ZIMBABWE ASSISTANCE PROGRAM IN MALARIA ANNUAL REPORT

REPORTING PERIOD: OCT 1, 2018 – SEPT 30, 2019 SUBMISSION DATE: OCTOBER 30, 2019

Recommended Citation: ZAPIM Year Four Annual Report, October 1, 2018–September 30, 2019. Rockville, MD, U.S., and , . 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, 2019

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

Commented [EM1]: Audrey, please update the headings and Contents link to the ToC (same for tables and figures). Ensure all headings and sub-headings are consistent. Please also check that it is single LIST OF FIGURES ...... iii spacing throughout the doc and left-justified text unless it is a table or graphic or something. LIST OF TABLES ...... iv

ABBREVIATIONS AND ACRONYMS ...... v 1. Executive Summary ...... 1 2. Background ...... 4 2.1 Project Design...... 4 2.2 Zimbabwe Operating Context ...... 4 3. Technical Strategy ...... 7 3.1 Target Districts for Implementation ...... 7 3.2 Capacity Building ...... 9 3.3 Community-Based Approach ...... 9 3.4 Using Data for Decision Making ...... 10 3.5 Coordination and Integration of Activities for Impact and Sustainability ...... 10 3.6 ZAPIM Quality Improvement ...... 10 3.7 Innovative Use of Digital Technology ...... 11 3.8 Sustainability ...... 11 4. Technical Activities ...... 13 4.1 Clinical Case Management ...... 13 4.1.1 Malaria case management and MIP trainings ...... 13 4.1.2 Malaria clinical mentorship ...... 14 4.1.3 Malaria death audit meetings ...... 22 4.2 Community Case Management ...... 23 4.2.1 CCM & MIP trainings ...... 24 4.2.2 Post training follow up ...... 26 4.2.3 Supportive supervision ...... 26 4.2.4 VHW Review meetings ...... 28 4.2.5 Issues/areas for improvement of the CCM program ...... 29 4.2.6 procurements for VHWs ...... 30 4.2.7 A success story related to CCM activities in Mbire...... 31 4.3 Long Lasting Insecticide Treated Nets ...... 31 4.3.1 Mass Distribution ...... 32 4.3.2 Continuous Distribution of LLINs ...... 44 4.4 Social and Behavioral Change Communication ...... 47 SBCC Areas of Intervention ...... 47 4.4.1 Branding of the NMCP ...... 48 4.4.2 Development, printing and dissemination of malaria SBCC materials and communication facilitation tools 48 4.4.3 Development and broadcasting of multimedia malaria communications (radio and audio)...... 49 4.4.4 ADVOCACY FOR ACTION ON MALARIA CONTROL AND ELIMINATION BY COMMUNITIES, COMMUNITY LEADERS AND STAKEHOLDERS – WORLD MALARIA DAY ...... 50 4.4.5 Evidence gathering for improved SBCC programming ...... 50 4.4.6 Production and publishing of NMCP reports on various thematic areas ...... 51

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4.4.7 Community Based SBCC ACTIVITIES ...... 51

PARTICIPATION OF HCCS IN OUTREACH EDUCATION SESSIONS WITH COMMUNITIES ...... 56

CHALLENGES ...... 62 4.5 Monitoring & Evaluation/Operations Research ...... 62 4.5.1 Assessment of Drivers of Continuing Malaria Transmission in Angwa Ward, , Mashonaland Central Province ...... 62 4.5.2 National Malaria SM&E Plan ...... 63 4.5.3 EPR Preparedness and Response Guidelines ...... 63 4.5.4 Malaria SM&E Training Manual ...... 63 4.5.5 CDCS ...... 64 4.5.6 MIS Alternative ...... 64 4.5.7 Document and Review Training Gaps by Thematic Area ...... 65 4.5.8 Net Durability Study at Month 36 ...... 65 4.5.9 Provincial Malaria Review Meetings ...... 65 4.5.10 DQAs ...... 65 4.5.11 Weekly VHW Mobile Reporting Pilot in Mbire District ...... 66 4.5.12 RDT Registers for VHWs ...... 67 4.5.13 Orientation of ZAPIM Staff in Global Information System Mapping ...... 67 4.6 Malaria Elimination Activities in , North ...... 67 4.6.1 Enhanced Surveillance Training ...... 67 4.6.2 Strengthening Foci Response ...... 68 4.6.3 EHT Entomology Training ...... 69 4.6.4 Training in GIS Mapping ...... 70 4.6.5 ZAPIM Micro Plan for Elimination ...... 71 5. Gender and Child Safeguarding ...... 72 6. Environmental Compliance ...... 73 6.1 Medical Waste ...... 73 6.2 Liquid and Solid LLIN Waste ...... 73 6.3 Management of Public Health Medicines and Commodities ...... 73 7. ADMINISTRATIVE ACTIVITIES ...... 74 7.1 Staffing and Management ...... 74 Conferences, Retreats, Trainings and Meetings ...... 74 7.2 ...... 74 7.2.1 Annual Malaria Conference ...... 74 7.2.2 VHW Logistics System Redesign workshop ...... 74 7.2.3 Provincial Health Team Meetings and Data Management Workshop ...... 75 7.2.4 National Malaria Vector Control Planning and Review Meeting, IRS Level I and II Trainings and IVM Strategic Plan Development Workshop ...... 75 7.2.5 Environmental Compliance Training ...... 75 7.2.6 Year 5 Work Plan Development Meetings ...... 75 7.2.7 ZAPIM/NMCP Meetings ...... 75 7.2.8 Fundamentals of SM&E and Evaluation Methods of Malaria Programs ...... 75 8. Challenges, Lessons Learned and Recommendations ...... 77 Annex A: Short-Term Technical Assistance ...... 79 Annex B: PMP Indicator/Year 4 Milestone Matrix ...... 81 Annex C: Year 4 Activities Affected By Anticipated Delayed Release of Year 5 Funding ...... 95

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LIST OF FIGURES

FIGURE 1: MAP OF ZIMBABWE SHOWING ZAPIM-TARGETED DISTRICTS ...... 9 Figure 2: Mentorship Activities carried out by Different Districts ...... Error! Bookmark not defined. Figure 3: Improvement in overall *competency in OPD in May 2019 compared to May 2018 baseline ...... 17 Figure 4: Comparison of performance across districts ...... 18 Figure 5: Parameters with notable performance improvement ...... 19 Figure 6: MENTORSHIP REVIEW DISCUSSION GROUPS ...... 20 Figure 7: Mentorship Review Group Feedback Session ...... Error! Bookmark not defined. Figure 8: CCM TRAININGS MEAN SCORES BY DISTRICT, FEBRUARY-APRIL 2019 ...... 25 Figure 9: VHWs giving feedback on RDT/Medicine register documentationError! Bookmark not defined. Figure 10: Solar powered light sourced by a VHW using her own funds in Mash. Central, Chawarura clinic ...... 27 Figure 11: Beneficiaries of the My Net My Life mass campaign displaying their just received LLINs ...... 32 Figure 12: Participants demonstrating how to hang a rectangular LLIN ...... Figure 13: Transport used in transporting LLINs from HFs to Distribution points in ...... Error! Bookmark not defined. Figure 14: The Provincial Field Officer sharing a lighter moment with some LLINs beneficiaries and some women on the right socializing after getting their LLINs...... 41 Figure 15: MASS DISTRIBUTION OF LLINS 2016 AND 2019 ...... 42 Figure 16: LLINs Distributed Through CD Channel by Quarter Year 1-Year 4 ...... 45 Figure 17 : Delayed presentation of a boy with severe malaria .... Error! Bookmark not defined. Figure 18: Kamativi HCC Nutrition Garden ...... Error! Bookmark not defined. Figure 19: Showcasing some HCC activities ...... Error! Bookmark not defined. Figure 20: Chart being used by Hwata HCC to track malaria cases in their area by month, week & by village...... 58 Figure 21: Breeding sites at Katoba River in Binga ...... Error! Bookmark not defined. Figure 22: Larviciding at Katoba River in Binga ...... Error! Bookmark not defined. Figure 23: Zimbabwe Malaria Foci Investigation and Response Algorithm ...... 69 Figure 24: Community participation in larviciding during entomology training in Lupane, April 2019...... Error! Bookmark not defined.

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LIST OF TABLES

TABLE 1: ZAPIM YEAR 5 IMPLEMENTATION PROVINCES AND DISTRICTS ...... 8 Table 2: CM and MiP Trainees by Profession in ZAPIM focused provinces (February-March 2019) ...... 14 Table 3: HEALTH WORKERS MENTORED UP TO DATE (MAY 2018 TO AUGUST 2019) ..... 14 Table 4: Data collected and response rates during mentorship assessment ..... Error! Bookmark not defined. Table 5: Recommendations from the mentorship review meeting ...... 21 Table 6: Findings and Recommendations from Death Audit Meetings ...... 23 Table 7: DISTRIBUTION OF CCM TRAINEES BY DISTRICT (FEBRUARY- APRIL 2019) ...... 24 Table 8: VHWs followed up after training, by district, April-June 2019 ...... 26 Table 9: VHWs Reached During Supportive Supervision ...... 27 Table 10: VHW attendance at VHW review meetings by District, September 2019 ...... 29 Table 11: ROLES AND RESPONSIBILITIES OF MASS DISTRIBUTION STAKEHOLDERS IN MASS DISTRIBUTION ...... Error! Bookmark not defined. Table 12: WARDS AND HEALTH FACILITIES WHICH PARTICIPATED IN MASS DISTRIBUTION OF LLINS (2019) ...... 35 TABLE 13: HEALTH WORKERS TRAINED ON MASS DISTRIBUTION BY DISTRICT AND GENDER ...... 36 Table 14 VILLAGE HEALTH WORKERS TRAINED BY DISTRICT AND BY GENDER ...... 37 TABLE 15: NUMBER OF COMMUNITY MEMBERS SENSITIZED BY GENDER 2019 ...... 38 TABLE 16: LLINS REGISTRATION DATA BY DISTRICT APRIL-MAY 2019 ...... 39 Table 17: LLIN DISTRIBUTION BY DISTRICT (JUNE-JULY 2019) ...... 41 .TABLE 18: SUCCESSES, CHALLENGES AND SOLUTIONS ...... 43 TABLE 19: RECOMMENDATIONS ON MASS DISTRIBUTION ...... 43 Table 20: CD of LLINs Oct 2018-Sept 2019 by District and Channel ...... 44 Table 21: Distribution by District and by Quarter October 2018-September 2019 ...... 45 Table 22: Health Workers Trained in CD August 2019 ...... 46 Table 23: VHWs trained by HF and by Gender August 2019 ...... 46 Table 24: key malaria behaviors and barriers identified during Explore phase for Binga and Districts...... Error! Bookmark not defined. Table 25: Distribution of HCCs Trained by District ...... 55 Table 26: Key findings and recommendations from DQAs, May-June 2019 ...... 66

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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 Program 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 RHC Rural health center SADC Southern African Development Community

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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 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 fourth year. It covers the period October 1, 2018 to September 30, 2019. 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 4 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), operational research (OR) and malaria elimination activities in Lupane District Matabeleland North Province.

As a result of a delay in funding for Year 4, ZAPIM was unable to implement activities in the first quarter of the year. The operating environment in the country changed towards end of June 2019 following introduction of a new statutory instrument (SI 142) banning the use of the United States dollars for local payments. As a result of this change, ZAPIM could not implement field activities in the month of July 2019. Further, due to yet another anticipated delay in release of Year 5 funding, the project had to slow down implementation of activities and could not implement any field activities in September 2019. Case Management (CM) In Year 4 the project supported the training of 183 health care workers (HCW) in CM and MIP. 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 worked with 25 district mentors in the five districts (Mbire, Murewa, , Binga and Hwange) to conduct mentorship visits to 134 mentees. ZAPIM also hosted a mentorship review meeting for the districts and other stakeholders to assess the performance of the mentorship and map a way forward for the program. In Year 4 ZAPIM provided technical and financial support for one malaria death audit meeting in each of the three project-supported provinces. Community Case Management (CCM) ZAPIM trained 317 Village Health Workers (VHWs) in CCM and MIPand conducted post-training follow up visits with 203 VHWs out of 282 VHWs trained in Mashonaland East and Mashonaland Central. ZAPIM conducted district supportive supervisions with 132 VHWs in Binga and Hwange Districts, meeting the VHWs at their respective health facilities and visiting 18 of these at their homes. ZAPIM further trained 38 VHW peer supervisors in Mutoko and carried out post training follow up with 11 of them. In addition, ZAPIM supported three district VHW review meetings in Mbire, Mutoko and Centenary Districts. ZAPIM provided 200 VHWS in Mbire with lockable medicine cabinets to store medicines.

Long-Lasting Insecticidal Nets (LLINs)

The project supported the distribution of 624,458 LLINs through mass distribution in 144 wards in 10 districts and 101,111 LLINs through continuous distribution (CD) channels. ZAPIM provided another 160,000 LLINs for distribution in Chimanimani and Districts in response to cyclone Idai

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induced flooding and participated in training 62 Environment Health Technicians (EHTs) in the two districts for the distribution of the nets. ZAPIM supported the training of data collectors, provided oversight of the field data collection, analyzed data, and developed the report for month 36 Net Durability Study (NDS). ZAPIM is currently responding to comments from PMI to finalize the report. Community Action Cycle (CAC) In Year 4 ZAPIM trained eight Ward Health Teams (WHTs) in Binga and eight Health Centre Committees (HCCs) in Hwange on Explore Health Issues and Setting Priorities, Planning Together and Act Together phases of the community action cycle (CAC). The project further trained 26 HCCs in Mashonaland Central and 34 in Mashonaland East on Evaluate Together phase of the CAC. Meanwhile the participation of the HCCs in CAC has begun to bear fruit with some HCCs having reached out to 18,239 community members through village meetings. HCCs have participated actively in supporting VHWs in their work by accompanying them on home visits, conducting village inspections and creating health and hygiene clubs. As a result of the training support from ZAPIM, some HCCs have become active in community lobbying for early ANC booking and early seeking of care in suspected malaria, community surveillance against LLIN abuse and Indoor Residual Spraying (IRS) refusal and community disease surveillance. ZAPIM supported HCC trainings on CAC has enabled HCCs to mobilize resources like transport, allowances, meals and refreshments to support staff during mass distribution of LLINs and IRS.

Social Behavior Change Communication (SBCC)

ZAPIM hosted a stakeholder meeting to help NMCP develop their branding concept. ZAPIM identified a branding consultant from Abt Associates Inc. to carry out the stakeholder survey and spear head the rebranding process. The actual branding process was postponed to 2020 due to the funding issues that ZAPIM experienced and due to the economic challenges described in detail under Section 2.2 in this report. ZAPIM developed and printed a leaflet “my net, my life” to promote the mass distribution of LLINs and developed radio spots to promote LLINs and IRS. The project also supported the 2019 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 World Malaria Day Commemorations held in the three provinces in Shamva, Binga and Hwedza Districts.

Surveillance Monitoring and Evaluation (SM&E) During the reporting period, ZAPIM printed 1,400 copies of the Revised Epidemic Preparedness and Response (EPR) Guidelines and 500 copies of the SM&E plan. The documents were distributed to the provinces at the Annual Malaria Conference held in in June 2019. ZAPIM is currently developing the training manuals for EPR and SM&E. ZAPIM supported one malaria review meeting in each of the three provinces. These meetings are platforms to review the malaria situation in the provinces, identify problems, find solutions, and plan for improvements in the delivery of services and reporting of malaria data. ZAPIM supported the three provinces to conduct data quality assessments (DQAs) at 47 selected health facilities in Binga (7), Hwange (2), Murehwa (12), Goromonzi (12), Mbire (7) and Guruve (7). Operational Research ZAPIM worked with PMI, NMCP, and VectorLink to write the Assessment Report on Drivers of Continuing Malaria Transmission in Angwa Ward, Mbire District. The report is currently being finalized. The project completed the Case Drug Consumption Study (CDCS) report and printed 50 copies of the report. The study sought to determine the factors that contribute to the observed disparity between recorded malaria cases and the consumption of first-line artemisinin-based combination therapy in the

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country. ZAPIM completed report writing on the 36-month NDS and is currently responding to comments from PMI in order to finalize the report. ZAPIM submitted one late breaker abstract for each of the researches for the American Society of Tropical Medicine and Hygiene (ASTMH) conference. The project developed and shared a concept note with PMI on six alternatives to conducting a periodic malaria indicator survey (MIS). The six options are: MIS within the Demographic and Health Surveys; MIS (stand-alone), continuous MIS, strengthening the District Health Information System (DHIS2), a ‘hybrid’ approach between the last two options and using antenatal clinic attendants as a surrogate for a population survey. ZAPIM shared short descriptions on each option and the advantages, disadvantages/limitations, and likely cost implications. VHW Reporting MoHCC with support from ZAPIM trained and provided smart phones to 186 VHWs and 13 nurses in Mbire District to enable VHWs to commence weekly mobile reporting on malaria data. Cellphone- based reporting is expected to improve the timeliness and completeness of data from VHWs. Malaria Elimination ZAPIM supported training of 45 HCWs on enhanced surveillance and strengthening foci response in Lupane District. EHTs and nurses from facilities with active malaria transmission in their catchment areas were trained. The training was aimed at ensuring that the health care workers treat, notify, classify and investigate all malaria cases according to national guidelines. In addition, the participants were trained on foci mapping, foci classification, and appropriate responses to malaria foci in elimination. All the 45 EHTs, environmental health officers (EHOs), and field orderlies in Lupane also received training in entomology over a three-day period. The training included identification of vector breeding sites, collection and transportation of female anopheles mosquitoes and use of larvicides to manage breeding sites. ZAPIM supported training of the 45 EHTs in Lupane on geographic information system (GIS) mapping to enable them to produce geocode-based electronic maps for mapping of malaria cases, vector breeding sites and transmission foci in their catchment areas. This training will enable the EHTs to produce more accurate maps that will replace hand drawn, estimated maps.

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2. BACKGROUND

2.1 Project Design 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 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) SM&E. The project operated in 15 districts for the first three years in three provinces: Mashonaland Central (, 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 4, the project scaled up to support pre-elimination work in Lupane District of Matabeleland North. This annual report provides a synopsis of the activities implemented in ZAPIM’s fourth year, covering the period of October 1, 2018 through September 30, 2019. During the reporting period, As a result of a delay in funding for Year 4, ZAPIM was unable to implement activities in the first quarter of the year. Once the funding was obligated, the project was able to catch up and implement most of the approved work-plan activities. However the changes in the regulatory framework in June 2019 detailed below led to challenges that affected project implementation. Furthermore as the year progressed and there was anticipated delay in the release of Year 5 funding, the project had to slow down implementation and could not implement field activities in September 2019. Some Year 4 planned activities were thus deferred to Year 5. The activities are detailed in Annex C. 2.2 Zimbabwe Operating Context

As in previous years, Zimbabwe’s complex operating context was characterized by volatility, uncertainty and ambiguity. Economic challenges continued to escalate and worsen throughout the year. Although new monetary and fiscal policy statements were introduced, the economic situation did not improve, instead they negatively impacted program implementation both at the project and staffing level. Inflation was on the rise while the currency was depreciating fast and scarce thereby fueling the existence of a parallel exchange rate market. Prices of goods and services in local currency increased drastically in line with the U.S. dollar (USD) parallel market exchange rate. The project managed to mitigate against the price increases by continuing to use the U.S dollar as the functional currency.

