the actual MIP situation. As such, they are likely to have little impact as they would not be grounded in evidence. This also increases the likelihood of making wrong and untimely decisions.

Social and Behavioral Change Communication (SBCC) implementation for malaria at health facility and community levels through community mobilization and dialogues

In line with NMSP, PAMO recognises the importance of BCC/IEC in increasing public awareness and knowledge on malaria prevention and control as well as improving uptake and correct use of interventions. For this reason, the implementation of SBCC for malaria at health facility and Figure 21: Number of districts with or community levels was assessed by without SBCC document analyzing availability of malaria communication strategies and presence 16 20 of IEC/BCC focal point personnel at district level.

Malaria communication strategy was No. of districts with SBCC document defined as any SBCC document or No. of districts without SBCC document written guidelines on promotion of malaria activities at district level. As Figure 22: Districts with or without IEC/BCC shown in Figure 21, 44.4% (16) of focal point personnel PAMO districts reported that they had an SBCC document while 65.6% (20) did not report to have any SBCC document. 21 districts 15 districts have an do not have IEC/BCC an IEC/BCC focal point focal point personnel personnel 15

Regarding personnel, 21 (58.3%) districts reported that they had an IEC/BCC focal point person to coordinate malaria activities in the district while the rest did not have.

Civil society and community-based organizations implementing malaria control activities Under this the me, two indicators were Figure 23: Percentage of districts with assessed. The first indicator inquired into CBOs implementing malaria activities in the involvement of CBOs in malaria the district activities in the districts while the second assessed planning with regard to Districts with community engagement and social CBOs, 33% Districts mobilisation. With regard to CBO without involvement, the results in Figure 23, CBOs, 67% show that 12 districts (33%) reported that there were CBOs in their respective districts involved in malaria activities. The CBOs were reported to be involved in activities such as encouraging use of ITNs, community sensitization and mobilisation, Figure 24: District with or without malaria IRS, testing with RDTs and treating community engagement/social mobilization malaria with ACTs. plan

On the other hand, 27 districts (75%) reported that they had a malaria community engagement and social mobilisation plan while 9 (25%) did not District have. It is evident that the majority of without District with malaria malaria PAMO districts malaria community community community engagement and social mobilisation plans. engagement/s engagement/s ocial ocial The project could build on this positive mobilization mobilization phenomenon by ascertaining the extent to plan, 27 plan, 9 which these plans are being implemented. This means that attention could be given to building capacities of districts without plans to develop them and helping those already with plan to implement them.

Objective 2: To assess and document management capacities of provincial and district MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions Five thematic areas were covered in order to assess and document management capacities of provincial and district MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions. These are: 1) management capacity; 2) tailored capacity building plans; 3) quality of HMIS data reporting; 4) technical/material assistance to DMOs, health facilities, and communities to assist with training for the roll out of DHIS2 in the targeted provinces and districts; and 5) capacity building for DMOs and health facilities to improve supply chain management for malaria drugs and related commodities in the targeted provinces and districts.

Management capacity To measure management capacity, information was collected on the number of districts with management capacity development plans for malaria programming. As shown in Figure 25, 11 districts (30.6%) reported having a management capacity development plan for malaria programming while 25 districts (65.4%) did not have. The highest and second highest number of districts with Figure 25: Districts with or without management capacity development plan for malaria these plans were in Luapula (5) and programming Northern (4) provinces respectively. These results show that there is a gap in planning for management 25 District with management capacity building for malaria capacity development plan programming. At national level, the for malaria programming 11 District with management NMSP is meant to provide guidance capacity development plan and direction in working towards for malaria programming malaria eradication. This plan, however, can only be effective if it is correctly interpreted at district level and localized to adapt the Figure 26: Does the district have improved situation on the ground. Such management processes, aligned with capacity building plans? localization requires proper planning, implantation, monitoring 14 and evaluation. For this to become 22 reality, there should be staff that are adequately trained in malaria programming and therefore the Number of districts with improved management processes, aligned with capacity need to constant and consistent building plans. capacity building. But without a Number of districts without improved management processes, aligned with management capacity building plan capacity building plans. in place, capacity building of staff cannot be properly targeted to ensure that the right staff are identified and trained. As such, staff may participate in capacity building activities but the impact of their participation may not be significant due to wrong targeting.