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Below is a summary of the policy/regulation changes and how they impacted the program:

Policy/Regulation Impact on the project Operationalization of the February 2018 ring- This resulted in delayed implementation of activities as the fencing policy on Nostro foreign currency project waited for the bank to put systems in place and provide accounts (FCAs) which seeks to separate clear guidance on the how the project would be affected. foreign currency accounts into two categories, namely Nostro FCAs and Real Time Gross Settlement (RTGS) FCAs by October 15, 2018. The Intermediated Money Transfer Tax was There was no direct impact on project implementation since the reviewed upwards from 5 cents per tax is levied on local transactions. Even though the project transaction to 2 cents per dollar transacted in continued to use the US$ as the operational currency, the local currency effective October 1, 2018. increased tax resulted in a price hikes for goods and services.

New tax regulation on Paye As You Earn Although there was no direct impact on project, staff net (PAYE) for employees paid in foreign incomes were severely eroded by between 11-15% and this currency was introduced by the Zimbabwe resulted in low staff morale. The project complied to the new Revenue Authority (ZIMRA.) The new regulation but attempted to mitigate the situation by: method involved converting the staff’s USD 1. Reviewing staff benefits: increasing the daily meals salary to local currency at the prevailing allowances and introducing a transportation allowance. interbank rate in order to determine the 2. Reviewing staff salaries in line with the revised FSN taxable bracket to apply. The interbank scale of June 4, 2019. exchange rate changes every day and month By the end of year, however, U.S$ denominated tax tables had thereby continuously eroding the net salary been re-introduced although staff salary net incomes could not of the employee. be re-instated to original levels. Statutory Instrument (SI), 142 of 2019, was The abrupt re-introduction of the local currency affected banks, introduced on June 24, 2019. The new vendors and MoHCC partner allowances because adequate instrument banished the use of multi change over time was not provided. The SI142 was silent on currencies (including the USD) and treatment of funding from NGOs, Embassies and International introduced a local currency. The local Organizations. The project could not implement activities or pay currency is denoted in RTGS$ and bond MoHCC officials allowances for about a month in July 2019 notes and is deemed as the sole legal tender while awaiting further guidance and while systems were being in Zimbabwe put in place. The project subsequently continued to use the U.S$ as the operational currency since a waiver from SI142 was granted for NGOs, Embassies and International Organizations.

Key activities planned for July 2019 that were affected by the policy changes, in particular, SI142 that had to be deferred are as follows: Affected Activity Planned Dates Actual Implementation Dates Mentorship visit for 1-5 July 2019 5-9 August, 2019 Support supervision for Binga and Hwange 15 to 19 July Cancelled. Could not be done in Year Districts 4 Post training follow up UMP VHWs 07-13 July 2019 4-0 August, 2019 Post training follow up Mutoko peer supervisors 21-26 July 2019 LLINs post distribution cluster review and 15-19 July Cancelled. Was not done in Year 4. planning meetings August 2019 but coverage was low. Training of VHWs on CD of LLINs 22-26 July Only 100 were trained out of target of 1,000.

Data verification of Mass Distribution data July-August, 2019 Cancelled. Was not done in Year 4.

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CAC Evaluate Together Trainings: 1-6 July, 2019 For Mbire done 5-10 August. Cancelled Mbire District 8-13 July, 2019 for Mt Darwin and Shamva and did not Mt Darwin District 5-20 July, 2019 happen in Year 4.

Activities to Document CAC in Mash East Was moved to August but the scope was limited compare to original plan CAC support supervision for Binga District 8-12 July, 2019 4-10 August

Supportive supervision for Lupane District 22-26 July, 2019 Cancelled. Could not be done in Year 4 as funding situation could not allow for implementation in September 2019.

Provincial death audit and malaria review 16-17 July, 2019 31 July-1 August meeting in Mash East

All the policy/regulation changes coupled with dealing with basics of fuel and power supply made program implementation difficult and called for constant re-planning and re-strategizing. The country started experiencing electricity load shedding which resulted in the project operating without power supply and resorting to generator back up for extended hours on many occasions since June. This has resulted in increased costs for fuel procurement, generator installation and maintenance. The power outages also resulted in loss of internet connectivity which hampered communication for the project. The project had to resort to using mobile phones which are more costly.

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3. Technical Strategy

In Year 4, ZAPIM’s technical strategy was shaped by lessons learned over the past three years and the project focused on consolidating already existing activities and building capacity for the MoHCC to implement the activities in an efficient and sustainable manner. Firstly, ZAPIM continued implementing CD of LLINs in addition to mass distribution. Further, ZAPIM continued to assist NMCP to address challenging areas jointly identified by the NMCP and ZAPIM in the past years, namely SBCC operationalization at the community level, improving commodity supplies and SS of VHWs, and facilitating the use of death audit findings to improve the quality of malaria care. ZAPIM increased integration and better coordination of activities within the project team and also with other partners working in the same districts. For example, the project coordinated closely with Isdell Flowers and Wild for Life on CCM in Binga and Hwange and with VectorLink in Mutoko and Mudzi. ZAPIM incorporated capacity building activities for the NMCP at all levels of the health system to enhance programmatic leadership and sustainability, including fostering a culture of continuous quality improvement by using data for rapid decision making and action. 3.1 Target Districts for Implementation In Year 4, ZAPIM continued to implement malaria control and prevention activities, focusing on the same thematic areas of CM/MIP, LLIN, SBCC, and SM&E in the same 15 target districts in the three focus provinces: Mashonaland East, Mashonaland Central, and two malaria control districts in Matabeleland North (Table 1). In addition, ZAPIM started supporting malaria elimination work in Lupane District in Matabeleland North Province. The level of implementation of activities across the thematic arears varied according to the burden of malaria and existing gaps. Details of the activities implemented are found under the various sections.

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Table 1: ZAPIM Year 5 Implementation Provinces and Districts

Province Districts Mashonaland Central 1. Mbire 2. Guruve 3. Centenary/ Muzarabani 4. Shamva 5. Rushinga 6. Bindura 7. Mt. Darwin 8. Mazowe Mashonaland East 1. Goromonzi 2. Mutoko 3. Uzumba-Maramba-Pfungwe (UMP) 4. Murewa 5. Mudzi 6. Hwedza (LLIN activities only) Matabeleland North 1. Hwange 2. Binga 3. Lupane (malaria elimination activities only)

Figure 1 shows the three provinces that ZAPIM targets, of which two, Mashonaland Central and Mashonaland East, are high-malaria burdened.

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Figure 1: Map of Zimbabwe Showing ZAPIM-Targeted Districts

3.2 Capacity Building Central to ZAPIM across all thematic areas and activities is building capacity within the NMCP at all levels (national, health facility and community) to implement sustainable, high-quality, evidence-based programing in accordance with national and international standards for the control, prevention, treatment, and reporting of malaria. Over the years, ZAPIM has built capacity through training of staff, review and updating of technical guidelines and standard operating procedures (SOP), and development of relevant job aids, supportive supervision (SS), and on-the-job training and mentoring. In Year 4, ZAPIM continued support for these activities to build capacity within NMCP structures, and also ZAPIM-supported communities, for effective activity implementation. 3.3 Community-Based Approach The MoHCC emphasizes primary health care and a community-based approach to the delivery of health services. In line with this approach, ZAPIM’s activities in Year 4 continued to build capacity at the community and health facility levels. Since Year 2, ZAPIM has conducted community-based activities, which involved training VHWs on CCM and LLIN distribution, as well as training health facility personnel to conduct SS of VHWs and training VHWs to perform their own peer-to-peer supervision. ZAPIM continued these community-focused efforts in Year 4, with emphasis on supervision and mentorship geared towards strengthening CM of malaria and improving accountability of malaria commodities supplied to VHWs. This community-based approach in Year 4 sought to strengthen

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preventive efforts, especially by increasing uptake of LLINs during the mass distribution through community sensitization and health education. Lastly, ZAPIM supported community empowerment through the CAC approach through HCCs, and other community leaders, to encourage their active participation in malaria prevention and treatment seeking. 3.4 Using Data for Decision Making All ZAPIM-supported activities promote evidence-based decision making through international, national, and local data sources—including ZAPIM research, assessments, and best practices from the past years. In Year 4 ZAPIM used locally generated data, such as the MIS 2016, the Net Usage Assessment, Case Drug Consumption Study (CDCS), Assessment of Drivers of Continued Malaria Transmission in Angwa Ward, and the Net Durability Study, to inform programming, deployment of interventions including LLINs, and training requirements. ZAPIM assisted the provinces and districts to use and analyze DHIS2 data for decision making, more particularly to identify, investigate, and respond to outbreaks. ZAPIM used data obtained from various activities (including malaria review meetings, death audit meetings, SS visits, and data quality assessments (DQAs) to inform training needs and plan interventions. To assess the extent to which the trainings increased participants’ knowledge of CM/MIP, ZAPIM administered a test before and after trainings. ZAPIM used data from the project’s Training System Monitoring and Reporting Tool (TrainSMART) and the provinces to document CM/MIP trainings and to identify training gaps. 3.5 Coordination and Integration of Activities for Impact and Sustainability ZAPIM offers a comprehensive package of support to the NMCP across key thematic areas that are necessary for achieving the national strategic goals outlined in the NMSP. In Year 4, ZAPIM activities were well coordinated across thematic areas to ensure the integration of activities for improved efficiency and impact. Activities were layered and sequenced systematically in the supported districts to complement each other and to share implementation costs. For example, malaria review meetings were held back-to-back with the malaria death audits. In addition to internal coordination and integration of activities, ZAPIM collaborated closely with other implementing partners working in the same districts to ensure coordination and uniform standards for activity implementation. For example, in Matabeleland North, ZAPIM coordinated CCM activities with Isdell Flowers and Wild for Life, who are implementing similar activities in Hwange and Binga Districts. In Mashonaland East, ZAPIM coordinated SBCC activities with the VectorLink project to support the IRS program. ZAPIM also collaborated with CHAI in Lupane District. 3.6 ZAPIM Quality Improvement In line with the PMI Malaria Operational Plan 2016, where it was identified as a key area, ZAPIM incorporated quality assurance and improvement interventions into implementation of activities across all technical areas—CM/MIP, LLINs, SBCC, and SM&E. It is important to emphasize that these interventions are not entirely new as they were developed in collaboration with the NMCP to build on existing SS and quality improvement processes at the provincial and district levels. The mentorship pilot program for facility-based health care workers that started in Year 3 continued in Year 4. The mentorship review meeting held in the last quarter of Year 4 will guide any improvements needed for the program going forward. ZAPIM continues support for peer-to-peer mentoring for VHWs. Peer-to-peer mentoring is particularly important as the project seeks to ensure sustainability of activities. ZAPIM used data quality assessments, SS visits, and malaria review meetings to inform areas requiring improvements.

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3.7 Innovative Use of Digital Technology ZAPIM team also set up an electronic inventory for LLINs during the mass distribution. ZAPIM continued the use of Short Message Services (SMS) reminders to facility-based health care workers post CM trainings. ZAPIM supported training of EHTs on the DHIS2 Tracker and geographic information system (GIS) in case investigations, notifications, and foci mapping in Lupane District. ZAPIM piloted weekly mobile reporting by VHWs in Mbire in Year 4. In Year 5, ZAPIM will document the experiences and lessons learned from the pilot, troubleshoot, and make any necessary adjustments to improve the efficiency, timeliness, reliability, and completeness of the mobile reporting. ZAPIM will also make use of the generated data for decision making to improve CCM programming in Mbire District. 3.8 Sustainability In Year 4, ZAPIM continued to build capacity within the NMCP in a manner that ensures sustained improvements to their activities in the fight against malaria. All ZAPIM activities were implemented through the existing NMCP structures and the capacity of the structures were strengthened to enhance independent future execution of the activities without partner support. In Year 4 ZAPIM targeted all activities to address critical gaps and enhance long term sustainability within the NMCP structure down to the community level.

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4. TECHNICAL ACTIVITIES

4.1 Clinical Case Management In Year 4, ZAPIM supported MoHCC to conduct the following case management and MIP activities:  Trained a total of 183 health workers from Mashonaland East, Mashonaland Central and Matabeleland North in CM and MIP  25 mentors reached a total of 134 mentees from 25 health facilities from Mbire, Murewa, Mutoko, Hwange and Binga Districts  Support one malaria death audit meeting in each of the three ZAPIM supported provinces.

4.1.1 MALARIA CASE MANAGEMENT AND MIP TRAININGS In Year 4, ZAPIM continued to provide technical support for the training of health workers in malaria case management and malaria in pregnancy. These trainings were timed to coincide with the malaria season and targeted recently recruited nurses. The main objectives of the training were to help participants understand the basic malaria situation in their areas of practice; acquaint them with the treatment guidelines for malaria management as revised in 2014; and enable them to appropriately diagnose and treat malaria patients including prevention and treatment of malaria in pregnancy. Furthermore, ZAPIM used this platform to disseminate August 2018 policy changes in treatment of severe malaria in all trimesters using intravenous artesunate and treatment of children weighing less than five kilograms using ACTs. ZAPIM printed and distributed an addendum to participants for further dissemination at their respective health facilities.

Out of a targeted 185 health workers, ZAPIM supported training of 183 (98.8%) including newly recruited providers from the three provinces: Matabeleland North (33), Mashonaland Central (71), and Mashonaland East (79) by 15 provincial trainers who also entered all the CM and MIP trainings into the TrainSMART database. To assess whether these trainings resulted in improvement in knowledge amongst participants, trainers administered a multiple choice malaria knowledge assessment questionnaire before and after the training. Assessment results indicate general increase in knowledge evidenced by median score increase from 65% to 72% in Matabeleland North, 65% to 78% in Mashonaland Central, and 65% to 74.5% in Mashonaland East. Participants who performed poorly will need ongoing support during supportive supervision and mentorship. Armed with skills gained from the training, health workers are expected to have improved capacity to intervene appropriately when faced with malaria cases hence contribute to reduction in malaria related morbidity and mortality. Table 2 below shows disaggregation of participants by type of cadre.

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Table 2: CM and MIP Trainees by Profession in ZAPIM focused provinces (February-March 2019)

Cadre Male Female Total

Medical doctors 4 2 6

Registered general nurses 35 84 119

Primary care nurses 10 31 41

Nurse aides 0 1 1

Environmental Health Officer (EHO)/ EHTs 2 4 6

Pharmacy technicians 0 2 2

Lab scientists/technicians 2 2 4

Field orderlies* 0 1 1

Dispensary assistants 2 0 2

Data clerks 0 1 1

Total 55 128 183

*Field orderly: this is a cadre who reports to the EHT. They are involved in supervision of spray operators, larval source management, water and sanitation, VHW support, and follow up of communicable disease cases including malaria and tuberculosis

4.1.2 MALARIA CLINICAL MENTORSHIP To support health care workers to implement their knowledge and skills obtained through CM and MIP trainings and equip health care workers to provide the highest standard of malaria care, in May 2018, ZAPIM commenced the malaria clinical mentorship pilot in Mbire, Murewa, Mutoko, Hwange and Binga Districts. ZAPIM supported the training of 25 mentors, five from each district. The participants included doctors, nurses, pharmacists and laboratory personnel with experience in malaria case management, MIP and good interpersonal skills. Thus far, each district has conducted the following number of mentorship visits: Mbire-5, Murewa-5, Mutoko-4, Hwange-3, and Binga-2. The program has reached 134 health workers including nurses, EHTs, pharmacy technicians, and nurse aides. Table 3 below shows the number of health workers mentored and disaggregated by district and cadre. Table 3: Health Workers Mentored to Date (May) 2018 – August 2019) Cadre Binga Hwange Mbire Mutoko Murewa Total Nurses 31 16 10 31 13 101

Pharmacy Tech 0 0 0 0 1 1 EHTs 3 5 6 0 0 14 Nurse Aide 1 5 5 0 3 14 Dispensary assistants 0 1 0 0 0 1 Doctor 0 0 0 1 0 1 Microscopist 0 1 0 1 0 2 Total 35 28 21 33 17 134

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Mentorship activities

 During the first visit held in June 2018, mentors introduced the malaria mentorship program to health facility staff. They explained the mentorship rationale, agreed on implementation approaches and communication channels, provided sensitization on mentorship tools, and, in instances where there were differing opinions agreed on how to tackle them. In addition, the mentors used the Mentee Self-Assessment, Clinical Performance Assessment of Mentees by Mentor, and Health Facility Assessment mentorship tools to conduct a baseline assessment of the quality of care for malaria at selected sites. The teams used assessment findings to identify challenges or gaps that mentors and mentees will address during program implementation. Subsequent visits used case studies, record review, group discussions, demonstrations to address the gaps identified e.g. demonstration on RDT, preparation of microscopy slides (thin and thick smears), observing mentees while managing malaria cases to recognize good practices and address shortfalls in history taking and examination of malaria case, mentorship on proper documentation and reporting practices. For MIP, mentorship included review of ANC registers to verify accuracy of gestational age calculation, eligibility for SP administration to pregnant women. Some facilities were giving IPTp doses before 13 weeks gestation and before completing 28days after the last dose as recommended. In instances where health workers were not adhering to IPTp guidelines, mentors reinforced the importance of administration of SP according to guidelines. ZAPIM is currently supporting the development of IPTp job aids in the form of a calendar to help correctly identify those eligible for the IPTp and will finalize this job aid development in Y5.

The pictures below show some of the mentorship activities carried out by different districts during the year.

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Mentorship results and achievements

To assess mentorship results and achievements, ZAPIM technical staff and mentors collected and reviewed data from various sources including summary of mentorship activities from mentorship reports, feedback from mentors and mentees (collected through google forms), malaria record review of registers including (OPD, IMNCI, ANC registers). Table 4 includes the data collected and response rates during the mentorship assessment, comparing May 2018 with May 2019.

Table 4: Data collected and response rates during mentorship assessment

Assessment Data points Response rate

Mentor feedback Common activities, satisfaction with mentorship approach, benefits of 21 out 25 mentorship, challenges mentees face during mentorship, how to mentors (84%) enhance sustainability of mentorship and recommendations for improving mentorship

Mentee feedback Common activities, satisfaction with mentorship approach, benefits of 49 out of 98 mentorship, challenges mentees face during mentorship and mentees (50%) recommendations for improving mentorship

Malaria records review OPD and Integrated Management of Neonatal and Childhood Illness Over 500 (IMNCI) registers: Assessing malaria diagnosis, treatment and records recording practices using a simple checklist for all malaria clients in reviewed the months of May 2018 and May 2019 (i.e. before and after implementation of mentorship activities)

ANC register: Assessing adherence to IPTp and LLIN guidelines for all pregnant women in the months May 2018 and May 2019 (i.e. before and after implementation of mentorship activities)

Mentee feedback

Nearly half of the mentees (45%) received two mentorship visits. The most common activities that they participated in during mentorship visits were clinical meetings (59%), side by side/bedside teaching

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sessions (51%) and case observations and studies (43%). On enquiring about their satisfaction with the mentorship program, 60% of mentees scored that they are very satisfied with the mentorship approach, 74% said mentorship helped them do their work better and 67% said that this has improved quality of services. On asking about the benefits of mentorship, mentees reported that they benefited most from learning new skills (97%), receiving direct support from the mentorship team (51%) and team problem solving (44%). The most common challenge that mentees face during mentorship is systems issues (63%) such as access to commodities and supplies followed by competing priorities. Mentees recommended that mentorship is integrated with other activities (80%), using WhatsApp groups (56%) for sharing ideas and prioritizing peak malaria season for mentorship (61%), rather than a regular activity the year round.

Mentor feedback

On enquiring about mentor satisfaction with mentorship program 62% scored “very satisfied”, 86% said mentorship helped mentees do their work better and 67% said that this has improved quality of services. Mentors reported that they benefited most from learning new skills themselves (86%) and supporting service providers (mentees) (76%). The most common challenges that mentors faced was the unavailability of transport (71%) and mentee unavailability (57%). Recommendations to make mentorship more sustainable are; integration with other activities, prioritizing peak season for mentorship, using WhatsApp and other means to provide virtual follow up. On asking mentors what they recommend going forward the following themes came up: reduce and improve the “paperwork” / forms / documentation of mentorship activities, strengthen consistency of approach across districts, reward improved performance of facilities (positive competition), scale to other facilities in the district, ensure that mentors are up to date and confident to reference latest guidance, develop local strategies to address the transport barrier and develop local strategies to promote integration.

Findings from malaria records review

The three Figures below show changes in performance or competency between 2018 and 2019. Figure 2 shows that there were higher scores for OPD, IMNCI and ANC practices with respect to malaria performance measures in 2019 compared to the 2018 baseline. Figure 3 shows the comparison of performance across the districts: most districts improved average performance from 2018 to 2019. Figure 3 shows change in competency across different services of clinical case management: there were notable performance improvements between 2018 and 2019.

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Figure 2: Improvement in overall competency across services in May 2019 compared to May 2018 baseline

100%

90% 76.4% 80% 72.4% 70% 63.3% 64.0% 57.6% 60% 53.2% 50%

40%

30%

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0% OPD Average Score IMNCI Average Score ANC Average Score

2018 2019

*Competency in this case is measured by adherence to recommended practices as shown in the registers measured using a checklist with different parameters including recording of vital signs, confirmation of HIV status, recording abnormal signs in red, recording examination findings, malaria diagnosis, classification and correct documentation of malaria treatment

Figure 3: Showing improved average performance from 2018 to 2019 by district

100%

90%

80%

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60%

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0% Hwange Binga Mutoka Murehwa Mbire

2018 2019

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Figure 4: Parameters with notable performance improvement from 2018 to 2019

100%

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0% OPD Vital Signs Index OPD Positive cases in red IMNCI Positive Cases in Confirm if taking Patient eligible for IPTp red Cotrimoxizole

2018 2019

Malaria clinical mentorship review meeting

In September 2019, ZAPIM supported a two-day mentorship review meeting in the five mentorship activity districts. This meeting was attended by Deputy Director NMCP, Mashonaland East and Matabeleland North PEDCOs, PMI Malaria Advisors, four ZAPIM technical staff, DHE members and mentors from five mentorship districts. The purpose of the meeting was to review the mentorship program, including (using the information described above), the approach that was used as well as highlight areas where mentees and mentors may need additional training or skills building. The meeting also provided an important opportunity for stakeholders and participants to reflect on one year of implementation experience and provide a platform to discuss three key themes:

 Implementation: Overview of mentorship implementation; was this done according to the guide?

 Achievements: Review of achievements; were goal and objectives met?

 Recommendations: Recommendations based on implementation experience

The mentorship review meeting activities included the following

 Overview presentation on mentorship design

 District presentations from five districts on their experience of implementation, lessons learned, successes and challenges and recommended way forward

 Presentation on mentorship results and achievements

 Group work and discussion focused on four main areas

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o Design of mentorship: Team formation, roles and responsibilities, site visits, supervision, how can we make mentorship more cost effective, recordkeeping, documentation, peak season vs low season

o Overcoming persistent mentorship challenges: Transport, commodities, availability of mentees, turnover, persistent gaps in case management

o Meaningful results: How can we better capture and report improvement of performance of health care workers and facilities due to mentorship

o Technology: How can we use technology more effectively

 Malaria case management and MIP technical updates: To ensure that mentors were up to date with case management and MIP technical updates, Matebeleland North PEDCO facilitated a session during the review meeting where mentors discussed August 2018 policy changes in treatment of severe malaria in all trimesters using intravenous artesunate and treatment of children weighing less than five kilograms using ACTs.

The photos below illustrate a) the mentorship review discussion groups and b) the mentorship review group feedback sessions. (Photos credit: ZAPIM)

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Based on discussions during district presentations and group work, participants came up with the following recommendations on some specific priority areas going forward (see Table 5).

Table 5: Recommendations from the mentorship review meeting Priority Preliminary recommendations from workshop Responsibility

Increase cost  Train peer mentors at health facility level, reducing transport, Mentors effectiveness of accommodation and per diem costs mentorship  Integrate mentorship visits with other programs where appropriate (e.g. EPI, HIV) DHE

 Prioritize facilities and / or service providers for mentorship DHE, mentors determined by needs at a specific facility e.g. If a facility needs mentorship on history taking/ physical examination only the clinician participates in that visit rather than the whole team

 Prioritize malaria season for mentorship by conducting 3 visits during peak malaria season and 1 visit off season

Improve availability  DHE leads planning for mentorship visits and reviews progress Mentors of transport and challenges

 DHE leads integration of mentorship visits with other programs DHE  Peer mentors at health facility level Mentors, ZAPIM

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Ensure mentee  Collaborate with health facilities to schedule mentorship visits Mentors, sister in charge availability during mentorship visits  Peer mentors at health facility level Mentors

 Ensure team feedback after mentorship visit to include staff not Mentees available during visit

Strengthen  Improve tools based on challenges noted ZAPIM, provincial executive mentorship records and reporting  Consider electronic tools to support recording and reporting of mentorship

Strengthen strategic  Use of electronic tools (but ensure security of data) ZAPIM, mentors, NMCP use of technology in mentorship  Explore affordable technologies such as WhatsApp, google forms, ODK etc. working closely with NMCP

Most of these priorities will be addressed during Year 5 to ensure that the mentorship approach is adapted and improved to meet real needs and realities.

4.1.3 MALARIA DEATH AUDIT MEETINGS ZAPIM provided technical and financial support for one-day malaria death audit meetings in May 2019 in Mashonaland Central and Matabeleland North (Binga and Hwange) Districts and Mashonaland East in August 2019. A total of 45 participants attended the meeting in Mashonaland Central, 43 participants in Matabeleland North and 50 participants in August 2019. Participants included ZAPIM staff, PMI malaria advisors, provincial health executives, district health executives, and health workers from selected facilities. The purpose of the meetings was to discuss malaria deaths experienced during the period from January to the time of death audit meeting. The process involved presentation of deaths experienced in the provinces, identification of gaps in the management of these cases, and crafting of recommendations to address these gaps in line with the MOHCC goal of reducing malaria deaths by at least 90 percent of the 2015 figure by 2020.

Key findings from the death audit meetings are listed below and recommendations in Table 6:  Unavailability of malaria commodities at VHW level resulting in delayed access to care;  Misclassification of malaria cases as uncomplicated, yet signs of severe malaria existed resulting inappropriate treatment of malaria patients;  Seeking treatment from traditional healers before visiting health facilities resulting in delayed medical treatment;  Traditional practices were used to treat the patient, such as ‘scratching the throat’ which unnecessarily harmed the patient and delayed treatment;  Unavailability of supportive equipment and diagnostic investigations such as pediatric catheters and urea and electrolytes machine.

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Table 6: Findings and Recommendations from Death Audit Meetings

Findings Recommendations Responsibility Unavailability of malaria  Ensure malaria commodities are adequately Health facility nurse in charge commodities at VHW level distributed to VHWs resulting in delayed access  Health facilities to order adequate to care commodities for VHWs  District Pharmacy Managers to assist health District Pharmacist facilities in verifying that they order adequate commodities  Provincial Pharmacist to assist in Provincial Pharmacist redistribution of commodities across districts Misclassification of malaria  Emphasize malaria classification and differing Malaria Case Management cases as uncomplicated yet treatment protocols during malaria case trainers there are signs of severe management trainings, mentorship and District and Provincial Health malaria supportive supervision Executives

 Develop clerk sheet to guide health workers ZAPIM Case Management on history taking, physical examination and specialists classification of malaria cases Seeking treatment from  Conduct community meetings with Health Promotion Officer, traditional healers before traditional and religious leaders and ZAPIM SBCC Specialists, visiting health facilities traditional healers to promote early referral ZAPIM Provincial including traditional of suspected malaria cases for diagnosis and Coordinator practices such as treatment and understanding of harmful ‘scratching the throat’ practices  Educate communities on early care seeking Malaria Case Management behavior and understanding of harmful trainers, ZAPIM Case practices Management Specialists and Commented [EM2]: Word missing  Improving health worker attitudes (including VHWs) which may be deterrent to accessing care from the formal system. Unavailability of supportive  Procure supportive equipment Health Center Committees, equipment and  Advocate for procurement of urea and Provincial Medical Director investigations such as electrolyte machines and reagents pediatric catheters and urea and electrolytes machines and reagents

In Year 5, ZAPIM will prioritize addressing the identified challenges as described in the table above. For challenges beyond ZAPIM’s scope of work such as procurement of equipment, we will play an advocacy role to with the responsible authorities. ZAPIM will continue to support death audits meetings in Year 5.

4.2 COMMUNITY CASE MANAGEMENT ZAPIM’s approach to community case management includes several interventions in an effort to promote quality case management at the village level. The interventions implemented by ZAPIM in Year 4 include:  CCM & MIP trainings  Post training follow up

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 Supportive supervision which encompasses local health facility staff supervision, VHW peer supervisors, EHT- led supervision, and orientation of health workers on VHW supportive supervision process and tools

 VHW review meetings

4.2.1 CCM & MIP TRAININGS ZAPIM supported the MoHCC VHW trainers to train a total of 317 Village Health Workers (VHWs) in CCM and MIP between February and April 2019. This is the period when most cases of malaria are experienced and the newly trained VHWs were able to practice during the peak period. Table 7 shows the distribution of the trained VHWs by district. Table 7: Distribution of CCM Trainees by District (February – April 2019) District Target Achievement Binga 40 35(88%) Mudzi 80 77(96%) Goromonzi 40 40(100) Centenary 80 80(100%) UMP 80 85(106%) Mbire 80 0 Total 400 317 (79%)

The facilitators assessed the participants’ knowledge of malaria prevention and control through pre and post- test evaluations. In all groups, participants gained knowledge as evidenced by higher mean scores in the post test results although there were participants who did not attain the 50% pass mark in the post test. At the end of training facilitators revised the pre and post- test highlighting the correct responses to the questions so that VHWs understood where they failed to respond correctly. It is during these revision sessions that the VHWs indicated that they failed to follow the instructions on the test which required one answer for some questions and multiple answers for others. ZAPIM has shared with NMCP concerns regarding layout of the test paper so that it can be revised, for example grouping questions into sections and giving appropriate instructions. NMCP indicated that this would be done when the training manuals are being revised. However over 75% of the VHWs attained a sound understanding of signs and symptoms of uncomplicated and severe malaria to enable them to provide quality case management in the community. The facilitators also assessed all the participants on RDT testing and all were able to perform the procedure according to the required guidelines. The VHWs were attached at their clinics soon after the training for five days under the supervision of the HF staff. This is a necessary requirement as per training guidelines so that VHWs put into practice skills of patient assessment and RDT testing learned in the classroom. ZAPIM also provided the VHWs participant manuals to take home after the training so that they continue to refer whenever necessary and adhere to guidelines. Figure 5 below shows the performance of all groups trained.

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Figure 5: CCM Trainings: Mean Scores of Training Participants by District (February – April 2019)

90 80 70 60 50 40

30 mean mean scores(%) 20 10 0

pre test post test

VHWs who did not attain the 50% pass mark continued to receive support at the clinic during their monthly meetings and were also targeted during the post training follow up and supportive supervision visits to strengthen their knowledge and skills. From the follow up and supportive supervision visits, HF staff and trainers are confident these VHWs are able to assess and manage malaria cases according to guidelines. The trainings also involved practice on documentation in RDT/malaria register, proper hygienic hand washing following the ten steps for infection prevention, assessment of a sick child and RDT testing. Below are two VHWs giving feedback to the group on documentation in the RDT register using a hand drawn chart of the RDT/malaria register. Facilitators provided the necessary feedback to ensure VHWS took home the correct information.

VHWs giving feedback on RDT/medicine register documentation Facilitators used the flip chart (above) to demonstrate how to properly fill out theRDT/medicines register and requested that ZAPIM procure an A1 size chart of the register. ZAPIM followed up the request and procured five A1 size charts of the RDT/medicines register which have been used by the Provincial

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Coordinators to reinforce to HF staff how VHWs use the register. This was done during selected scheduled district meetings for Mbire, Centenary and Mutoko districts and will continue in the other districts in Year 5. Regarding the use of the A1 chart, one nurse from Centenary had this to say: “I have seen the registers used by VHWs, but I was not sure there was a section for the staff to fill in. Thank you for taking us through this RDT/medicines register.”

4.2.2 POST TRAINING FOLLOW UP According to the World Health Organization (WHO)/UNICEF course on Integrated Management of Childhood Illness for first-level health workers,1 follow up is the second component of training which should take place four to six weeks after the initial training. The three day course which the VHWs go through is designed to equip them with the skills and knowledge to manage patients more effectively in the community. However the VHWs may find it difficult to begin using these skills hence they need help to transfer what they have learned in the classroom to their community where they work from. This is achieved through the five day VHW attachment at the clinic that takes place within four weeks post training after which a follow up visit is conducted by trainers four to six weeks after the training. The objectives of post training follow up are; to reinforce skills on assessment of patient (adult and sick child) and help VHWs transfer these skills to community work. ZAPIM supported trainers from four districts (Centenary, Goromonzi, Mudzi and UMP) to conduct post training follow up for VHWs trained in 2019 as shown in the table below. Table 8: VHWs followed up after training, by district, April-June 2019 District Dates of Dates of follow Target Achievement training up Centenary 19-24 March 09-15 June 77 68 (88%) Goromonzi 12-16 March 03-07 June 40 24 (60%) Mudzi 26 Feb-03 March 05-11 May 80 59 (74%) UMP 07-14 April 04-10 August 85 52 (61%) Total 282 203(64%) The follow-up team included one staff from the facility responsible for supervising the VHWs where feasible, two VHW trainers and ZAPIM staff. All the VHWs trained completed their post training attachment and are contributing significantly in malaria case management. Trainers were able to support a total of 203 VHWs at their respective health facilities and fifty (25%) received home visits to assess storage of malaria commodities, waste management and suitability of space used for consultations. Home visits were only conducted for VHWs who had medicines and RDTs at their homes on the day of the visit.

4.2.3 SUPPORTIVE SUPERVISION The post training follow up is followed by regular ongoing supportive supervision. Ideally supportive supervision should be ongoing however this has not been happening as expected due to competing priorities at facility level, lack of transport at district level and non-availability of fuel for motorized EHTs. The objectives of the supportive supervision are to:  Strengthen the skills of VHWs by evaluating their ability to assess cases, perform RDTs, give appropriate treatment and refer severe cases  Support the VHWs in proper storage of malaria medicines, RDTS and other supplies  Support the VHWs in proper record keeping  Support the VHWs in solving problems related to their role in CCM

1 https://apps.who.int/iris/bitstream/handle/10665/66095

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4.2.3.1 SUPPORTIVE SUPERVISION BY DISTRICT SUPERVISORS ZAPIM provided technical support and covered allowances for supervisors from Binga and Hwange to enable them to conduct supportive supervision of VHWs trained in 2017-2018. The approach was to visit VHWs in their homes and provide the support however the DNO’s office informed the VHWs to assemble at the health facilities thus affected the number of VHWs visited at home. All the VHWs (132) who assembled at the facilities were supported and 18 eventually visited at home. The table below summarizes the distribution of VHWs supported at health facilities and at homes. Table 9: VHWs Reached During Supportive Supervision in February 2019 District VHWs supported at health VHWs reached at facilities homes Binga 91 6 Hwange 41 12 Total 132 18  During the supportive supervision visits, VHWs indicated that they provide services during the night and have challenges with lighting and requested ZAPIM to support them with solar lamps.  In Mashonaland Central the Community Health Nurse from Centenary reported the same issue and mentioned that one VHW from Chawarura Clinic realizing the need for good lighting during case management at night bought a solar powered light using her own resources. This solar powered light serves as a light source and can recharge mobile phones. ZAPIM will explore the possibility of supplying VHWs with solar powered lights in Year 5 if funding permits (see photo).

Solar powered light sourced by a VHW using her own funds in Mashonaland Central, Chawarura Clinic

4.2.3.2 VHW PEER SUPERVISOR TRAINING, APRIL 2019 Peer supervision is a cost effective way of supporting VHWs. A peer supervisor is selected by other VHWs under the guidance of the nurse in charge at the facility. According to the MoHCC VHW peer supervisor guidelines 2016, the selection is based on the performance of the VHW in case management and also considers the following; reliability, honesty, empathy, approachability and good interpersonal communication skills. In Mutoko 40 peer supervisors were selected at 12 clinics in high malaria burden areas. In 2019 ZAPIM supported the District VHW trainers to train 38 VHW peer supervisors. The training aimed to equip the VHW peer supervisors with knowledge and skills to conduct supportive

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supervision of their peers. This included the ability to conduct observation of a peer providing services, active listening, coaching, giving feedback and developing an action plan.

4.2.3.3 VHW PEER SUPERVISORS POST TRAINING FOLLOW UP, AUGUST 2019 ZAPIM supported two VHW trainers from to conduct post training follow up of VHW peer supervisors. A subset of supervisors was visited and the approach was to: 1) visit the peer supervisor at their home and see if their quality of care is still up to standard, review their peer supervision reports and action plans developed and 2) visit a peer’s home to observe the SS process. The following was achieved:

 A total of 11 peer supervisors were followed up at their homes. Their registers and action plans were reviewed. All 11 had conducted at least one peer supervisory visit to their peers, and thus 30 peers were visited before the follow up date.  Six peer supervisors were observed actually providing support to their peers and they all provided their support in a stress free manner, used the SS checklist appropriately, identified gaps in their peers’ performance and provided constructive feedback. The other five peer supervisors had simulations of a support visit and facilitators were taken through how the peer supervisors had conducted the supervision. The review of action plans indicated that the peer supervisors were able to report the work they were doing.  Six VHWs supervised by the peers during the follow up indicated that the strategy is good as it provides an opportunity for the peers to support and teach each other.

4.2.3.4 EHT LED SS ZAPIM is supporting MoHCC to revitalize the EHT led supervision of VHWs in three districts namely Mbire, Mutoko and UMP where selected motorized EHTs will provide SS to VHWs. The Provincial Coordinator for Mash East organized fuel for the 10 EHTs from the two districts and they are currently conducting their baseline visits. Reports will be shared by the end of October 2019. For Mashonaland Central availability of petrol in Mbire District is a challenge. The Provincial Coordinator is working closely with the PEDCO to ensure the petrol for the eight EHTs selected is safely delivered to the District by first week of October. Detailed reports regarding this activity will be produced in the first quarter of Year 5.

4.2.3.5 ORIENTATION OF HCWS TO VHW SUPPORTIVE SUPERVISION PROCESS AND TOOLS, MAY 2019 UMP is one of the malaria high-burdened districts supported by ZAPIM and has trained 271 VHWs in community case management. However ZAPIM noted that staff at health facilities in UMP were not well versed with the tools and job aids used by the VHWs during malaria community case management. Therefore, ZAPIM supported the orientation of 18 health workers including six nurses and 12 EHTs in UMP to equip them with the knowledge and skills to provide supportive supervision to VHWs.