Tailored capacity-building plan Tailored capacity-building plan was measured by establishing the status of two indicators. The first indicator tracked the number of districts with improved management processes, aligned with capacity building plans and the results in Figure 26 show that only 14 districts (38.9%) had such processes in place. The other indicator was the percentage of planned case management supervisory visits conducted at health facilities in all districts in the target provinces. Only 5 districts (13.9%) reported that all the planned case management supervisory visits were actually implemented (Figure 27). Further analysis revealed that the majority (3) of these districts were in Luapula province. It was further observed that districts in Luapula province exhibited better performance on both indicators. For example of the 14 districts that reported having improved management processes aligned with capacity building plans, 6 were from Luapula province alone while the other 8 were shared among the remaining three provinces. Similarly, of the 14 districts that reported having conducted some case management supervisory visits, 6 were from Luapula province.

Figure 27: Percentage of case management supervisory visits conducted at health facilities in the past 12 months

100 100 100 100 100 100 96

80 75

60 50 50 50 50 50 50 50

20 11 10

Quality HMIS data reporting The quality HMIS data reporting was measured by the percentage of health facilities that submitted HMIS data every month within two weeks after the end of the month during the previous quarter; percentage of health facilities that submitted completed HMIS data every month during the previous quarter; and percentage of health facilities with HIA2 data that was Figure 28: percentage of health facilities reporting consistent with the registers quality HMIS data during the previous quarter.

The results are presented in Mwense 100 100 100 Figure 28 respectively. 11 Mwansabombwe 100 100 85 districts (30.6%) reported that Mporokoso 100 100 57 all their facilities submitted Milenge 100 100 HMIS data every month within Mbala 100 100 67 two weeks after the end of the Mafinga 100 11 20 month during the previous Lunga 100 100 50 quarter while 13 districts Lundazi 100 100 100 reported the range 38% - 93% Kawambwa 100 45 100 38 84 of facilities that submitted HMIS Katete Isoka 100 100 100 data. However, 12 districts Kasama 93 100 62 (33.3%) did not report any Mpika 80 80 55 percentage of facilities having Kaputa 80 100 60 submitted HMIS data. This Chama 78 85 85 could imply that these districts Chinsali 77 100 67 did not have any facilities that Samfya 75 94 100 submitted HMIS data every Mpulungu 72 100 month within two weeks after Nsama 71 71 28 the end of the month during the Chilubi 68 92 48 previous quarter. Nakonde 60 100 76 Sinda 50 14 Further, 13 districts (36.1%) Chiengi 50 69 80 reported that all their facilities Mansa 38 87 69 submitted completed HMIS data Nchelenge 71.4 100 every month during the 0 50 100 150 200 250 300 previous quarter while 11 districts (30.6%) reported that Facilities that submitted HMIS data the percentage of facilities that Facilities that submitted completed HMIS data submitted completed HMIS data Facilities with HIA2 data consistent with registers was in the range 4% - 94%.

However, only 5 districts (13.9%) reported that all the facilities had HIA2 data that was consistent with the registers during the previous quarter. It was further observed that 25 districts reported on at least two of the three HMIS data reporting indicators. This could imply that the remaining 11 districts did not have any facilities reporting HMIS data every month during the previous quarter.

It cannot be overemphasized that quality data is key to the success of all interventions aimed at malaria prevention and control. Poor and untimely data leads to poor and untimely decision making. As observed by WHO, efforts to prevent and control malaria cannot be sustained if the systems for data collection, analysis and sharing are ineffective and inefficient. All the gains being recorded in the fight against malaria in Zambia could be eroded due to lack of timely and quality data.

Technical/material assistance to DMOs, health facilities, and communities to assist with training for the roll out of DHIS2 in the targeted provinces and districts Two indicators were assessed. The first indicator focused on the proportion of staff trained in HMIS while the second indicator tracked the number of staff trained in i-CCM in each district. Regarding training in HMIS, Figure 29 shows that 50% of PAMO districts (18) reported that some or all staff had been trained

Figure 30: Number of staff trained in i- Figure 29: Percentage of staff CCM related to HMIS by district trained in HMIS 20 Mwansabombwe 100 20 Mporokoso 100 Milenge 100 18 16 Mansa 100 16 14 Chilubi 100 14 13 Mpika 93 Nsama 85 12 10 10 10 Isoka 82 10 8 8 Nakonde 80 8 Lunga 75 Mwense 64 6 Kasama 52 4 3 3 Kaputa 50 1 1 Chama 43 2 Chinsali 33 0 Chiengi 23 Nchelenge 16 Mbala 15 0 50 100 150 in HMIS. 5 of these districts (13.9%) reported that all their staff had been trained in HMIS. The proportion of staff trained in HMIS for the other13 districts (36.1%) was in the range 15% to 93%. Most of the districts (8) that reported that some or all staff had been trained in HMIS were from Luapula province.

As earlier alluded to, weak data management systems are detrimental to the sustainability of malaria programmes. These systems may be set up but cannot serve any meaningful purpose if they are managed by staff without adequate training. As such, ensuring that all districts have adequate staff sufficiently trained in HMIS remains one of the core pillars of the fight against malaria.

Figure 30 shows the number of staff in each district reported to have been trained in i-CCM related to HMIS. 13 districts (36.1%) reported having at least one staff trained in i-CCM with Katete recording the highest number of staff (20) followed by Mbala (16) and Mporokoso (14). Chama and Kawambwa had the lowest number of staff trained in i-CCM each with only one staff. Most districts do not have sufficient numbers of staff trained in iCCM. However, data would have been more decisive if presented in terms of percentages because numbers alone may not truly reflect what is on the ground.

Capacity building for DMOs and health facilities to improve supply chain Figure 31: Percentage of facilities that management for malaria drugs and experienced stock-out of related commodities in the targeted ITNs/SP/ACTs/RDTs during the last 6 provinces and districts months per district Improving supply chain management for malaria drugs and related commodities can Nsama 100 help increase uptake and ultimately result Lundazi 100 into better prevention and treatment. As Chilubi 100 such, the assessment established the extent Chiengi 100 90 to districts experienced stock-outs of Mbala Mansa 86 ITNs/SP/ACTs/RDTs during the last 6 Mafinga 80 months and the status of facilities with Katete 66.7 regard to the percentage of health facilities 0 20 40 60 80 100 currently with staff trained in supply chain and logistics management. The results are shown in Figures 31 and 32 respectively. Figure 32: Percentage of health facilities currently with staff trained in supply chain Figure 31 shows that only 22.2% (8) of PAMO and logistics management districts reported that either some or all of the facilities experienced stock-outs of Samfya 100 ITNs/SP/ACTs/RDTs during the last 6 Nsama 100 months. Of the eight districts, 50% reported Nakonde 100 Mwense 100 that all their facilities had experienced stock- Milenge 100 outs of ITNs/SP/ACTs/RDTs during the last 6 Kawambwa 100 months while the other 50% reported Katete 100 Chiengi 100 between 66.7% and 90% of facilities that Nchelenge 92 experienced stock-outs. Some of the Kasama 90 75 challenges associated with distribution of Lunga Mansa 63 ITNs under objective one are inadequate Chama 50 supply and stock-outs. Despite the small Mpulungu 18 Mafinga 11 percentage of districts reporting stock-outs, Mbala 5 the fact that all facilities in some districts can 0 20 40 60 80 100 experience this challenge within just six months shows that the problem is significant enough to warrant attention.

On the other hand, Figure 32 shows the percentage of health facilities currently with staff trained in supply chain and logistics management. 22.2% (8) reported that all their health facilities had staff trained in supply chain and logistics management. Another 22.2% reported having between 5% and 92% of staff trained in the named area. Further analysis shows that districts from Luapula province have more health facilities with staff trained in supply chain and logistics management. For example, of the eight districts that reported that all their facilities had staff trained in supply chain and logistics management, five were from Luapula province while the other three were from Eastern, Muchinga and Northern provinces only with a district each.

Objective 3: To establish the levels of malaria health care financing with focus on financing sources and trends Financing plays a pivotal role in malaria prevention and treatment. As earlier observed, financing is one of the challenges that Zambia faces especially because it is heavily dependence on external funding for malaria prevention and control. Therefore, establishing levels of malaria health care financing was relevant to identify financing gaps that the PAMO project should consider in its implementation for evidence-based support. Areas explored include financing levels for planned malaria activities, sources of funding and perceived funding challenges in 2015 and 2016.