4.2.4 VHW REVIEW MEETINGS These meetings provide VHWs with a platform to share their experiences, successes, and challenges. The meetings also provide the HF staff and DHE opportunity to hear the issues from the community from representatives of VHWs. In Year 4 ZAPIM supported three districts, Mbire, Centenary and Mutoko to hold their VHW review meetings. These meetings integrated all community activities supported by ZAPIM (CCM, LLINs and SBCC). The meetings were generally well attended with DHEs well represented. Table X shows attendance by district

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Table 10: VHW attendance at VHW review meetings by District, September 2019 District VHWs Nurses EHTs DHE Total members Mutoko 18 17 4 5 44

Mbire 13 13 6 4 36

Centenary 13 13 8 5 39

Total 44 43 18 14 119

4.2.5 ISSUES/AREAS FOR IMPROVEMENT OF THE CCM PROGRAM The following achievements, issues and challenges were identified and recommendations were discussed during the post training follow up, supportive supervision and VHW review meetings: Achievements  VHWs contribute significantly to malaria case management across all districts.  Malaria commodities were available throughout the year in the districts although were often not in adequate amounts to allow a consistent supply to VHWs. ZAPIM will continue to lobby for adequate supplies for VHWs to enable communities to access early testing and treatment.  VHWs are able to identify cases that need urgent referral thus preventing deaths from malaria.  All VHWs reached were making use of their registers: RDT/Medicine register, improvised adult consultation register and the sick child registers, documentation in the registers was good.  All the VHWs were recording page totals and monthly totals in the RDT/Medicines registers.  Adult consultation registers: Although improvised, the VHWs followed a standardized format, given by facilitators, to capture adult patient information. Generally, these registers were well written with the required information captured.

Areas for improvement  Generally there is need for the consistent and adequate supply of RDTs and malaria medicines to VHWs across all the districts. This will enable VHWs to maintain their skills and knowledge in malaria case management at optimum. In Year 5 ZAPIM will continue to lobby for adequate supplies through the NMCP and GHSC.  VHWs not suppled with rectal artesunate, zinc and oral rehydration solution (ORS), gloves and cotton wool. HFs were encouraged by the DHEs to provide VHWs with all commodities to facilitate provision of integrated community case management. ZAPIM’s CCM specialist shared the 2014 memo from the MoHCC Permanent Secretary that authorized VHWs to give ORS and zinc. Following the meetings, VHWs are now receiving zinc and ORS, rectal artesunate, gloves and cotton wool.  Over 75 percent of the VHWs were not indicating the opening and closing stocks in the RDT/malaria medicines register. This is a persistent gap among VHWs across all districts and requires continued support from the health facility, District and ZAPIM staff. In Year 5, ZAPIM Provincial Coordinators will make use of the laminated A1 RDT/medicine register job aid to reinforce the importance of this information during selected monthly nurses’ meetings in the districts.  The main gap in the adult consultation register was that VHWs were not indicating the duration of illness. ZAPIM discussed with the VHWs and corrected this. ZAPIM highlighted to the VHWs that the duration of illness is crucial to assist them to identify how early the community members

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seek treatment when they suspect malaria. ZAPIM reminded the VHWs that individuals should seek treatment within 24 hours of suspecting malaria to avoid complications.  VHWs were referring patients with fever who tested RDT negative for malaria to health facilities as per the guidelines but most of these patients were not reporting to health facilities despite the VHWs having explained the importance of further assessment. The HF staff will support VHWs in giving information to the communities in the on-going sensitization meetings in the districts.  Use of IEC materials in English yet some community members may not understand the language. The District Health Promotion officers are working with health facilities and ZAPIM SBCC team to produce IEC materials in Shona.  Health facility staff were not conducting VHW supervision in the community due to competing priorities especially for the nurses. EHTs now supporting the VHWS to ensure quality community case management services however they have reported transport challenges. In Year 5 ZAPIM will continue the provision of fuel to the selected 18 EHTs from high burdened wards in Mbire (8), Mutoko (5) and UMP (5).ZAPIM will also strengthen the VHW peer to peer support.  Some trained VHWs absconding duties or relocating to urban areas thus compromising availability of CCM services in affected areas. HF staff were advised by the DHE members to provide information to the district regarding VHWs. HF staff are to report all VHWs who are not active each month giving the reasons so that those persistently unable to provide services can be replaced.  Outdoor activities like stream bank cultivation, artisanal mining along Mazowe and Nyadire Rivers in UMP in Mashonaland East, and sleeping outdoors due to extreme temperatures are predisposing community members to mosquito bites. The District is mapping where the artisanal miners are and will share with the PEDCO and ZAPIM so that the miners are considered for LLINs.  Depending on available funding, gaps in CCM training for VHWs and EHTs will be considered in ZAPIM-supported Year 5 trainings for selected malaria high burdened districts.

4.2.6 PROCUREMENTS FOR VHWS ZAPIM supported the MoHCC, Mbire District in Mashonaland Central with procurement and distribution of 200 medicine cabinets for the safe and secure storage of commodities at the community level. Three cabinets were lost within the district during transportation at the time of distribution and the incident was reported at Mahuwe Police station by the DHIO. The three cabinets have not been recovered to date. The ZAPIM Provincial Coordinator will continue to follow up the issue with the police until the case is closed. ZAPIM also supported the MoHCC and Mashonaland Central Province with procurement and distribution of 186 smart phones to VHWs who provide CCM in Mbire District. This support from ZAPIM will enable mobile reporting of weekly malaria data by VHWs (see SM&E section 4.5.11). The phones were well received by the DHE, HF staff and VHWs as they also provide easier means of communication between the facility and VHWs. For example HFs have created WhatsApp groups with their VHWs thus information is travelling faster than before. The phones also provide a light source for VHW during case management at night.

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4.2.7 A SUCCESS STORY RELATED TO CCM ACTIVITIES IN MBIRE

VHW Itariya Butau (Photo credit: ZAPIM) On 17 April 2019, a pregnant woman (six months pregnant) visited VHW Itariya Butau of Chikafa clinic in Mbire District, complaining of fever, headache and loss of appetite. The VHW did an RDT and confirmed malaria. She had the woman startcommenced the woman on artemether-lumefantrine and instructed her on how to take the medicine. As a norm following the clinical protocol, after two days the VHW made a follow up visit to the patient, and noted that the woman’s condition was not improving. The VHW reassessed the woman and found she was now developing jaundice and was not feeding well. Mrs. Butau counselled the woman and her family and referred them urgently to Chikafa clinic. The family took the pregnant woman to the clinic where she was further referred to Chitsungo Hospital, the designated District hospital, after receiving pre referral treatment. On arrival at the hospital the woman was transferred to Parirenyatwa Hospital for further treatment for severe anemia, renal failure and jaundice. The woman stayed at Parirenyatwa hospital for two months, recovered and was discharged. Although she lost her unborn child she is grateful her life was saved. The woman said: “VHWs are important because they stay close to the people so I went there first. They also give free services.”

4.3 LONG LASTING INSECTICIDE TREATED NETS In an effort to reduce malaria morbidity and mortality and to strengthen health systems, Zimbabwe adopted the 2007 World Health Organization recommendation calling for universal coverage of the entire population at risk of malaria.

According to Zimbabwe’s National Malaria Control Strategy of 2016-2020, the country deploys Long Lasting Insecticidal Treated Nets (LLINs) in areas with Annual Parasite Incidence (API) of 2-4/1,000 population. Whilst those with an API of 5 and above benefit from Indoor Residual Spraying (IRS) and those with an API of less than 2 are put on surveillance and Social Behavior Change Communication (SBCC) interventions. The country, however also recognizes the existence of special communities where some populations live in areas with an API that requires Indoor Residual Spraying (IRS) as the choice of intervention but reside in unsprayable structures/rooms. In this regard, ZAPIM in Year 4 supported the MOHCC in distributing LLINs to cater for this special community population, who reside mostly along the border with Mozambique.

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In Year 4 ZAPIM supported the NMCP in conducting both Mass and Continuous Distribution of LLINs under the theme “My Net My Life”. The following were the major achievements:  Trained of 348 Health Workers (HWs) on mass distribution and 29 on Continuous Distribution (CD)  Ten districts were supported in training 1,632 Village Health Workers (VHWs) on Mass Distribution and 100 HWs on CD of LLINs  A total of 28,592 people comprising of community leaders and ordinary community members were sensitised prior to conducting mass distribution activities  Distributed 624,458 blue and white rectangular LLINs through mass distribution covering 993,852 people  Supported the distribution of 101,111 rectangular LLINs through CD channels  Supported NMCP in training 62 EHTs who were involved in distributing LLINs to Cyclone Idai affected communities in Chimanimani and Chipinge Districts of .

4.3.1 MASS DISTRIBUTION

ZAPIM supported the 2019 Mass Distribution campaign of LLINs to ensure universal coverage of the targeted populations in 10 districts of Bindura, Centenary, Guruve, Goromonzi, Mazowe, Mbire, Mt Darwin, Murewa, Rushinga and Shamva. ZAPIM strategically established LLINs 421 distribution points consisting of both static and outreach points in the communities so that beneficiaries were within 10 km radius of the outreach points. This was to ensure that the 967,141 targeted populations are covered.

The photo below shows some of the beneficiaries of the 2019 mass campaign happily holding their LLINs. The wards which benefited from the campaign had either 1) benefited from the 2016 mass distribution campaign 2) new wards which were not sprayed in 2018/2019 season or 3) had some special populations living along the border with Mozambique. These communities are considered to be special due to their socio –economic activities as they live in temporary homes in Mozambique or along perennial rivers where they are involved in streambank cultivation. They have two homes one temporary and one permanent and spend a greater part of the year residing at the former between October and July of each year. They also reside far away from others and health facilities and are at greater risk of getting malaria than their counterparts who reside in the villages and have their houses sprayed annually. These communities are normally left out of most health programs as they reside far away from health facilities. The broad objective for the 2019 campaign was to increase ownership, access, correct and consistent utilization of LLINs and eventually reduce malaria transmission. Specific targets were: 1. To replace the LLINs distributed in 2016 by July 30, 2019; 2. To provide an LLIN to every registered sleeping space in the targeted 144 wards in 10 districts by the 30th of July 2019. In line with the above objectives the mass distribution campaign of 2019 which started on June 10, 2019 was completed on July 5, 2019. A total of 624,458 (99.9%) sleeping spaces against a target of 625,283 were covered. :

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Beneficiaries of the My Net My Life mass campaign displaying their just received LLINs

4.3.1.1 LLINS MASS DISTRIBUTION PREPARATORY ACTIVITIES Prior to the commencement of the Mass Distribution campaign, ZAPIM developed a guidance document along with several tools to facilitate activity execution, data capture and reporting in order to standardize implementation of mass distribution activities. The following tools were developed:  LLIN 10: this form was used by the Village Health Workers (VHWs) to collect household information. Key information collected included number of people in the household, number of sleeping places, inside and outside, number of LLINs available and required;  Form LLIN 11: used by HF staff to consolidate information by village from Form number 10;  Form LLIN 12: a district summary of data by ward for the household registration data;  Form LLIN 13: a summary of LLINs distributed by ward for each district;  Form 7: used to assess LLINs coverage and challenges in utilization of LLINs. These tools were used from village level up to national level. This ensured that data transmission was standardized. Another tool used at national level by ZAPIM LLIN/Vector Control Specialist was the LLINs Daily Master Tracker. This tool completed by VHWs and EHTs was used to monitor the daily performance of districts and to identify and resolve challenges faced in the field.

4.3.1.2 LLINS COORDINATION For effective implementation and coordination, ZAPIM and the NMCP outlined the roles and responsibilities of the various players who were involved in LLINs distribution right from the onset. The modus operandi was that supervisors and LLIN distributors were responsible for running the distribution activities in their respective areas of operation. Each ward had six VHWs, one Environmental Health Technician (EHT) and one nurse. Each distribution point also had two security guards. Secondly each district had an LLIN focal person who coordinated the distribution activities and reported to the District Environmental Health Officer (DEHO). The LLINs focal person communicated with the ZAPIM LLINs/Vector Control Specialist on a daily basis and provided daily updates to ZAPIM. At operational

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level the EHTs and nurses were responsible for ensuring that all appropriate and useful information on LLINs reached the targeted audiences through ward and village meetings and household visits. They also supervised and supported LLINs distribution activities at ward level. Table 11 outlines the roles and responsibilities of each structure at each level of the health system. Table 11: Roles and Responsibilities of Mass Distribution Stakeholders

Level Key Coordination Staff Key roles National NMCP  Coordination of Mass Distribution activities ZAPIM  Logistical and technical support GHSC  Training of personnel in Mass Distribution  Development of guidelines and tools  Support and supervision  Delivery of LLINs to district holding points

Provincial Provincial Field Officer (PFO)  Coordination of activities Provincial Environmental Health  Supporting districts Officer (PEHO)  Logistical support ZAPIM Provincial Coordinator  Training support  Provincial level sensitization District District Medical Officer (DMO)  District planning District Environmental Health  Logistics coordination Officer  Support and supervision of ward personnel Environmental Health Officer  Documentation and reporting (LLINs Focal person)  Training support  District level sensitization Health Facility (HF) Environmental Health Technician  Training of VHWs Nurse  Community sensitization  Supporting VHWs (sensitization meetings and household registration)  LLINs distribution Community Leaders Village Heads  Community sensitization Health Centre Committee  Supporting work of VHWs  Developing community policing measures.  Overseeing distribution of LLINs Community VHWs  Community sensitization  Household registration  Selection of distribution points  Supporting distribution activities

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4.3.1.3 MASS DISTRIBUTION PARTICIPATING DISTRICTS, WARDS AND HEALTH FACILITIES The 2019 Mass Distribution campaign was implemented in the same areas where LLINs were distributed in 2016 with new areas being added. However no LLINs were distributed in IRS areas as per national policy, except in circumstances where concurrence for such targeted distribution was reached with the NMCP and provinces. These special areas were in Centenary, Mbire and Rushinga Districts and are located along the border with Mozambique. These communities are considered to be special due to their socio-economic activities. They are engaged in stream bank cultivation, gold panning, charcoal making in the forests and relocate to Mozambique for farming between October and June of each year. As a result they are left of the IRS program and have to be provided with LLINs although the rest of the communities benefit from IRS. Table 12 below indicates the number of wards and HFs by district which participated in the 2019 Mass Distribution campaign. Table 12: Wards and Health Facilities that participated in Mass Distribution of LLINs (2019) Province District Districts LLINs # of distribution points used Health Wards Wards Facilities in LLINs Wards Static Outreach Mash Central Bindura 22 10 8 5 8 Centenary 29 16 7 12 8 Guruve 24 14 11 8 12 Mazowe 35 25 21 78 20 Mt. Darwin 40 16 9 20 9 Rushinga 25 9 6 3 7 Mbire 17 4 5 8 5 Shamva 29 16 13 20 12 Total 221 110 80 154 81 Mash East Goromonzi 25 17 13 97 13 Murewa 34 17 13 64 13 Total 59 34 26 161 26 Total 10 280 144 106 315 107 A total of 107 Health Facilities (HFs) covering 144 (51%) wards participated in the 2019 LLINs mass distribution campaign. This is 10 wards more than those which participated in 2016. Mazowe District had the largest number with 25 out of 35 wards participating in LLIN distribution. This was followed by Goromonzi and Murewa at 17 wards each and Mt Darwin and Shamva with 16 wards each. Mbire was the least with four wards involved in the Mass Distribution campaign.

4.3.1.4 MASS DISTRIBUTION TRAINING The VHWs were trained over the course of one day on the mass distribution of LLINs. The facilitators were drawn from the districts, provinces and ZAPIM. In some cases HFs decided to engage all the trained VHWs in their wards for the purposes of properly executing the program. However no additional financial and logistical resources were provided by ZAPIM outside the six VHWs targeted. The trainings covered the following topics:

 National Malaria Program goal and objectives for malaria and Vector Control  Malaria prevention and control with a focus of LLINs and how they work  LLINs distribution methods-mass and continuous distribution  Demonstration on how to properly hang the rectangular net

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 Safe disposal of net plastic bags  Net aeration, maintenance, care and repair including beneficial repurposing for old torn nets  Community policing measures aimed at promoting net use and discouraging misuse of nets  Data collection using the various forms LLIN 10,11, 12 and 13  Net follow ups using form LLIN 07

The trainings were done in a participatory and interactive way and the methods used were:  Presentations and Discussions  Practical work on using the data collection tools  Group work  Role play  Demonstrations on various ways of hanging the rectangular net

District orientation trainings were conducted for the people directly involved in sensitization, registration and distribution of LLINs. This included mainly the Environmental Health Technicians (EHTs) and nurses from beneficiary wards or HFs, key district personnel (District Medical Officers, Administrators/Stores managers, District Environmental Health Officers, EHOs, Health Promotion Officers and District Nursing Officers) were trained as trainers for the ward level personnel. The district orientation trainings were held from April 8 – May 17, 2019. Major outcomes of these district trainings included: development of ward level action plans, identification and mapping of distribution points and development of strategies for effective implementation of the mass distribution. Table 13 below indicates the number of health workers (HWs) trained by gender and district. Table 13: Health Workers Trained on Mass Distribution (by district and gender)

District Date Target Males Females Total Bindura 4/8/2019 25 14 13 27 Rushinga 4/11/2019 20 15 3 18 Shamva 4/12/2019 30 21 19 40 Mazowe 4/9-10/2019 60 30 36 66 Centenary 4/11/2019 30 25 14 39 Guruve 4/12/2019 35 24 14 38 Mbire 4/13/2019 10 6 3 9 Mt Darwin 4/26/2019 40 20 19 39 Goromonzi 5/17/2019 40 14 20 34 Murewa 5/17/2019 40 9 29 38 Total 330 178 170 348 ZAPIM trained a total of 348 HWs on mass distribution. Goromonzi trained 34 (85%) of the HWs as others were engaged in other district health programs. However the district provided on-the-job training for those who had missed the district level trainings. ZAPIM provided technical and logistical support for the districts and provinces to hold one-day orientation trainings for HWs. The trainings were held in hospital and rural district council boardrooms (free venues). After the district trainings the HWs were then tasked with the training of VHWs. Table 14 shows the number of VHWs trained by district and by gender.

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Table 13: Village Health Workers Trained (by district and gender)

District Target Males Females Total Bindura 60 14 118 132 Rushinga 54 18 36 54 Shamva 96 36 126 162 Mazowe 150 81 455 536 Centenary 102 27 133 160 Guruve 84 33 102 135 Mbire 24 22 33 55 Mt Darwin 96 34 50 84 Goromonzi 102 182 18 200 Murewa 102 16 98 114 Total 870 463 1169 1632

A total of 1,632 VHWs were trained by health facility workers. Of these 463 (28.4%) were male and 1169 (71.6%) were female. In some districts, HFs engaged all the VHWs in their area of operation instead of working with the targeted 6 VHWs only. This was due to the need to have each VHW work in his or her area. This approach resulted in the doubling of the numbers trained to 1,632 when compared to the target of 870. The engagement of these extra VHWs was undertaken at no extra cost to the project in terms of finance and other logistics, as the resources for the six VHWs were shared equally amongst all the participating VHWs for that ward. Mazowe District trained the largest number of VHWs of 536 (32.8%) of all the VHWs trained, followed by Goromonzi and Guruve Districts with 200 and 135 VHWs trained respectively. Mt Darwin District had some VHWs away from their home stations, hence could not be trained on the due dates. However they were trained on job before they embarked on mass distribution activities. The HWs and VHWs were then tasked to conduct community sensitization meetings before embarking on household registration.