Funding of Malaria Activities Funding of malaria activities was assessed by asking respondents to indicate the proportion of planned malaria activities that were funding in 2015 and 2016 and the results are shown in Figure 33. A number of observations can be deduced from the results. Firstly, there was no district that received 100% funding for their activities in 2015. The highest level of funding received was 95% for Isoka district followed by 80% for Mporokoso. However, the funding situation changed in 2016 with four districts, that is, Milenge, Chiengi, Katete and Nakonde, receiving 100% funding for their activities. Generally, the funding situation improved from 2015 to 2016. For example, most of the districts that received funding in 2015 also received it in 2016. Moreover, there was a slight increase in the percentage of malaria activities planned in 2016 that were funded as compared to 2015. For example, out of the 17 districts that reported some level of funding, 64.7% recorded an increase, 11.8% recorded the same level while 23.5% recorded a reduction in the proportion of planned malaria activities that were funded in 2016 as compared with 2015.

Figure 33: Percentage of district malaria activities planned in 2015 and 2016 that were funded

Isoka 95 87 Mporokoso 80 Samfya 75 50 Mwense 75 80 Mpika 75 80 Milenge 68 100 Chiengi 67 100 Chinsali 60 60 Mpulungu 57 3 Katete 50 100 Chama 43 60 Mbala 37 Lunga 35 20 Mafinga 32 32 Sinda 20 Kawambwa 20 Nchelenge 2 55 Mansa 23 Lundazi 33 Chipata 86 Nakonde 100 0 20 40 60 80 100 120 140 160 180 200

% of 2015 malaria activities funded % of 2016 malaria activities funded

Sources of Funding Respondents were asked about the sources of funding for malaria activities in 2015 and 2016. Figures 34 and 35 show that most respondents cited GRZ as the source of funding for both 2015 and 2016 malaria activities at 47.1% and 57.9% respectively followed by a combination of GRZ and AIRS at 41.2% and 21.1% respectively. Unfortunately, respondents were not able to provide information on the proportion of funding from the identified sources.

Figure 34: Percentage of respondents Figure 35: Percentage of respondents that indicated sources of funding for that indicated sources of funding for malaria activities in 2015 malaria activities in 2016

47.1 57.9 50.0 41.2 60.0 40.0 50.0 40.0 30.0 30.0 21.1 15.8 20.0 20.0 5.3 5.9 5.9 10.0 10.0 0.0 0.0 GRZ GRZ and GRZ, AIRS GRZ, AIRS, GRZ GRZ and GRZ, AIRS GRZ, AIRS AIRS and PAMO NMCC and AIRS and CDC and CHAZ CHAZ

Funding Challenges The funding challenges for malaria activities in 2016 were only two as shown in Figure 36. The first one was lack of sufficient funds for programming (84.6%). The other one was a combination of partners not having fully implemented the programme like IRS and limited ceiling towards IRS programme by partners. However, the two challenges were just two versions of the same issue which was limited funding.

Figure 36: Perceived funding challenges for malaria activities in 2016

15.4%

84.6%

Lack of sufficient funds for programming

Partners have not yet fully implemented the programme like IRS and limited ceiling towards IRS programme by partners (PMI-AIRS)

Major Gaps in Malaria Prevention and Treatment. The assessment tracked many indicators related to PAMO’s three objectives. While performance across districts was varied from indicator to indicator, the following are the major issues that were identified:

 Low percentage of districts with distribution and supervision plans.  Low ITN coverage for under-five, ANC and mass distribution in most of PAMO districts.  Few facilities with at least a staff trained in performing RDTs.  Inadequate provincial supervision of district level staff in a number of areas such as iCCM, MIP and IPTp-SP.  Low adherence to the MIP policy of ensuring that all women who attend ANC clinics receive at least two doses of IPTp against malaria.  Small proportion of PAMO districts with staff trained in MIP.  Lack of MIP data review by most districts.  There is need for the project to ensure that all districts develop management capacity building plans.  Few districts with improved management processes aligned with capacity building plans.  Inadequate HMIS data management skills and practices.  Insufficient staff trained in supply chain and logistics management.  Data collection was not uniform across all districts. For example, the questionnaire that was administered in Northern Province was different from the one administered in Eastern province. This led to incomplete information on certain indicators.