4.3.1.5 COMMUNITY SENSITIZATION AND PARTICIPATION In order to achieve maximum cooperation from the communities, ZAPIM launched an intensive sensitization campaign activity. The involvement and participation of communities, partners, and other stakeholders was critical to the successful implementation of the 2019 mass distribution campaign. The main focus was to disseminate appropriate information to the communities. This raised their awareness on understanding malaria transmission, the benefits of LLINs, household responsibilities (before, during and after distribution). This also helped to increase community acceptance, accessibility, ownership, access and use of LLINs. In order to achieve the above, ZAPIM’s 2019 Mass Distribution sensitization campaign used a four-tiered approach. The four tiers were the province, district, ward and village level sensitization meetings. This tiered approach ensured that the program had appropriate buy-in from all the important stakeholders. Immediately after training HF staff and VHWs, ward and village sensitization meetings were conducted before embarking on household registration. At ward level, councilors, village heads, VHWs, and other community leaders were sensitized on the objectives of the program. The community sensitization meetings started on April 11, 2019 and continued throughout the whole distribution period. The most important meetings were those for community leaders held at ward level as they are the custodians of local customs and cultures. The ward level meetings were presided over by the local councilor with

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support from the trained local HWs. The community leaders were advised and encouraged to come up with community policing measures for those who misuse the nets. A total of 844 district, ward and village meetings were held reaching 28,592 people as indicated in table 15. Other key issues discussed included:  Wards targeted and why  Benefits and importance of using LLINs and how they work  Encouraging people to come and collect nets on the designated days  Encouraging the use of LLINs when people sleep outside.  To get LLINs for use at the farm if they spend nights there  How to hang up a rectangular net  How to hang a net on outside sleeping spaces  Net aeration  Care and maintenance of the nets for them to last a long time  Disposal of plastics and waste water after washing a net  LLIN repurposing and disposal of very torn and unusable LLINs  Community responsibilities in ensuring that nets are used properly and not misused . The village meetings were lead by VHWs with support from the village head and HWs. These meetings were for all village residents. The focus was on the importance of registering the exact number of sleeping spaces, collecting their nets on time, importance of using an LLIN at all times, net aeration, care of the net and how to hang the rectangular net (see photo). Village meetings were held for at least 2-3 hours. Each HFs conducted at least one community leaders meeting and at least one meeting per village. Table 15 shows the number of community members sensitized prior to and during LLIN distribution.

Table 15: Number of Community Members Sensitized in 2019 (by gender)* District Males Females Total Bindura 357 445 802 Rushinga 198 67 265 Shamva 5,080 7,805 12,885 Mazowe 532 383 915 Centenary 117 216 333 Guruve 272 200 472 Mt Darwin 78 149 227 Goromonzi 3,977 5,223 9,200 Murewa 1,257 2,236 3,493 Total 11,868 16,724 28,592

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*For Goromonzi, Murewa and Shamva the figure includes that of community members sensitized prior to net distribution. For the rest of the districts the figures are for community leaders sensitized.

4.3.1.6 HOUSEHOLD REGISTRATION After holding the community sensitization meetings VHWs moved from house to house registering the number of people and sleeping spaces per household including outdoor sleeping spaces in their respective villages. The EHTs and nurses from the local health facility provided the needed support. The activity was carried out over a maximum period of ten days per ward between April 24 and May 31, 2019. One special feature about the 2019 Mass Distribution campaign was the aspect of registering outdoor sleeping spaces including those located at the fields or tobacco curing bans. Table 16 gives a summary of the household registration data by district. Table 14: LLIN Registration Data by Distrit (April-May 2019)

District Household Population in Sleeping Spaces LLINs Registered in LLIN wards Delivered LLIN Wards Inside Outside Total Bindura 15,395 71,398 44,227 651 44,878 47,700 Centenary 16,032 76,828 38,985 2,383 41,368 42,600 Guruve 24,804 99,206 58,559 2,506 61,065 67,250 Mazowe 47,465 208,782 131,175 2,514 133,689 194,300 Mbire 3,128 15,926 9,893 1,856 11,749 12,350 Mt Darwin 16,947 80,733 43,684 7,821 51,505 54,100 Rushinga 7,457 32,565 18,132 871 19,003 21,100 Shamva 12,265 84,567 51,147 1,631 52,778 55,400 Total 143,493 670,005 395,802 20,233 416,035 473,600 Goromonzi 38,412 177,130 109,708 623 110,331 112,750 Murehwa 30,279 155,179 97,378 1,539 98,917 98,700 Total 68,691 332,480 207,086 2,162 209,248 211,450 Grand Total 212,184 1,002,485 602,888 22,395 625,283 685,050

4.3.1.7 MASS LLINS DISTRIBUTION LOGISTICS Two delivery approaches were adopted during APIM’s Mass Distribution campaign. Mashonaland Central Province used the provincial distribution approach. In this case LLINs were first delivered to two regional warehouses at Nzvimbo Growth point in Mazowe and Camsasa in Guruve Districts respectively. For the provincial approach the Provincial Field Officer in close liaison with ZAPIM coordinated the delivery of LLINs to the districts and eventually to the distribution points. The province provided five lorries which carried nets from the regional ware houses to distribution centers. Mashonaland East Province used the district-based approach where coordination was in the hands of the DEHO who worked closely with ZAPIM in ensuring timely delivery of LLINs to distribution points. The province provided one lorry which delivered nets to distribution centers in the two districts of Goromonzi and Murewa. Delivery of LLINs from the national warehouse to the district and regional stores was done by Global Health Supply Chain Management (GHSCM) team. The district-level stores personnel of MoHCC and some EHTs engaged as stores personnel managed the delivery of LLINs to the districts and distribution points. Once the LLINs were delivered guards were immediately engaged to provide security for the

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LLINs. As per the guidance document districts, distribution of LLINs to beneficiaries was done within two days of delivery. This led to cut down on costs and unforeseen risks. Stock cards were used to manage the stocks of LLINs. Various modes of transport were used from the HFs to outreach points. The provinces, ZAPIM and the private sector provided transport which distributed LLINs to various designated distribution points. The mode of transport provided ranged from lorries, twin cabs, pick-up trucks, tractors, motorbikes and scotch carts as seen in the photo (right), ZAPIM provided fuel for the MOHCC lorries, while the private sector provided vehicles and fuel at their cost as seen in the photo (below).

4.3.1.8 MASS DISTRIBUTION MODEL AND DISTRIBUTION TO BENEFICIARIES This was the second mass distribution supported by ZAPIM. Lessons were drawn from the 2016 mass distribution campaign including the adoption of a village-based distribution model by taking the nets to the people, assigning villages specific days and time to collect their nets, establishing LLINs outreach points and providing LLINs even for outside sleeping spaces. LLINs outreach points were established in areas which were 10km or more from the nearest health facility. A total of 421 distribution points were established consisting of 106 static facilities (HFs) and 315 outreach points. This is a big increment when compared to the 2016 mass campaign when 180 distribution points were used. Distribution of LLINs to beneficiaries started on the 10th of June 2019 and was completed on July 5, 2019. The Provincial Field Officer for Mashonaland Province was always on the ground as seen in in the photos below, shares a lighter moment with some beneficiaries of the 2019 mass distribution campaign LLINs.

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The LLINs in 2019 were distributed over an 8 day period. Table 17 shows the LLIN distribution coverage by district.

Table 15: LLIN Distribution by District (June-July 2019)

Total Nets Distributed Population H/H District Targeted Covered Inside Outside Total Covered Bindura 16,136 71,398 75,824 46,898 1,087 47,985

Centenary 16,763 76,828 76,265 38,781 2,023 40,804 Guruve 23,650 99,206 92,937 55,833 2,017 57,850

Mazowe 47,465 208,782 203,123 128,008 1,118 129,126

Mbire 4,690 15,926 15,926 9,887 1,733 11,620

Mt Darwin 17,109 80,733 82,744 45,426 6,454 51,880

Rushinga 7,747 32,565 33,060 19,006 1,364 20,370

Shamva 17,763 84,567 86,188 52,579 2,174 54,753

Total 151,323 670,005 666,067 396,418 17,970 414,388

Goromonzi 40,068 177,301 175,427 109,956 1,737 111,693

Murewa 31,879 155,179 151,768 97,217 1,160 98,377

Total 71,947 332,480 327,195 207,173 2,897 210,070 Grand Total 223,270 1,002,485 993,262 603,591 20,867 624,458

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The 2019 Mass Distribution covered a total of 223,270 Households and 624,458 sleeping spaces. Of the 624,458 LLINs distributed, 20.867 (3%) were for covering outside sleeping spaces. This was the first time in the history of mass distribution campaigns in the country that outside sleeping spaces were specifically earmarked for LLINs distribution. These spaces included those at the fields, along stream banks, at the tobacco curing barns and at small scale miners (gold panners) locations. The total population covered was 993,262 out of a target population of 1,002,485 (99.1%). When compared to the Mass Distribution of 2016 there has been an increase in the coverage for all key figure indicators. Figure 5 shows a comparison of coverage between the 2016 campaign and the 2019 campaign. Figure 2: Mass Distribution of LLINs (2016 and 2019 campaigns)

1200000 1000000 800000 600000 2016 400000 2019 200000 0 Population Covered LLINs Distributed Sleeping Spaces Covered

In 2019, a total of 993,262 people were covered by LLINs. This is a 16% increase in population coverage when compared to 854,385 population covered in 2016. A total of 624,458 LLINs were distributed in 2019 which is an 11% increase compared to the 562,489 LLINs that were distributed in 2016. The difference in coverage between 2016 and 2019 may be due to the fact that in 2019 outside sleeping spaces were considered for LLINs distribution which was not the case in 2016. Furthermore, the 2019 mass campaign included ten more wards than in 2016.

LESSONS LEARNED AND RECOMMENDATIONS ZAPIM has the following lessons learned from the 2019 Mass Distribution Campaign: o Using a simple theme My Net My Life that resonated with the community members ensured their buy in. Furthermore the beneficiaries were kept engaged during the distribution process as they were constantly reminded of the benefits of using a net irrespective of its color, shape and place of use. o The use of appropriate communication structures (councilors, health centre committees, VHWs, traditional/village leaders and local leadership and schools) to notify beneficiaries, ensured that word reached all the targeted communities. o The aggressive approach adopted in LLINs promotion is beginning to bear fruit as most communities are requesting and are using LLINs for malaria prevention. o The appointment of a LLIN focal person at district level improved communication, coordination and implementation of activities. o Tobacco farmers and gold panners preferred LLINs instead of IRS. o The use of the daily master tracker ensured that LLINs distribution was monitored on a daily basis by districts and ZAPIM and challenges quickly resolved. Table 18 below captures the success, challenges and proposed solutions following the 2019 Mass Distribution Campaign.

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Table 16: Successes, Challenge and Solutions of the 2019 Mass Distribution Campaign

Successes Challenges Solutions  People received instruction on use of the  Some people were  Those LLIN, how it works, how to hang the LLIN out of the ward households including handling, care and maintenance during registration (H/Hs) which of the LLIN did not receive  LLINs were provided to outside sleeping LLINs will be spaces unlike in previous years were covered by CD. LLINs were only meant for use inside houses only  HFs should  Some registered  LLINs were brought closer to the people verify data from households had by establishing outreach LLINs distribution VHWs at all travelled and hence points times were missed  The distribution was very orderly as  There should be villages were given specific days for LLINs  Names wrongly inter- district collection omitted during the meetings to  The village based approach also ensured transfer of data from harmonize that people received appropriate messages the VHWs books to operations along in small numbers the main register  Community leaders actively supported the the district program by holding sensitization meetings  Border challenges boundaries. and some accompanied their villagers to between districts on the distribution points registration of  Religious communities/objectors accepted beneficiaries  The 5% the program as they also collected the contingency was LLINs  Temporary shortage used to cover  The 5% contingency minimized shortage of LLINs the gap. of LLINs as this covered those missed during registration.

The following are the recommendations (Table 19) to address these challenges and indicates who has responsibility for addressing these challenges going forward. Table 17: Recommendations for LLIN Mass Districution

Challenges Recommendations Responsibility o Local partners failed to provide the o Future project to consider hiring private ZAPIM/NMCP promised vehicles to service outreach transport for delivering nets from HFs to points outreach points o The activity to be accorded a national NMCP/PMDs event so that resources are availed from provincial to districts level MOHCC/ZAPIM o Engage business and farming communities/organizations in all developmental programs from the planning stage o Timing of campaign did not coincide with o Future campaigns should be done NMCP/ZAPIM timing of peak transmision season, when between March and May for impact protection is needed o Delays in daily reporting and sending data o Provinces should take charge and play an PEHO/DEHO by districts active role in LLIN activities in the same way they conduct IRS operations

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o Appearance of people who had not o Conduct an intensive awareness campaign ZAPIM/NMCP/PMDs registered prior to net distribution due prior to household registration Partner organisations to some past false promises by other o Organizations should fulfil their promises organizations to the communities o Workers not released to receive LLINs o Continue to engage local leaders and DEHO/ZAPIM on the scheduled distribution dates employers on best distribution methods for these communities o Low collection rates in peri-urban areas o Engage business community and also DEHOs/HPOs as people were at work (formal and non- conduct some intense awareness formal) as they could not get time off to campaigns prior to net distribution collect their nets.

The provision of LLINs for outdoor sleeping places and the establishment of LLINs distribution points closer to the people by adopting the village/farm based distribution model was a huge success. The leadership role played by MoHCC personnel at the provincial, district and HF levels enabled the campaign to achieve the desired objectives within the stipulated time frame. Future mass distribution should consider establishing outreach points to bring the nets closer to the people. VHWs conducted door-to-door household registration and educating beneficiary households for LLINs. In this year’s mass distribution campaign the chief mobilizers were the village heads/kraal heads and councilors. The program has been successful in making people aware about malaria in general and LLINs in particular. Through this multipronged approached, acceptance of the program has been very encouraging and ZAPIM and the MOHCC will build on this success for future campaigns.

4.3.2 CONTINUOUS DISTRIBUTION OF LLINS In Year 4, ZAPIM continued to support the MOHCC and NMCP in implementing the CD activities in 11 districts. The districts are Bindura, Centenary, Guruve, Mazowe, Mbire, Mt Darwin, Rushinga and Shamva in Mashonaland Central Province. In Mashonaland East Province three districts namely Goromonzi, Hwedza and Murewa are supported. Table 20 indicates the number of LLINs distributed as from October 2018 to September 2019 by district and by channel. Table 18 Continuous Distribution of LLINs, Oct 2018-Sept 2019 (by District and Channel)

District EPI ANC Community Total Bindura 1,170 1,302 2,500 4,972 Centenary 492 1,147 10,883 12,522 Guruve 1,139 1,141 8,854 11,134 Mazowe 3,360 4,954 12,144 20,458 Mbire 178 224 3,047 3,449 Mt Darwin 2,668 3,226 13,391 19,285 Rushinga 140 186 1,122 1,448 Shamva 789 841 5,390 7,020 Goromonzi 2,044 1,625 9,354 13,023 Hwedza 35 196 891 1,122 Murewa 232 713 5,733 6,678 Total 12,247 15,555 73,309 101,111

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In Year 4 a total of 101,111 LLINs were distributed in the 11 ZAPIM supported districts. Mazowe District distributed the highest number of LLINs with 20,458 (20%) followed by Mt Darwin with 19,285 (20%) and Centenary with 12,522(13%). Hwedza distributed the least 1,122 (1%), Rushinga followed with 1,448 (1%) and Mbire with 3,449(3%). For distribution by channel the community channel remain the major channel with 73,309(74%) followed by ANC with 13,606 (14%) and lastly the EPI channel with 11,109 (12%). The analysis by quarter in Table 10 indicates that the highest uptake was during the 1st and 2nd quarters of Year 4. The second quarter had the highest number of LLINs 39,015 (41.5%). Distribution in quarters 3 and 4 were affected by the mass distribution campaign. Table 19: Distribution by District and by Quarter, October 2018-September 2019

District Q1 Q2 Q3 Q4 Total Bindura 1,270 2,580 321 801 4,972 Centenary 2,286 5,303 3,976 957 12,522 Guruve 1,230 4,760 3,477 1,667 11,134 Mazowe 4,749 10,202 2,904 2,603 20,458 Mbire 1,143 1,568 385 353 3,449 Mt Darwin 7,837 6,642 1,516 3,290 19,285 Rushinga 73 427 439 509 1,448 Shamva 2,424 3,486 682 428 7,020 Goromonzi 7,376 405 1,815 3,427 13,023

Hwedza 146 56 355 565 1,122 Murewa 508 3,586 644 1,940 6,678 Total 29,042 39,015 16,514 16,540 101,111 Starting in April 2016 when ZAPIM started supporting the NMCP in rolling out CD a total of 261,240 LLINs have been distributed to the communities through the continuous distribution channels. Figure 5 shows the distribution by year and quarter. Over the last four years the trend has been that the uptake of LLINs is highest during the second quarter of the year (January-March). This period coincides with the starting of the peak malaria transmission period. Figure 5: LLINs Distributed Through CD Channel by Quarter Year 1-Year 4

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60000 50000 40000 30000 20000 10000 0 Year 1 Year 2 Year 3 Year 4 Quarter 1 0 2964 10226 29042 Quarter 2 0 8013 54329 39015 Quarter 3 25411 6127 29809 16514 Quarter 4 998 8465 20958 9371

Quarter 1 Quarter 2 Quarter 3 Quarter 4

4.3.2.1 CONTINUOUS DISTRIBUTION TRAINING OF HWS AND VHWS CD training of HWs and VHWs only targeted HFs which commenced CD of LLINs this year. These facilities were located in Rushinga (5 HFs), Centenary (1 HF) and Mbire (1HF). A total of 29 HWs and 100 VHWs as indicated in Tables 22 and 23 were trained in CD of LLINs.

Table 20: Health Workers Trained in Continuous Distribution (August 2019)

Dates District HF covered Health Workers Trained M F Total 19-23/08/2019 Rushinga 5 17 6 23 8/29/2019 Centenary 1 1 1 2 8/27/2019 Mbire 2 2 2 4 Total 8 20 9 29

Table 21: VHWs trained by HF and by Gender (August 2019)

Health Wards Date VHWs Trained Comments facility covered Target M F Total 19/08/2019 Mafigu 1 11 6 1 7 20/08/2019 Mukosa 2 11 5 5 10 21/08/2019 Chimandau 2 14 4 8 12 The VHWs who missed the CD 22/08/2019 Nyatsato 1 14 9 4 13 trainings were trained by the EHT and Nurse who had attended the CD 23/08/2019 Nhawa 2 24 12 12 24 trainings 27/08/2019 Chidodo 1 16 6 10 16 29/08/2019 Chiwenga 1 18 7 11 18 Total 7 10 108 49 51 100

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Challenges: Continuous Distribution Training of HWs and VHWs  Refresher courses for those trained in 2016 and some new trainings were not conducted due to the time required to implement the the mass distribution campaign. This was further affected by the economic situation as the trainings scheduled for the last quarter of Year 4 had to be postponed.  The timely payment of mass distribution participants was affected by the directives from Central Government which affected the established Ecocash payment method.  Non availability of transport and fuel at the district and ward level affected the establishment of more LLINs outreach points as planes.

4.4 SOCIAL AND BEHAVIORAL CHANGE COMMUNICATION In Year 4 of ZAPIM, the SBCC thematic area pursued the 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.” The program also began implementing activities in support of the country’s drive towards malaria elimination and continued to offer support for the strengthening of the NMCP’s SBCC program for malaria control.

The socio-ecological model remained the theoretical model that informed the ZAPIM SBCC approach. ZAPIM designed and applied interventions that address not only individual practice and behavior, but also the norms, beliefs, and socioeconomic and structural determinants influencing the demand for and use of malaria services.

Selection of activities was based on the NMCP’s strategic behavior change priorities, which included community awareness and adoption of lifestyle actions for the following: early illness identification and timely health-seeking behavior, correct and consistent use of LLINs, IRS uptake, personal protection against malaria infection, and appropriate epidemic-conscious behavior during high transmission season. The activities were also aligned to the communication objectives in the National Malaria Communication Strategy 2016–2020 under the areas of advocacy, vector control, CM, surveillance, cross-border initiatives, special populations, and malaria branding and messaging.

The community-based approach of CAC mobilization model was applied to ensure intensification of malaria community action planning and the effective implementation of those activities. SBCC Areas of Intervention The following areas of intervention were implemented in Year 4. Activities were conducted in collaboration with the NMCP national, provincial, and district levels as well as the national SBCC subcommittee: 1. Branding of the NMCP 2. Development, printing and dissemination of malaria SBCC materials and communication facilitation tools 3. Development and broadcasting of multimedia malaria communications (radio) 4. Advocacy and communications for malaria elimination 5. Evidence gathering for improved SBCC programming 6. Production and publishing of NMCP reports on various thematic areas 7. Supporting communities for self-driven malaria actions through the CAC process and other community-based approaches (including community dialogue forums)

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4.4.1 BRANDING OF THE NMCP ZAPIM provided support to the NMCP to reposition the NMCP into a brand that is strategic. Through this exercise the NMCP sought to:

 Understand how it is perceived by others within the MoHCC and among the communities it serves

 Define how it wants to be perceived given its current achievements and situation

 Make a plan to accomplish the re-branding.

During the reporting period ZAPIM convened a number of working sessions and consultative processes that resulted in the following branding timeline:

Phase 1: Outline the Brand Strategy Concept and engage stakeholders.

Phase 2: Conduct data collection

Phase 3: Perform data analysis and articulate conclusions

Phase 4: Translate the research into the brand

Phase 5: Senior level review process of the brand

Phase 6: Launch and roll out the brand

To date ZAPIM has supported NMCP to achieve Phase 1 of the pathway. ZAPIM will continue to provide support in Year 5. ZAPIM facilitated two key branding consultative sessions with stakeholders and secured a branding specialist to oversee the process. Draft data collection to facilitate Phase 2 (Conduct data collection) were also developed. Phase 2 is expected to commence in January 2020 (Quarter 2 of Year 5).

4.4.2 DEVELOPMENT, PRINTING AND DISSEMINATION OF MALARIA SBCC MATERIALS AND COMMUNICATION FACILITATION TOOLS

The following SBC materials were developed and printed during this period:

• Development of LLIN promotional leaflet - My net my life.

ZAPIM developed and distributed a leaflet to promote LLIN usage in communities. The 6 panel A4 size Shona language leaflet was themed "My net, my life" based on the promotional by-line used in promoting the LLINs at distribution. ZAPIM distributed 5,000 copies of the leaflet in Mashonaland Central. The ZAPIM community level officers in collaboration with MOHCC staff distributed the leaflet in Mbire Centenary and Rushinga Districts where the "My net, my life" slogan was coined and used as a byline by the distribution teams. The project further printed 200 copies of the leaflet and distributed it at key events such as the Mashonaland East Agricultural Show and community level meetings conducted by ZAPIM.

 Reprinting of the Communication guide for the introduction of rectangular nets for distribution in Manicaland in response to Cyclone Idai.

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The Cyclone Idai that affected the country in March 2019 called for an immediate response in terms of malaria prevention. The NMCP deployed LLINs as a matter of urgency and ZAPIM supported the efforts through providing LLINs and 500 copies of LLIN introduction communication guidelines for use by health workers. Health workers and other active volunteers used the communication guide in educating community members on the correct use, care and correct hanging instructions of the LLINs.

 Development of material for malaria elimination areas (Lupane)

ZAPIM made a commitment to assist the NMCP with the development and printing of material to be used in sensitizing communities in malaria elimination districts since most communication materials for malaria behavior change and tools were developed for malaria control districts. ZAPIM supported Lupane district to draft and develop Ndebele language material for targeting the elimination districts. ZAPIM will be supporting the process of developing and printing of such materials. The drafted materials include: o Flipchart tool for VHWs to use in educating communities on malaria prevention in elimination settings,

o Behavior change communication leaflet

o Wall painting posters messaging

o A flow chart malaria guide for use by health-workers in elimination districts

ZAPIM will discuss the drafted materials with PMI and make necessary adjustments before printing them in Year 5.

4.4.3 DEVELOPMENT AND BROADCASTING OF MULTIMEDIA MALARIA COMMUNICATIONS (RADIO AND AUDIO)

In partnership with VectorLink, ZAPIM conducted radio based IRS sensitization activitis from mid- October to November 2018 to encourage uptake of IRS services by communities. The radio spot messages included content on: announcing the spraying season and that the program is conducted free of charge, encouraging participation in IRS by allowing spray operators to spray homes and rationale for chemical rotation.

ZAPIM developed a 60-second radio advertisement using three voices (artists) which was aired on one national radio station (National FM -11 slots) and one provincial radio (Diamond FM -22 slots).

In September 2019, the project developed a radio spot to promote use of LLINs amongst populations that received LLINs through the CD and the 2019 Mass Distribution campaign. The message raises awareness on the LLINs as a malaria intervention for use indoors and outdoors, encouraged correct and consistent use of LLINs and gave tips on correct care of the net to avoid adverse effects. ZAPIM has paid for the radio spot to commence broadcasting in October2019 on three radio stations, namely National FM (27 slots), Radio Zimbabwe (30 slots) and Diamond FM (24 slots). The project has made bookings to continue broadcasting the radio spot into the peak malaria season (November and December). The radio spots are aimed to reach over eighty percent of the population targeted by the IRS and LLIN interventions nationally.

In addition ZAPIM continued to support and monitor dissemination of malaria control messages for the Chikunda speaking ward of Chapoto via the Malaria Control audio book gadget. ZAPIM ensured that the ZAPIM Provincial Coordinator made routine and regular follow ups with VHWs and Chapoto Health facility regarding community level use of the Dipa gadget. The Provincial Coordinator ensured the gadget

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reached targeted villages particularly sections of Mariga village where most of the Doma ethnic group live. He also brought feedback on broken down gadgets and noted the gap for purposes of replenishment.

4.4.4 ADVOCACY FOR ACTION ON MALARIA CONTROL AND ELIMINATION BY COMMUNITIES, COMMUNITY LEADERS AND STAKEHOLDERS – WORLD MALARIA DAY In Year 4, ZAPIM focused on the critical role of community level stakeholders and leaders in support of malaria control and elimination activities through advocacy and awareness efforts. ZAPIM supported malaria commemorative events and provided malaria information materials for communities such as LLIN messaging banners, and leaflets copies on malaria facts and IPTp sourced from NMCP. The commemorative events were used as forums for community leaders to drum up support for malaria positive behaviors within their respective communities. ZAPIM supported World Malaria Day commemorations at the national level and in three ZAPIM supported provinces. ZAPIM supported the national level World Malaria Day newspaper supplement by inserting advertorial materials highlighting malaria support provided through USAID ZAPIM in the Sunday Mail April 25, 2019 and provided technical support for the national level malaria advocacy press conference arranged by the NMCP SBCC and MOHCC Public Relations Department. ZAPIM’s Chief of Party (COP) Noe Rakotondrajaona attended the press conference. ZAPIM supported the provincial leveI commemorations in Matabeleland North, Simatelele Ward in Binga District on June 6, 2019, Mashonaland East Province on June 13, 2019 at Goneso Clinic in Hwedza District, and Mashonaland Central, Centenary District at Hoya Clinic on May 24, 2019. ZAPIM provided financing, technical and material assistance and attendedthe commemorations. The COP and provincial coordinator attended the Mashonaland East commemorations and the COP gave a speech, ZAPIM was represented by the respective Provincial Coordinators in Mashonaland Central and East. Key issues that emerged as advocacy points by community leaders and stakeholders at these events include:  The need to scale up malaria control activities along borders of malaria control and elimination districts ( Hwedza Border)  Encouraging people to spread the message of malaria elimination in the elimination district such as Hwedza  Encouraging people in areas covered by IRS to support IRS teams during spraying season  Encouraging people to act on malaria through the Community Action Cycle community mobilization model  Encouraging the local authorities to partner with MOHCC on health issues  Complimenting VHWs in assisting government efforts for health for all  Encourage use of LLINs in outdoor sleeping spaces in districts where the sleeping practice is prevalent

4.4.5 THE SBCC THEMATIC AREA WILL TAKE INTO ACCOUNT THESE KEY OBSERVATIONS IN THE DESIGN OF FUTURE PROGRAMMING BEYOND YEAR 4.EVIDENCE GATHERING FOR IMPROVED SBCC PROGRAMMING In Year 4 ZAPIM continued to develop and finalize the report for the Assessment of the drivers of continuing malaria transmission in the Angwa Ward, Mbire District. The report was developed and extensively reviewed by ZAPIM, PMI and NMCP. The final draft report was submitted to PMI and NMCP for review. NMCP and ZAPIM commenced the development of a follow on plan that takes into account the key findings and recommendations from the assessment. NMCP intends to use the plan to

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make malaria program improvements in the ward, including SBCC program improvements. The plan will be included in the final published report and inform future programming across thematic areas.

4.4.6 PRODUCTION AND PUBLISHING OF NMCP REPORTS ON VARIOUS THEMATIC AREAS SBCC facilitated the production of print-ready copies of the following reports and guidelines on behalf of the NMCP:  Malaria Epidemic Preparedness Guidelines  Surveillance Monitoring and Evaluation Plan  Assessment to determine the factors that contribute to the observed disparity between malaria case and first-line artemisinin-based combination therapy consumption in Zimbabwe The SBCC thematic area provided services to ensure design and layout of the documents, cover designs, ensuring NMCP approval processes and printing of final copies.

4.4.7 COMMUNITY BASED SBCC ACTIVITIES The main activities supported during year 4 were training of health center committees (HCCs) in the following CAC phases : CAC Explore Health Issues and Setting priorities, CAC Plan Together, CAC Act Together, CAC Evaluate Together, Supportive Supervision post training on each phase, and activities facilitated by HCCs after the CAC trainings .

4.4.7.1 CAC EXPLORE HEALTH ISSUES AND SETTING PRIORITIES TRAININGS ZAPIM supported Binga and Hwange Districts in Matabeleland North to start training on the CAC in 2018. This process started with orientation of District Health Executives from the two districts and staff drawn from the participating facilities on CAC. Eight ward health teams in Binga (54 participants) and eight health center committees in Hwange (80 participants) were trained on the CAC Explore Health Issues and Setting Priorities, and the Plan Together phases. During these trainings, the communities were assisted to develop their own community action plans. Training in Binga was conducted from 13 May to17 May 2019 and in Hwange from 8 April to 12 April 2019. The CAC Explore Health Issues and Setting Priorities phase is the third phase of the cycle that seeks to equip communities with relevant knowledge and skills to analyze their malaria situation, to prioritize malaria issues in terms of importance and changeability. An assessment tool was used before the CAC Explore Health Issues and Priorities Setting training to assess the participant’s perceived roles compared to the roles as outlined in the HCC training manual, achievements, challenges and perceived top conditions in their areas compared to the actual top diseases as reflected by facility data. The findings will be used as baseline. Communities identified the following issues in Table 24 below, and were assisted to understand the cause-effect relationship of these issues through use of participatory and conceptual tools such as community mapping and problem tree. Table 24 Malaria Behaviors and Barriers Identified During Explore phase for Binga and Hwange Districts

Key malaria behavior Barriers identified

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 Fear to be tested for HIV and bearing the burden to disclose results to partner when one is positive  Ashamed to disclose that pregnancy was unplanned.  Teen pregnancies and fear of being reported to police Late ANC booking  Inadequate knowledge on benefits of booking early  Long distances to travel to clinic

 Fear of losing unborn baby due to fear of being bewitched.  Ashamed to disclose person responsible for pregnancy  Beliefs that illness is caused by witch craft. (See photograph below Figure of a 6 year old boy brought to Chitse clinic unconscious and father holding a bottle with water and stones Delays in seeking inside bottle; an indication that they had visited a faith healer and treatment/ in the process delayed seeking treatment.  Long distance to travel to clinics.  Flooded rivers during rainy season

 Skin irritations/itchiness  Causes dirty walls  Insecticide perceived as ineffective to kill other insect pests  Perceptions that mosquito density increases soon after spraying. Refusal or missing IRS  Involves labor to pack and unpack in some households  Late notifications by spray teams  Some homes being missed because spray operators are not familiar with areas being sprayed

From the barriers identified, the communities were assisted to develop draft malaria community action plans. The main strategies adopted by HCCs for addressing these barriers include raising awareness through conducting targeted outreach education activities prioritizing areas experiencing more malaria cases ,formulation of community policy to minimize misuse of nets or refusal of IRS, identification of mosquito breeding sites , mobilizing resources for malaria activities such as additional food stuff for spray operators, fuel , supporting minor repairs for motor-cycle for EHTs and prioritizing procurement of anti-malaria commodities. Before introduction of the CAC, ward health teams did not have malaria plans nor did they conduct outreach education sessions. Presentation of the national malaria targets were shared with the ward health teams and this was compared with each respective facility’s malaria burden which helped communities to appreciate that malaria was indeed a problem they should aggressively address. Some of the common issues identified by the communities that contributed to malaria transmission include: active mosquito breeding sites; large numbers of community members who sleep outdoors at night to guard their crops from wild animals; and individuals who sleep in unsprayable structures (sleeping structures which are constructed of poles and are elevated to ensure adequate ventilation as the area experiences high temperatures most of the times). The photo to the right shows the delayed presentation of a boy with severe malaria.

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4.4.7.2 POST CAC EXPLORE HEALTH ISSUES AND SETTING PRIORITIES TRAINING SUPPORT AND FOLLOW-UP FOR BINGA AND HWANGE DISTRICTS The ZAPIM team and Ministry of Health CAC facilitators followed up on five ward health teams in each district in Binga and Hwange reaching 80 health team members (46 males and 34 females). The following were the observations noted:  All ten ward health teams that visited are now conducting community disease surveillance and targeted community-based malaria awareness campaigns in areas of high reported malaria cases, in areas with high cases of late antenatal care bookings, and areas of high IRS refusals or low IRS coverage.  Ward health teams visited are now conducting outreach and community education activities, and are documenting the activities.  Kamativi, Mwemba and Simangani HCCs had identified active breeding sites.  Kamativi, Mwemba and Sidinda shared their malaria community action plans with Isdell Flowers (a local church related organization). Isdell Flowers supported Kamativi HCC with fuel and transport to conduct an outreach in one of the hard to reach area (Katete village) to conduct CAC activity reaching 24 males and 58 females with information on malaria. Kamativi HCC had also raised $50 from their income generating project which they recently started from their CAC members wearing blue T-shirts supplied by ZAPIM. Kamativi nutrition garden which is their income generating project. Note the vegetable garden. This income will gentleman on the right has one hand. He works in the garden showing be used to fund their planned how ZAPIM activities are inclusive of all regardless of disability activities. This is one of the preconditions for sustainability of the HCCs (see photo).  All ward health committees had finalized development of their malaria community action plans  There was a high sense of empowerment expressed by committee members attending the trainings. “These type of trainings are unique in that they really empowered us to address our challenges and we wish ZAPIM will continue to support such trainings” said the councilor of Siabuzuba in Binga, Mr. Josen Mundenda.

4.4.7.3 CAC ACT TOGETHER TRAININGS (BINGA AND HWANGE DISTRICTS) The Act Together phase is the fifth phase of the CAC, and includes the goal of building implementation, monitoring and analytical skills for realizing the activities in their action plans and to help ensure for communities regarding their capacities. This is critical in raising their self- awareness, an understanding of what capacities and resources are available in their communities, what assistance they can get outside their communities, and an opportunity to network. In the two districts a total of 137 participants (85 males and 52 females) attended the CAC Act Together trainings. The training encompassed participants being asked to reflect on skills that they have and feel they can teach others and what knowledge that they have on any particular field including malaria. These skills were written on board for participants to

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have an overall vision of their collective skills and talents. The second part of the assessment involved the committees in groups to list all the planned activities in their malaria plans and identify the knowledge, skills and resources needed to implement each activity and to identify whether it is available in the community or whether they would need to source it from outside their community. Find below the major findings from the capacity assessments:  While assessing the individual capacity on existing knowledge and skills, the community shared that they are a rich source of diverse skills and knowledge, including counselling, planning, selling and marketing, gardening, mobilizing communities, leadership, support groups, and coaching football.. The participants realized that there are a lot of underutilized skills amongst committee members that they could can harness when implementing their action plans.  During HCC’s capacity assessments, all the HCCs and WHTs had inadequate knowledge on malaria causes, transmission, signs and symptoms of simple and severe malaria, comprehensive options on malaria prevention methods, comprehensive knowledge on IRS, insecticides use, safety issues, benefits of spraying, and benefits of early booking for Ante Natal Care. The facilitators addressed the gaps identified though this requires constant reminding given their varying levels of comprehension. Lack of educational materials and jobs aids in the local language to support such trainings is an added challenge. To address this challenge the Health Promotion Officer for Binga developed a flier in Tonga and had followed the entire processes of pre- testing the material and is awaiting support from ZAPIM for printing.  Sidinda and Kamativi attempted to write proposals seeking support from partners with Kamativi having yielded positive results whereby they received support from Isdell Flowers in the form of fuel and transport to conduct outreach education session with one of the hard to reach Katete village reaching an audience of 82 (24 males; 58 females) HCCs are found in poor resource settings and for them to implement their activities ; it requires resources such as transport to travel to remote areas, refreshments, or to pay for some of the inputs necessary for them to implement their planned activities.

 Before introduction of the CAC, all HCC meetings mainly focused on procurement issues, infrastructural development, and hardly addressed the local disease burden, strategies for interventions or the need to conduct outreach education meetings with affected communities.  The HCC chairpersons, secretary and treasurer had clearly defined roles in carrying out activities with communities on malaria prevention. However the rest of the committee members do not have clear roles. As a result ZAPIM recommended the formation of sub- committees for monitoring and evaluation, resource mobilization and publicity that would provide updates on their progress in implementing malaria plans and other health related issues This helps to ensure that everyone has a role to play and share responsibilities.  All participants during the CAC Act Together trainings expressed appreciation on the micro teaching demonstrations which participants performed and the subsequent feedbacks from the district CAC facilitators which served to provide information gaps on general malaria, benefits of ANC early booking, IRS and on guidance in responding to frequently asked questions from the community on key malaria issues.