Conclusion and Recommendations The assessment shows that various malaria prevention and treatment interventions are being implemented in all the PAMO districts. The districts are not at the same level in terms of performance in relation to PAMO indicators. Moreover, there are some indicators such as IRS where performance is good in the majority of PAMO districts and indicators such as ITN coverage where performance is generally low. Generally serious gaps were identified in relation to health delivery systems, skills by staff in key malaria interventions and supervision at both provincial and district levels. In some districts, there are systems but without sufficiently trained staff to fully implement them. In other districts, systems have been developed and staff trained in ensuring their operation but there is inadequate supervision and mentorship. As a result, there is no quality control to ensure that such systems are working in line with national guidelines. With these observations, it is evident that there is need for support in implementation of evidence-based interventions, capacity building and financing to scale up the current efforts in all districts to sustain the fight against malaria.

In view of the findings, the following recommendations are proposed:

References

Central Statistical Office (CSO) [Zambia], Ministry of Health (MOH) [Zambia], and ICF International. (2014).

Ministry of Health. (2011). National Malaria Control Programme Strategic Plan for FY 2011‐2015: “Consolidating malaria gains for impact”. Lusaka: Ministry of Health

Ministry of Health. (2012). Zambia National Malaria Indicator Survey 2012. Ministry of Health

PATH. (2010-2016). Making inroads against malaria and more. Accessed on 2nd December 2016 from http://sites.path.org/zambia/

World Health Organisation. (2015). World Malaria Report 2015. Geneva: WHO Press.

Zambia Demographic and Health Survey 2013-14. Rockville, Maryland, USA: Central Statistical Office, Ministry of Health, and ICF International.

Zambia Malaria Operational Plan FY 16

Annex

Questionnaire

Interviewer/Data Collector name: ______Date: ______

Province: ______District: ______Health facility: ______

Name and details of contact person: ______

Introducing the objective of the PAMO malaria health systems gap analysis The principal objective of this gap analysis is to identify programmatic requirements needed to fully plan and implement PAMO activities in line with the National Malaria Strategic Plan. The information here obtained will be helpful in designing malaria work plans by provincial and district health offices.

PAMO objective 1: To establish the status of PAMO supported provinces and districts with regard to implementation of proven malaria interventions.

ITN distribution in PAMO target districts Questions Responses/Findings 1. Does district have ITN distribution and supervision plan? Yes/No 2. What was the target for ITN distribution in 2015? Disaggregate target by: ITNs for ANC ITNs for under-five children ITNS for mass distribution 3. What was the number for ITN distribution coverage against target in 2015? Disaggregate target by: ITNs for ANC ITNs for under-five children ITNS for mass distribution 4. If there were variances between targeted and achieved ITN distribution figures, what were the reasons for the variance? 5. Did the district receive any INTs in 2015 for distribution? Yes/No 6. If the district did receive ITNs in 2015, who provided them? 7. What is the target for ITN distribution in 2016 and achievements so far? Disaggregate target by: ITNs for ANC ITNs for under-five children ITNS for mass distribution

8. If there are variances between targeted and achieved ITN distribution figures so far, what are the reasons for the variance? 9. Has the district received any ITNs in 2016 for distribution? Yes/No 10. If the district has received ITNs for 2016, who provided them? 11. Out of the total number of health facilities in the district how many conduct ANC ITN distribution? 12. Out of the total number of health facilities in the district how many conduct under five clinic ITN distribution? 13. Out of the total number of health facilities in the district how many conduct mass ITN distribution? 14. Besides the mass campaign and health facilities, what are other ways in which households are getting ITNs? 15. Do you think most families know where to get ITNs? Yes/No 16. What methods are used to inform families about the availability and use of ITNs?

17. Do you think most families who receive ITNs actually use them for the intended purpose of malaria prevention? Yes/No 18. In your view, what are some of the common beliefs or attitudes that are preventing families from using ITNs for the intended purpose of malaria prevention? 19. Are there any activities going on to promote ITN use? (Such as use of mass media, community mobilization, interpersonal communication in health facility or communities, other). Please mention them 20. If there are no activities currently going on to promote ITN use, what are the reasons? 21. If activities to promote ITN use have been conducted in the recent past, when was that? 22. If some activities to promote ITN use have been conducted in the recent past, which ones were most well-received? 23. Are there any planned ITN activities in this district? Yes/No

24. If there are any planned ITN activities who is implementing them? 25. What challenges affect ITN distribution and coverage? Focus on: Under five ITN distribution/ ANC ITN distribution/ ITNS for mass distribution/ Stock-outs/ Training/ Supervision/Communication/ Coordination/ Reporting/ Any other 26. What do you think should be done to deal with the identified challenges?