4.4.7.4 CAC EVALUATE TOGETHER TRAININGS MASHONALAND EAST AND MASHONALAND CENTRAL The CAC Evaluate Together phase seeks to institutionalize the participation of project beneficiaries in monitoring and evaluation of their own community activities and community action plans at all stages of the project cycle. In addition to fostering inclusivity, other benefits of this approach include supporting

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teamwork, enabling project beneficiaries and external evaluators to see issues from different perspectives, promoting data analysis, building skills, and facilitating critical dialogue. The ZAPIM team and district CAC facilitators supported six districts, namely Goromonzi, Mudzi, Mutoko, Centenary, Bindura and Mbire to train HCCs on the CAC Evaluate Together phase. The Arcturus Mine Clinic in Mashonaland East is no longer functional following closure of the mine by Mine Authorities which has led to the dissolving of the HCC. Therefore, the total number of HCCs where CAC was introduced in Mashonaland East and Mashonaland Central is now 83 in the 8 districts which have a combined total of 152 facilities. All the HCCs trained on the CAC Evaluate Together phase were assigned to develop evaluation plans for their 2018 malaria plans and proceeded to implement the evaluation plans, analyze the results and share the findings with the community. Furthermore, The PEDCO for Mashonaland East has also assigned the CAC facilitators in Mash East to document the effectiveness of CAC In order to do this ZAPIM worked with the CAC facilitators to develop data collection too and pre-testing of the data collection tools was done in Mudzi. Results of the pre-testing still being analyzed by the time of writing this report. Below is a table summarizing the state of CAC trainings in the 3 provinces to date. Table 22: Distribution of HCCs Trained by District Province District CAC phase Trained Facilities in Target the district CAC Explore Health Issues and Set Priorities 14 14 CAC Plan Together 14 14 Mudzi CAC Act Together 14 14 27

CAC Evaluate Together 14 14 Mashonaland East CAC Prepare to Scale Up 14 0 CAC Explore Health Issues and 11 11 Set Priorities Mutoko CAC Plan Together 11 11 24 CAC Act Together 11 11 CAC Evaluate Together 11 11 CAC Prepare to Scale Up 11 0 CAC Explore Health Issues and 10 10 Set Priorities CAC Plan Together 10 10 Goromonzi CAC Act Together 10 10 23 CAC Evaluate Together 10 9 CAC Prepare to Scale Up 9 0 CAC Explore Health Issues and 5 5 Set Priorities CAC Plan Together 5 5 13 Mbire CAC Act Together 5 5 CAC Evaluate Together 5 4 CAC Prepare to Scale Up 5 0 CAC Explore Health Issues and 12 12 Set Priorities CAC Plan Together 12 12 13 CAC Act Together 12 12 Mashonaland Centenary CAC Evaluate Together 12 12 Central CAC Prepare to Scale Up 12 0

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CAC Explore Health Issues and 10 10 Set Priorities Bindura CAC Plan Together 10 10 17 CAC Act Together 10 10 CAC Evaluate Together 10 10 CAC Prepare to Scale Up 10 0

CAC Explore Health Issues and 9 9 Set Priorities 19 CAC Plan Together 9 9 CAC Act Together 9 9 Mt Darwin CAC Evaluate Together 9 0 CAC Prepare to Scale Up 9 0 CAC Explore Health Issues and 13 13 Set Priorities CAC Plan Together 13 13 16 Shamva CAC Act Together 13 13 CAC Evaluate Together 13 0 CAC Prepare to Scale Up 13 0 Matabeleland CAC Explore Health Issues and 8 8 North Set Priorities CAC Plan Together 8 8 15 Binga CAC Act Together 8 8 CAC Evaluate Together 8 0 CAC Prepare to Scale Up 8 0 Hwange CAC Explore Health Issues and Set Priorities 8 8 CAC Plan Together 8 8 18 CAC Act Together 8 8 CAC Evaluate Together 8 0 CAC Prepare to Scale Up 8 0 Grand total 10 99 185

4.4.7.5 ACHIEVEMENTS: PARTICIPATION OF HCCS IN OUTREACH EDUCATION SESSIONS WITH COMMUNITIES The HCCs, during implementation of the CAC, visited areas/villages that had reported high malaria cases, to carry out informational sessions on malaria prevention with communities. The topics for discussion were based on an analysis of health data from the clinics. This is a good practice which needs to be strengthened as SBCC interventions should be evidence-based and targeted. The HCC’s used dialogue, demonstrations, community mapping, and other participatory approaches to involve participants while filling in information gaps and addressing misconceptions on the causes of malaria, signs and symptoms, insecticides used in spraying, the aeration of nets, net hanging, and net care. In response to HCC members presentations, the communities agreed to act on issues such as identifying and eliminating mosquito breeding sites, conducting outreach distribution of nets to identified remote areas (such as in Chinyani and Always), and strengthening community policing against the misuse of nets. HCCs also continue to work through village committees (a committee chaired by village head), to accompany VHWs during village inspections and door to door visits, coordinate with village based malaria agents, participate in health and hygiene clubs addressing malaria and during monthly ward assembly meetings, carry out village drama groups and through church meetings, or have one on one discussions with community members. Observations by CAC facilitators and testimonies from some village heads

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during supportive supervision and during trainings show that communities now report fewer incidences of skin itchiness (one of the key barriers for not using nets) resulting from sleeping in nets not properly aerated. Village heads are also playing a key role in prevention, including enforcing their by-laws against net misuse and mobilizing resources, including seconding community volunteers for malaria activities. Some village heads speak confidently and are aware of the number of houses not sprayed, and understand related challenges associated with IRS refusal, demonstrating that they would have participated in the programs. More than 18,239 participants from 78 communities were reached during outreach education sessions facilitated by HCCs. However, some of the HCCs had not documented their outreach sessions, so more people than the number mentioned were actually reached. The HCC’s were encouraged to document their outreach activities, in which case ZAPIM provided all the trained HCCs with stationery. Find below photos with captions from the field demonstrating how the HCCs work:

Takuramombe drama group: an initiative of Dendera HCC chair Mr. Mustang giving a presentation HCC. Chidikamwedzi HCC during an outreach.

HCC member leading a discussion in Mugwiza village HCC members participated in overseeing the in Shamva District. distribution of LLINs in Goromonzi.

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The HCCs continue to demonstrate the important role that they can play in malaria programming. In , Suswe and Chiunye HCCs established drama groups which disseminate malaria information. Chiunye HCC reached 17 village heads in 28 villages and 319 people, promoting IRS acceptance for the 2018 spraying season. In , five HCCs: Nyava, Rutope, Muonwe, and Farm Health Scheme, discussed the disease burden in the area, analyzing areas most affected, and identified possible actions to be taken. In 2018, the Bindura District’s five HCCs had reviewed the malaria burden and malaria campaigns in some of the farms and had also identified seven active mosquito breeding sites. However they had not treated these areas with standing water by the time of writing this report as they had not received the biolarvicides though the intention was to treat the sites. In Centenary District, Muzarabani, Hwata, Chadereka, the HCCs had well-documented records of activities conducted. Hwata had six outreach meetings reaching more than 276 people. The committee had conducted an analysis and identified areas contributing to high malaria cases and reviewed malaria outbreaks in the area. Hwata displayed monthly malaria infections via a community bulletin board that was displayed during the outreach meetings (see Figure 6). Figure 23: Chart being used by Hwata HCC to track malaria cases in their area by month, week and village

4.4.7.6 HCC SUCCESS STORIES AND HIGHLIGHTS Success Stories 1. Always HCC-Centenary (LLINs): The HCC ran a campaign from January 2018 to December 2018 with the theme, “Campaign against malaria” and slogan, “Munhu wese muneti”, or “everyone sleep

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under a net.” During the campaign, the HCC conducted several community meetings in its catchment area and reached 625 people (324 males and 301 females). The HCC produced accompanying reports and videos during their outreach. One specific action the HCC took was to identify four farms that were contributing more malaria cases in their area. Challenges these four farms face with these specific areas include long distances to travel to the health clinic, the nearest farm being 24 km from the health clinic. This effectively limits the ability to collect nets and access other health services, like ANC. In response, the HCC managed to source transport to carry the nets to the village health worker to distribute the nets to the affected farms. Additionally, the HCC had requested to have the all standing water in these farms to be treated with larvicides. The HCC successfully reviewed its 2018 malaria activities, produced a detailed annual report, and used the lessons learned and challenges to plan for 2019. 2. Chiriseri HCC-Bindura (LLINs): The HCC carried out a number of good practices, including a well-written malaria plan and well documented achievements. The village head reported that they use a neighbor-to-neighbor approach to monitoring, which requires each community member to take responsibility of their neighbor health concerns to ensure that any suspected fever cases are reported to the VHW. With this approach, they did not encounter any severe cases in 2018 compared to 2017 when they experienced an outbreak with reported community deaths. Due to the village committee‘s monitoring efforts, all 6 pregnant women in 2018 were booked early for Ante Natal Care and ensured that they receive nets. The HCC also conducted a successful door-to-door education campaign that reached 45 of 63 households in Nhevera village and discussed malaria, net aeration, net hanging, misuse of nets, and monitoring of net use. All households visited reported using nets. Highlights

HCC’s advocacy role in community policing measures HCCs have demonstrated their capacity to effectively discourage negative practices through the enactment of local policies against misuse of nets, wanton refusal of IRS, and delays in booking early for ANC mothers. For example in Chidikamwedzi, with support from the HCC the community identified 2 individuals who were misusing nets and were asked to do community work at the clinic to increase their awareness on the importance of malaria prevention. This has gone a long way in mitigating against misuse of nets in the area. This demonstrates the effectiveness of malaria prevention when village heads are involved and take ownership. Some HCCs have not received similar support from the local leadership thereby requires continuous advocacy with the leadership.

HCC’s participation in community resource mobilization One of the indicators of success for community action groups is whether communities can mobilize resources needed to implement their planned activities. Establishing income generating projects is one way to ensure that the groups are financially sustainable after ZAPIM or partners leave. All the HCCs receive Results Based Funds (funds which clinics receive based on their performance on certain indicators) and in a way some of the committees do not appreciate the importance of raising additional funds. RBF cannot be used for other activities. However some HCCs have heeded this advice and have started income generating projects such as vegetable gardening, small shops, and selling printed health cards. HCC’s use the profits to fund their malaria activities, such as repairing EHT’s motorcycle for David Nelson HCC in Centenary; they also occasionally provide fuel and lunch allowances to the EHT and Nurse when they do outreach malaria activities, giving fuel support to EHT’s malaria activities for example Chibuli HCC in Mt Darwin which provided the EHT with 200 liters and Farm Health Scheme in Bindura which allocates 3 liters per week to the EHT to support malaria activities, air time to the VHW coordinator and refreshments to VHWs doing LLINs mass distribution activities in Goromonzi . Based on the capacity assessments done during the CAC Act Together trainings, all the HCCs need capacity building on resource mobilization including developing successful proposals. Only Kamativi HCC had received support from a local partner (Isdell Flowers).

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HCC’s participation in community disease surveillance Communities play a significant role if they are well capacitated, to conduct disease surveillance activities for malaria prevention and control. After CAC training, communities have participated in analysis of areas most affected by malaria and have initiated targeted education sessions in the respective areas while others have supported outbreak investigations, and subsequent implementation of interventions as well as in identification of mosquito breeding sites and the treatment of such standing water. Activities such as the identification of breeding sites and their treatment when implemented on a wide scale has high potential of reducing risk of mosquito bites and malaria in particular. Below are photos and captions of an HCC treating mosquito breeding site at Katoba River in Binga in Binga (Sinansengwe HCC).

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Katoba Larviciding photos

A) Some of the identified breeding sites at Katoba River

B) With Katoba community members and 2 CAC Members collecting Larvae

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Photo B above shows HCC Chair Mr. Moses Siamubeze (green shirt) and the EHT Philan Ncube all in khaki showing larvae to villagers

EHT Philani Ncube demonstrating how to apply larviciding chemicals

CHALLENGES Despite the achievements noted above, there are other HCCs that have shown slow progress in generating quality malaria plans, implementation of activities, and documentation of activities despite receiving the same training. The total number of such HCCs could not be computed given that these observations were obtained during post training supportive supervision visits which were limited to five HCCs per district visit. The expectation was that district CAC facilitators would in addition to the support provided by ZAPIM integrate this activity as they perform their routine work. For example the standard practice is that the EHT or nurse is the secretariat of HCC and should document all activities but is not the case in some facilities. The slow progress observed on the HCCs could be attributed to: low motivation, poor attendance of committee meetings, long distances to travel to clinic without reliable transport, and inadequate support from facility staff and CAC facilitators, or improvised equipment for entomology. After a half day training on a CAC phase, not all HCC members will automatically comprehend all the issues and apply them given that they have diverse educational backgrounds. Additional support or training may not be permissible due to limited budgets. The above challenges can be easily addressed if both district CAC facilitators and local staff fully embrace and integrate the approach in their routine work and by providing frequent onsite trainings during the HCC scheduled monthly meetings and support visits to the HCCs.

4.5 MONITORING & EVALUATION/OPERATIONS RESEARCH

4.5.1 ASSESSMENT OF DRIVERS OF CONTINUING MALARIA TRANSMISSION IN ANGWA WARD, MBIRE DISTRICT, MASHONALAND CENTRAL PROVINCE ZAPIM continued to develop a report on the assessment of drivers of continuing malaria transmission in the Angwa Ward in Mbire District during the year. The project worked with the NMCP to review and refine the report. The report was submitted to PMI for further review and approval. The report is

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expected to inform future programing as per findings from the assessment. Some of the findings were also used during the development of ZAPIM’s Year 5 work plan.

4.5.2 NATIONAL MALARIA SM&E PLAN ZAPIM worked with the NMCP to finalize the malaria SM&E Plan. The project supported the printing of five hundred copies. The NMCP used the annual malaria conference platform to distribute 500 copies of the Malaria SM&E Plan to the NMCP’s provincial and district offices.

4.5.3 EPR PREPAREDNESS AND RESPONSE GUIDELINES The Emergency Preparedness and Response (EPR) guidelines were finalized during the year. ZAPIM printed 1,600 copies of the guidelines and the NMCP distributed about 800 copies to the provincial and district offices at the annual malaria conference. The remainder was set aside for the orientation of the rapid response teams and health workers on the revised guidelines. The project also continued to have discussions with the NMCP on the best approach to orient the rapid response teams and health workers. The NMCP requested ZAPIM to work with the Provincial Epidemiology and Disease Control Officer for Mashonaland East Province to come up with the training schedule and materials. The training will be scenarios-based to enhance practical application of the principles in the guidelines. The development of the scenarios and training materials is on-going and will be finalized in October 2019. The trainings were initially scheduled for August and September 2019 before the peak malaria season. However, due to budgetary constraints, these were rescheduled for the first and second quarters of Year 5.

4.5.4 MALARIA SM&E TRAINING MANUAL Following the successful development of the new Malaria SM&E Plan, ZAPIM offered to support the revision to the SM&E Training Manual. The SM&E Training Manual and training materials need to be revise to align with the new Malaria SM&E Plan, the revised EPR Guidelines, the new World Health Organization Malaria SM&E Reference Manual, USAID/PMI M&E documents, and other relevant M&E documents. This prudent step to align materials is meant to enhance the quality of SM&E trainings and ensure that implementation processes occur at all levels. The facilitator’s guide and participant’s manual will form part of the SM&E Training Manual. In order to kick start this task, ZAPIM supported a three-day workshop from May 2-4, 2019. The workshop involved key malaria stakeholders in building consensus on the contents and format of the new SM&E training manual as well as coming up with a draft facilitator’s training manual. It began with an experience-sharing session to identify issues with use of the previous manual. Some of the main issues noted include:  Inconsistencies between the old training manuals and new tools  Time allocation and shortages of funds compromise quality of trainings  Practical hands-on experiences at times not accommodated as the training materials might not be available  Training delivery methods not well customized to the content  Given the increased need/use of technology, there will be need to increase the length of trainings to accommodate hands-on learning  Trainees should be those cadres that will actually use the information and skills in their day-to- day work on the ground  Post-training follow-up is usually not done  Pre- and post-evaluations on the training sometimes not done.

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The participants utilized the above reference resources – NMCP’s 2016-2020 Malaria Strategic Plan and accompanying SM&E plan, the EPR guidelines, WHO guidelines, among other documents. Given the limited face-to-face time, the development process consisted of group sessions to plan the modules, develop modular structure and content areas, and then flesh-out the contents including examples and emphasize areas for training sessions and tools to the new SM&E Plan and other relevant documents. The SM&E training manual will cover a total of seven modules:  Learning Module 1: Overview of malaria SM&E system in Zimbabwe  Learning Module 2: Introduction to SM&E fundamentals  Learning Module 3: M&E program cycle and M&E tools  Learning Module 4: M&E log frame development, results framework and indicators  Learning Module 5: Data management 1- Collection, collation and submission  Learning Module 6: Data management 2- Data analysis, presentation and use, and dissemination  Learning Module 7: Data quality assurance

The NMCP requested ZAPIM to continue developing the SM&E Manual so that it will be ready for review by other partners during the SM&E sub-committee meeting or any other forum to be convened in the first quarter of Year 5. ZAPIM will share a solid draft of the SM&E Training Manual before the end of October 2019.

4.5.5 CDCS The CDCS report was reviewed and finalized during the year. The CDCS Report was submitted to PMI for final review before printing and dissemination. A total of 50 copies of the report were printed and will be distributed to key partners at national and sub-national levels. MOHCC requested ZAPIM to present the findings of the study since they were relevant in the redesigning of the VHW logistics system. All relevant partners acknowledged the relevance and importance of the findings and the recommendations of the assessment as they have great potential to help strengthen the delivery of malaria services in the facility and community, Health Management Information System (HMIS), and Logistics Management Information System (LMIS), thus improving the quality of malaria data reporting. ZAPIM will continue to work with the NMCP in reviewing the final findings, and taking action on the areas that need improvement. The recommendations of the assessment are expected to help strengthen the Health Management Information System (HMIS) and Logistics Management Information System, thus improving the quality of data reported on malaria.

4.5.6 MIS ALTERNATIVE Zimbabwe conducted MIS exercises in 2008, 2012, and 2016. Zimbabwe has a heterogeneous malaria epidemiology which requires a carefully considered national survey methodology. This transmission variability, and the fact that Zimbabwe is overall a malaria low prevalence country, has brought about discussions among malaria stakeholders on the most appropriate type of national survey to measure malaria indicators. During the third quarter of the year, ZAPIM assisted the NMCP to look for other examples of countries that are developing unique alternative methods to the standard MIS. Six options were identified, namely: MIS within the Demographic and Health Surveys; MIS (stand-alone), continuous MIS, strengthening the DHIS2, a ‘hybrid’ approach between the last two options and antenatal care attendees as a surrogate for a household survey. ZAPIM developed a brief description for each option and its advantages, disadvantages/limitations, and likely cost implications. Where appropriate, experiences from elsewhere on the use of the proposed options were mentioned. The brief is intended to be the starting basis for further discussions with the NMCP, PMI and other partners to decide on which option(s) to pursue. Once the partners have chosen a method(s), ZAPIM will develop a detailed proposal for it in Year 5. Based on time, resources, and NMCP availability, ZAPIM will facilitate NMCP’s development of a high-level suggested roadmap to implementation.

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In the meantime, however, a decision has been made to integrate the 2020 MIS into the Demographic and Health Survey. ZAPIM will work with NMCP and other stakeholders to develop an appropriate methodology, review the protocol, questionnaires and the draft report.

4.5.7 DOCUMENT AND REVIEW TRAINING GAPS BY THEMATIC AREA ZAPIM devised a systematic approach of assisting the NMCP and provinces to establish a reliable database on training gaps by thematic area. ZAPIM took advantage of other activities that it supported, such as the provincial and district malaria review meetings, to gather and update the database information. In Year 5, the ZAPIM provincial coordinators will work closely with the provincial and district staff to quantify and verify the number and type of staff positions, active employees, and staff training history in order to more accurately identify actual training gaps.

4.5.8 NET DURABILITY STUDY AT MONTH 36 Month 36 is the last time point of the Net Durability Study. ZAPIM trained field staff and collected data in February 2019 with support from NMCP and NIHR. Soon after the field work, the project cleaned the data and also prepared the ground work for data analysis. Data analysis and report writing were conducted in quarters 3 and 4. The first draft report was submitted to NMCP and PMI for review. The project responded to the comments and re-submitted the report to PMI for further review and approval. Meanwhile, an abstract has been developed, reviewed and approved by NMCP and PMI. It has since been submitted for the ASTMH Conference which is scheduled for November 2019.

4.5.9 PROVINCIAL MALARIA REVIEW MEETINGS ZAPIM provided both financial and technical support to Mashonaland Central, Mashonaland East and Matabeleland North provinces to undertake malaria review meetings. A total of 134 participants (99% of target) attended the meetings. Participants were drawn from the PMD’s Offices, DHEs, and health facilities. The main objectives of the review meetings were to:  Review the malaria situation in the provinces.  Share progress in the implementation of malaria interventions in the two provinces  Share and discuss the DQA findings and recommendations. It was also a platform to discuss the quality of data which is generated both at community and facility levels  Share and discuss the revised EPR guidelines  Share best practices among the districts and health facilities

ZAPIM also used this opportunity to share and discuss the remaining activities up to the end of September 2019, covering all ZAPIM thematic areas. The proposed VHW mobile reporting pilot in Mbire District was one of the activities presented at the Mashonaland Central provincial malaria review meeting and the provincial leadership accepted it. There was a consensus that NMCP, ZAPIM and MOHCC lower level structures should learn from the pilot as there is great potential to cascade the initiative in other districts in the country.