Note to interviewer: Collect reports on any ITN activities from 2014-current.

HMIS data review: % of pregnant women attending ANC for the first time who received a net: ______% of Under-five children who received a net: ______

IRS coverage in PAMO target districts Questions Responses/Findings 27. What was the number of structures targeted for IRS in 2015? 28. What was the percentage of structure sprayed against the target in 2015? 29. Was the target achieved in 2015?

30. If the target was not achieved what were the reasons? 31. How many structures have been targeted to be sprayed in 2016 32. How many structures have so far been sprayed out of those targeted in 2016?

33. What are the challenges affecting IRS coverage?

34. What do you think should be done to deal with the identified challenges?

Improving access to and quality of malaria case management at public health facilities and community level to ensure prompt, accurate diagnosis and appropriate treatment of malaria Questions Responses/Findings 35. What percentage of malaria cases reported to the HMIS in the past 12 months were confirmed with an RDT?

36. What percentage of malaria cases reported to the HMIS in the past 12 months were confirmed with microscopy? 37. What is the number of health workers who have successfully completed iCCM training of trainers (disaggregated by gender, health worker type, e.g. DHO staff, health facility staff, CHA)? 38. What is the number of community health workers who have successfully completed iCCM training (disaggregated by gender) 39. What is the number of health workers who have successfully completed iCCM training (disaggregated by gender and by health worker type, e.g. DHO staff, health facility staff, CHA)? 40. What is the number of health workers trained in case management (disaggregated by gender and by health worker type (e.g., DHO staff, health facility staff, CHA)? 41. What is the percentage of health facilities with at least one health worker trained in performing RDTs? 42. What is the number of health staff trained in IMCI? (disaggregated by gender and by health worker type (e.g., DHO staff, health facility staff, CHA)? 43. What is the percentage of health facilities with Community health workers trained in performing RDTs? 44. How many community health workers have been trained in performing RDTs? 45. Does the province provide supervision of district level mentors in iCCM according to national guidelines? Yes/No 46. Does the district provide mentoring of facilities in iCCM according to national guidelines? Yes/No 47. Does the district review malaria case data at monthly DMO meetings? Yes/No 48. What is the percentage of health facilities in the district that do quality control in malaria testing? 49. What is the percentage of health facilities in the district that do quality control in malaria treatment? 50. What is the percentage of health facilities in the district that follow SOP when doing RDT?

51. What is the percentage of health facilities in the district that have treatment guidelines and algorithms? 52. What does the district health team do to ensure that health facilities adhere to quality assurance procedures? 53. In your view, where do most people go first when they are looking for care for fever? 54. Do you think most families in the district are familiar with RDTs? Yes/No 55. Do you think most families in the district are familiar with ACTs? Yes/No 56. Are there any activities going on to promote RDT use? (Probe on mass media, community activities, health facility activities, other). If yes, mention them 57. Are there any activities going on to promote ACTs use? (Probe on mass media, community activities, health facility activities, other). If yes, mention them 58. If not currently going on, when were they last conducted in the most recent past? 59. Were there any planned/upcoming case management activities in the district? 60. If so, who implemented them?

61. Which of activities were most well- received?

Delivery of Intermittent Preventive Treatment to pregnant women (IPTp) using Sulphadoxine- Pyrimethamine (SP) as part of an integrated package of antenatal services Questions Responses/Findings 62. What was the number of first antenatal clinic visits in last 6 months? 63. Out of the total number of first antenatal clinic visits in last 6 months, how many received two or more doses of IPTp under observation? 64. How many health workers in the district have been trained in MIP during the past 24 months? 65. Does the province provide supervision of district level mentors in MIP and IPTp-SP according to national guidelines? Yes/No 66. Does the district provide mentoring of facilities in MIP and IPTp-SP according to national guidelines? Yes/No

67. Does the district review MIP data at monthly DMO meetings? Yes/No 68. Are there any activities going on to promote early ANC booking and IPTp use? (Probe on mass media, community activities, health facility activities, other). If yes, mention them 69. If not currently going on, when in the most recent past were these activities conducted? 70. If they were conducted in the recent past, which of these activities were most well- received? 71. Are there any planned MIP activities in the district? Yes/No 72. If there are any planned MIP activities, who is implementing them?

Social and Behavioral Change Communication (SBCC) implementation for malaria at health facility and community levels through community mobilization and dialogues Questions Responses/Findings 73. Is there a designated officer handling SBCC/health promotion activities with focus on malaria at district level? Yes/No 74. Is there any SBCC document or written guidelines on promotion of malaria activities at district level? Yes/No 75. Is there a district malaria community engagement/social mobilization plan? 76. Is there a district IEC/BCC committee in place? Yes/No 77. If there is a district IEC/BCC committee in place how often do they meet? Yes/No 78. Are there any means of communication that you would particularly recommend we use when doing SBCC in this district? (Probe for details like use of mass media, community mobilization, popular theater, interpersonal communication, other) If yes, please mention them

Note: Collect reports on any SBCC activities from 2014-current. Obtain copies of SBCC materials used. For sampled facilities, look out for malaria SBCC materials such as posters and job aids and do take pictures and file them with other SBCC materials.

Civil society and community-based organizations implementing malaria activities Questions Responses/Findings 79. Are there CBOs involved in malaria activities in the district? Yes/No

80. If so what specific activities are they implementing? 81. In your own view, how active are these organizations? 82. Where do these organization get their funding from?

83. Would you describe the coordination of malaria activities among stakeholders in the district as effective? Yes/No 84. If yes or no, please explain

Objective 2: To assess and document management capacities of provincial and district MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions

Management capacity Questions Responses/Findings 85. Is there a district task force on malaria? Yes/No 86. If there is a district task force on malaria, how often do they meet? Yes/No 87. Does the province provide district capacity building activities? Yes/No 88. If the province does not provide district capacity building activities, what are they currently doing to improve capacity at district levels? 89. Does the district have a management capacity development plan for malaria programming? Yes/No 90. Does the district have improved management processes, aligned with capacity building plans? Yes/No 91. What is the percentage of case management supervisory visits conducted at health facilities out of the total planned case management supervisory visits in the past 12 months? 92. Is there a need to strengthen coordination and planning activities within the district? Yes/No 93. If so, what do you see as the challenges and potential ways to address them?

Quality HMIS data reporting Question Responses/Findings 94. What is the percentage of health facilities that submitted HMIS data every month within two weeks after the end of the month during the previous quarter? 95. What is the percentage of health facilities that submitted completed HMIS data every month during the previous quarter? 96. What is the percentage of health facilities with HIA2 data that was consistent with the registers during the previous quarter?

Technical/material assistance to DMOs, health facilities, and communities to assist with training for the roll out of DHIS2 in PAMO target districts Question Responses/Findings 97. What is the percentage of districts with Not analysed. Needed to be answered by provincial district level staff trained in HMIS? level staff. 98. What is the percentage of health facilities with staff trained in HMIS? 99. What is the percentage of health facilities with community HMIS? 100. How many health facilities in the district have had staff trained in i-CCM related community HMIS 101. How many health staff have been trained in i-CCM related community HMIS 102. What challenges do you face with regard to HMIS? 103. What do you think should be done to deal with the HMIS challenges identified?

Capacity building for DMOs and health facilities to improve supply chain management for malaria drugs and related commodities in PAMO target districts

Question Responses/Findings 104. During the last 6 months, what is the percentage of health facilities in the district that experienced a stock-out of ITNs/SP/ACTs/RDTs, other………………..? (Circle if applicable) 105. What is the percentage of health facilities currently with staff trained in supply chain and logistics management with focus on malaria drugs and related medical commodities?

106. What are the main challenges faced with regard to supplies of malaria drugs and related medical commodities?

107. What do you think can be done to deal with the identified challenges?

Objective 3: To establish the levels of malaria health care financing with focus on financing sources and trends

Malaria health care financing Questions Responses/Findings 108. What percentage of district malaria activities planned in 2015 were funded? 109. What percentage of district malaria activities planned in 2016 have been funded? 110. What were the sources of funding for malaria activities in 2015 and in what proportions? 111. What is the source of funding for malaria activities in 2016 and in what proportions? 112. Were there funding challenges experienced in 2015 for malaria activities and how were they dealt with?

113. What are the funding challenges in 2016 and how will they be dealt with?

General comments Do you have any other comments about challenges to malaria control in the district and how to deal with them? If yes, please explain: ______

______

End.