4.5.10 DQAS During the year, ZAPIM supported the three provinces to conduct DQAs at selected health facilities in the districts. A total of 32 health facilities: Binga (4), Hwange (6), Rushinga (6), Mt Darwin (6) and Mudzi (10) 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

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 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.  Ensure that the environmental compliance component is integrated into the DQAs

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 26 highlights some of the key findings and recommendations.

Table 23: Key findings and recommendations from DQAs, May-June 2019

Key Findings Recommendations Although improvised, registers (T12 and IMNCI) were ZAPIM assisted the three provinces to come up with in place and in use standard registers. The districts were requested to print these registers using RBF resources, whilst awaiting standard registers from MOHCC All the T5 forms were in place and well filed Health facilities were encouraged to keep up the good work T5 forms were being submitted and entered into the The district offices were requested to verify the data DHIS2 before entering into DHIS2 VHW data was being incorporated into the rapid Health facilities were encouraged to keep up the good disease notification system work Malaria cases were managed according to the national Health facilities were encouraged to keep up the good malaria treatment guidelines work Data discrepancies between the T12 and T5 and the The district offices were requested to verify the data DHIS2 before entering into DHIS2 Low index of suspicion with most cases that qualify to All suspected cases to tested for malaria be malaria suspects being missed for malaria RDT Patients treated based on clinical diagnosis because of There is need to properly document and ensure that stock out of RDTs. such patients are not considered as confirmed cases Binga District hospital incinerator had broken down The district was encouraged to mobilize resources and expedite the repair or replacement of the incinerator if it is beyond repair

4.5.11 WEEKLY VHW MOBILE REPORTING PILOT IN MBIRE DISTRICT ZAPIM provided financial and technical support in piloting the weekly mobile reporting by VHWs in Mbire District. Mashonaland Central Province’s Mbire District—one of the highest malaria burden districts in the country, was selected, in consultation with the NMCP and the PMD’s Office. Mbire District has a total of 13 health facilities. Timely reporting will assist the district to detect, investigate, and respond to any reported epidemic. ZAPIM supported this initiative through the design of the system, using Open Data Kit (ODK) platform, pretesting the system, orientation of one hundred and eighty-six VHWs and twenty-six health facility staff (13 nurses and 13 EHTs) in the district and the procurement of cellphones. ZAPIM, NMCP, PMD and DMO’s offices were represented during the pretesting and training exercises. The system works offline during data entry and only requires the mobile network to be active when the VHW is ready to send the data through SMS to the health facility. VHWs started reporting to their respective health facilities from the fourth week of August 2019. However, a total of 61mobile lines were mistakenly deactivated by Econet before some of the VHWs started reporting and this affected the reporting rate on a weekly basis (67%). Econet failed to re-

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activate the lines and issued new lines on the last week of September 2019. ZAPIM and DMO’s office are making frantic efforts to ensure that the affected VHWs receive the new mobile lines before the second week of October 2019.

4.5.12 RDT REGISTERS FOR VHWS As per request from the three provinces, ZAPIM printed 1,160 copies of RDT registers for VHWs. The project will start distribution of the printed copies in April 2019.

4.5.13 ORIENTATION OF ZAPIM STAFF IN GLOBAL INFORMATION SYSTEM MAPPING As part of partner collaboration, ZAPIM requested the Clinton Health Access Initiative to orient ZAPIM technical staff on Quantum Geographic Information System mapping. This is one of the steps that ZAPIM has taken as it prepares to collaborate with the Clinton Health Access Initiative on implementing elimination activities in the country. This orientation will enable staff to map the coverage of interventions supported by the project. As the project started moving into malaria elimination work, mapping of cases becomes a key activity in surveillance and monitoring of malaria foci.

4.6 MALARIA ELIMINATION ACTIVITIES IN LUPANE DISTRICT, MATABELELAND NORTH ZAPIM started implementing malaria elimination activities in Lupane District in Year 4. Zimbabwe has been implementing malaria elimination work since 2012, beginning with seven districts in Matabeleland South and growing to 20 districts in 2015. The National Malaria Strategic Plan or NMSP (2016-2020) aims to implement malaria elimination in 30 districts by 2020. Zimbabwe is currently on track to reach this target as another eight districts were added to the list following a capacity assessment done in 2018. To develop a plan of elimination activities to support in Year 4, ZAPIM met with the Matabeleland North provincial team, Lupane District staff, Clinton Health Access Initiative (CHAI), and the NMCP focal person for elimination to understand where ZAPIM support could be most beneficial and to harmonize and coordinate approaches where possible. ZAPIM, CHAI, and NMCP held several meetings to identify, discuss, and better coordinate the elimination activities. Following these meetings, ZAPIM created a micro plan that it shared with PMI before finalization. In Year 4 ZAPIM supported the following key areas:  Enhanced surveillance trainings for nurses and EHTs. This training gave HCWs an overall understanding of their roles and the scope of activities in malaria elimination and the national guidelines for malaria elimination.  Strengthening foci response. This training equipped HCWs with the knowledge and skills needed to proactively and reactively respond to potential and existing malaria transmission foci— in accordance with the national guidelines.  Entomology training for EHTs. ZAPIM worked with Vector Link and Adeline Chan from CDC to identified key areas for the entomology training. The training gave cadres the theoretical and practical skills they need for active and routine vector surveillance of breeding sites and adult vectors within their communities.  Geographic Information System (GIS) mapping. ZAPIM also supported training in electronic mapping of malaria cases, vectors, vector breeding sites and malaria transmission foci.

4.6.1 ENHANCED SURVEILLANCE TRAINING ZAPIM supported enhanced surveillance training for all the environmental health cadres in Lupane District (18 EHTs, three Environmental Health Officers (EHOs), and four Field Officers). The training took place in from March 18-20. Twenty-four of the participants were from Lupane District, including the

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District Environmental Health Officer (DEHO) and five new EHTs who were recruited in 2019. The Provincial Field Officer also participated in the training. The facilitators included the Provincial Epidemiology and Disease Control Officer (PEDCO), the Provincial Environmental Health Officer (PEHO), and DEHOs for Umguza, Bubi, and Tsholotsho Districts. The training covered the following topics:  Overview of malaria in Zimbabwe generally and Lupane District specifically  Introduction to malaria elimination  Basic malaria epidemiology and transmission  Approaches and tools specific to malaria elimination programs  Introduction to key concepts in pre elimination  Community-based surveillance and preparedness for malaria elimination  Malaria investigation and surveillance in elimination  Road map to elimination from advanced control to the prevention of re- introduction phase  Foci classification group work  Entomological surveillance  Pre-elimination indicators, data tools, and timelines (including group work)  DHIS2 tracker  Tracker practical  Case management in elimination o RDT testing practical o Slide collection practical

As part of the training, the participants developed and discussed ward-level and district-level malaria elimination plans.

4.6.2 STRENGTHENING FOCI RESPONSE ZAPIM provided technical and financial support for this two-day training held on April 1 and 2, 2019. The training was attended by 17 EHTs, two EHOs and six nurses. The nurses included the District Community Health Nurse and five nurses selected from Dongamuzi, Jotsholo, Dandanda, Fatima and Gwayi Clinics with active foci. Training topics included case management for elimination, case investigation and classification, active case finding, foci mapping, foci classification, SBCC, and vector control responses to local malaria cases. The case management training emphasized the use of single dose primaquine for clearance of gametocytes to cut out malaria transmission and the active surveillance and reporting of any primaquine related side effects. The trainer highlighted the importance of active case finding and performance of microscopy in all RDT positive cases. Other key learning points were notification of cases within 24 hours, classification of cases within 72 hours and foci investigations within seven days. The training taught the participants the classification of cases as follows:  Local: malaria cases acquired within the elimination district by mosquito borne transmission. The alternative terms are indigenous, introduced or autochthonous case.  Imported: malaria cases originating from a malarious area outside of the 28 malaria elimination districts.  Intraported: malaria cases acquired from a malarious area outside the district but within another malaria elimination district. The training was guided by the Zimbabwe Malaria Foci Investigation and Response Algorithm shown in Figure 7 below.

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Figure 7: Zimbabwe Malaria Foci Investigation and Response Algorithm

The participants were taught the classification of foci as per WHO 2017 guidelines as follows:  Active foci: where there is ongoing transmission where locally acquired cases have been reported in current calendar year.  Cleared foci: where there has been no local malaria transmission for more than three years and which is no longer considered residual non-active.  Residual, non-active foci: where transmission was interrupted recently (i.e., one to three years). The last local case was detected in the previous calendar year or up to three years earlier. During the training, participants had a practical session in which they were placed into groups and given information for RDT positive cases from the nearby Gwayi Clinic. They were then tasked to conduct case follow up, investigations, classification and foci mapping around the identified cases.

4.6.3 EHT ENTOMOLOGY TRAINING All the environmental health cadres in Lupane District (19 EHTs, the DEHO, two EHOs, and three Field Orderlies) attended the three-day training in Lupane from April 3 to 5, 2019. ZAPIM coordinated with trainers from VectorLink, Africa University, National Institute of Health Research (NIHR) and Adeline Chan from the Centers for Disease Control and Prevention, Atlanta. The training focused on essential skills required for routine vector surveillance for elimination and active response to malaria cases. The topics covered included identification and staging of vector mosquito larvae, identification of adult female anopheles mosquitoes and differentiation from male anopheles and culicine mosquitoes. The participants received training related to the identification of vector breeding sites, larval scooping, methods of

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collecting adult mosquitoes, preservation and transport of mosquitoes and biolarviciding. There were practical sessions on larval scooping, setting up of Centers for Disease Control and Prevention light traps, Pyrethrum Spray Catch (PSC), use of suction tubes, using Prokopack aspirators (PPA) and biolarviciding. The advantages and disadvantages of each method of collecting mosquitoes were also discussed. These included the need for expensive equipment and functional batteries for PPA versus the cheaper PSC. The PSC needs adequate reliable supply of the pyrethrum spray cans. Given the limited availability of the PPA and the challenges of batteries even when the aspirators are available, the district was encouraged to get enough pyrethrum spray cans for use and to ensure ready access to the available equipment for the EHTs. During the training, the participants had a practical session on biolarviciding at breeding sites in Maganganga. The community of the area was involved in the biolarviciding session as part of the community engaged in the areas that was started through the CAC process. The photo below shows the community involvement in biolarviciding of a breeding site.

Community participation in larviciding during entomology training in Lupane, April 2019. Going forward, ZAPIM will consider redesigning the entomology training to allow for more days (i.e., five to seven), develop a standard training manual, and ensure availability of adequate equipment and mosquito specimens for the training and better instruction on biolarviciding.

4.6.4 TRAINING IN GIS MAPPING ZAPIM supported the training of 25 EHTs from Lupane District on Geographic Information System (GIS) mapping for quality mapping of malaria cases, vectors, vector breeding sites, and malaria transmission foci. The training occurred in Bulawayo from April 15 to 17, 2019. In the past, facilities have been relying on hand drawn maps. Training in GIS mapping allows for more accurate mapping using geo-codes that are obtained using the DHIS2 Tracker tablets that are used in cases investigations and notification in elimination districts.

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4.6.5 ZAPIM MICRO PLAN FOR ELIMINATION ZAPIM developed a micro plan for supporting elimination activities in Lupane District with inputs from PMI. PMI encouraged ZAPIM to learn from current implementation efforts to improve future implementation. The micro plan will guide ZAPIM’s activities in Year 5. Based on the micro plan, ZAPIM will promote uniform, quality training of all partners and trainers to ensure there is a full array of training (including MOP-UP) materials, standard operating procedures, and any other tools/job aids for CM, SM&E, SBCC and vector control in elimination, including refresher trainings. ZAPIM will review the need for job aids and tools including support for slide preparation. There is a need to improve on the quality of entomology trainings by allowing more time and more hands on access and use of key equipment by the trainees. ZAPIM will institute supportive supervision visits, elimination specific review meetings and data quality audits.

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5. GENDER AND CHILD SAFEGUARDING Gender equality and child safeguarding remained key guiding principles for ZAPIM in Year 4. ZAPIM took the opportunity to re-commit to gender equality and raise consciousness amongst its entire staff through participating in the #Better for balance campaign held on International Women’s Day 2019. The campaign which was supported by Abt Associates in all countries of operation saw ZAPIM personnel at all levels and across gender supporting it overwhelmingly. The scheduled occasion was well attended and supported by male staff and a genuine interest was shown as all levels of staff from Directors to support staff such as the drivers from both ZAPIM and Vectorlink projects discussed issues of gender equality openly and objectively. ZAPIM also participated in celebrating the 100 year achievements of Save the Children’s work in child protection the world over and in Zimbabwe. ZAPIM implemented the Year 4 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 4, 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 4, 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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6. 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

6.1 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 4, 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 the community level, 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.

6.2 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.

6.3 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 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 supervision visits for

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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.

7. ADMINISTRATIVE ACTIVITIES

7.1 STAFFING AND MANAGEMENT In Year 4, 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. During Year 4, Dr. Noe Rakotondrajaona continued as the project’s Chief of Party, Dr. Anthony Chisada as Technical Director and Angeline Zengeni as the Finance and Administration Director. The project recruited three provincial coordinators and two new drivers. In Year 4, ZAPIM benefitted from several short-term, technical assistance assignments from Abt Associates, Save the Children and Jhpiego. Details of these visits and remote support are in Annex A.

7.2 CONFERENCES, RETREATS, TRAININGS AND MEETINGS

7.2.1 ANNUAL MALARIA CONFERENCE The ZAPIM Chief of Party, Technical Director, M&E/OR Manager, Senior CM Specialist, SBCC Specialist and LLIN Specialist attended the national annual malaria conference hosted by NMCP in Mutare from June 24 to June 27, 2019. ZAPIM presented on malaria death audits, NMCP branding, Angwa assessment and month 24 NDS results. The other presentations supported by ZAPIM were the CDCS presented by Mr. Sanyanga from the DPS and community dialogues presented by the NMCP SBCC focal person. The major take-away message from the conference was the need to make use of the key findings from these activities to implement evidence-based programming.

7.2.2 VHW LOGISTICS SYSTEM REDESIGN WORKSHOP ZAPIM Technical Director and the M&E/OR Manager attended the VHWs logistic system redesign workshop hosted by Chemonics in Mutare form May 22 to May 24, 2019. This was a consultative workshop with stakeholders from the NMCP, MOHCC Health Information department, DPS, ZAPIM, PMI, Chemonics, Mhuri/Imuli, NatPharm, provinces and districts. The workshop also included focus group discussions with VHWs. The purpose of the workshop was to understand the gaps and challenges of the current VHW logistic system in preparation for the system’s re-design. ZAPIM presented the key VHW-related finding from the CDCS for the stakeholders’ consideration in the re-design of the system. Chemonics engaged a consultant to facilitate the workshop and develop a new design for the system. The new system, once fully developed, will be piloted in selected districts guided by a protocol which Chemonics is currently developing. The re-design is expected to deal with the challenges of VHW stock management, stock outs, reporting and use of data from VHWs among other issues. By end of September 2019, the consultant had developed draft training manual for system users and supervisors and system design standard operating procedures. The two documents were circulated to the stakeholders for stakeholders for review

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7.2.3 PROVINCIAL HEALTH TEAM MEETINGS AND DATA MANAGEMENT WORKSHOP ZAPIM participated in the Provincial Health Team Meetings in Mashonaland Central and Matabeleland North provinces, and data management workshop in Mashonaland Central. The project was represented by the Provincial Coordinators and presented project achievements to date, planned upcoming activities and data quality issues for the provinces. The meetings and workshop were also used as a platform to review the performance of the malaria program in the provinces. The ZAPIM Provincial Coordinator in Matabeleland North used this forum to hold discussions with Wild 4 Life, one of the malaria implementing partners in the province, and agreed on areas for collaboration in Binga District. ZAPIM shared the supportive supervision tools with Wild 4 Life to ensure same standard in the activities. The activities for the two projects will be coordinated to avoid overlap in the same geographical areas and also to ensure that all the wards in the district are covered.

7.2.4 NATIONAL MALARIA VECTOR CONTROL PLANNING AND REVIEW MEETING, IRS LEVEL I AND II TRAININGS AND IVM STRATEGIC PLAN DEVELOPMENT WORKSHOP The ZAPIM LLINs Specialist participated in the planning and review meeting in from September 2 to 6, 2019. The meeting reviewed vector control in the country including LLINs. He also provided technical support in the development of IVM Strategic Plan and IRS Level I training between September 9 and September 20, 2019. The Provincial Coordinators in Mashonaland Central and Mashonaland East participated in the IRS Level II training from September 23 to 27, 2019.

7.2.5 ENVIRONMENTAL COMPLIANCE TRAINING The LLIN/Vector Control Specialist, Case Management Specialist, and Data Quality and Reporting Officer attended an Environmental Compliance training hosted by USAID. The training aimed to familiarize participants with key terms and definitions used in environmental compliance and highlight USAID’s policies, standards, and procedures. New USAID regulations require that implementing partners include Climate Risk Management in their proposals and implementation plans and strategies. Since the training, ZAPIM is now emphasizing the importance of integrating environmental compliance into all thematic areas.

7.2.6 YEAR 5 WORK PLAN DEVELOPMENT MEETINGS ZAPIM met with the three provinces to gather their views on the priorities for Year 5. NMCP endorsed the proposed priorities with minimal changes. The project made it clear to the provinces and NMCP that the final activities to implement in Year 5 depend on the available budget and PMI approval. The project presented the consolidated work plan to NMCP before submitting to PMI.

7.2.7 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.

7.2.8 FUNDAMENTALS OF SM&E AND EVALUATION METHODS OF MALARIA PROGRAMS The ZAPIM Data Quality and Reporting Officer attended a ten-day training session on fundamentals of SM&E and evaluation methods of malaria programs at the University of Ghana from June 24 to July 05, 2019. The training involved plenary sessions, discussions, group work, and hands-on experience. This

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training is beneficial to the project particularly in the implementation of evidence-based programming for elimination work in Lupane District.

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8. Challenges, Lessons Learned and

Recommendations

The following is a list of challenges that the ZAPIM project faced in Year 4 and some recommendations for how to mitigate or avoid these challenges in the future.  Some facilities are giving IPTp doses before 13 weeks gestation and before completing 28 days after last dose as recommended: Mentees were instructed on the importance of adhering to clinically established guidelines. ZAPIM is currently supporting the development of IPTp job aids in the form of a calendar.  Shortage of malaria commodities (RDT kits, Dextrose 50%, sulfadoxine- pyrimethamine, and ACTs): ZAPIM encouraged the District Managers to redistribute commodities from facilities with low malaria burden to those with high burden and also ensure that malaria commodities are enough to distribute to VHWs. The provinces were also requested to assess the magnitude of the problem and document for possible discussion at higher level meetings (e.g., CM subcommittee, PMI meeting, Provincial Health Team meetings, etc.). Through the mentorship program, facilities were encouraged to calculate minimum and maximum stocks and reminded on when to do an emergency order and what they should do when commodities ordered are not delivered by Zimbabwe Assistance Pull System.  Low index of suspicion with most cases that qualify to be malaria suspects being missed for malaria RDT: Give emphasis on importance of testing all fever cases during training, supportive supervision or mentorship so that no suspected cases are missed  Delay treatment seeking behavior: Seeking treatment from traditional healers before visiting health facilities including traditional practices such as ‘scratching the throat’ in still a common practice. There is a need to conduct community meetings with traditional healers to promote early referral of suspected malaria cases for diagnosis and treatment and understanding of harmful practices and to educate communities on early care seeking behavior and understanding of harmful practices.  Unavailability of transport for mentorship program: Involve the DHE in planning mentorship visits and also integrate mentorship visits into other programs. In some instances, mentees were not on site during mentorship visits. This can be mitigated by involving health facilities in scheduling mentorship visits. In addition, there is need to train peer mentors at health facility level in Year 5 to cut on transport challenges  Threshold graphs not distributed at the beginning of the year in some health facilities: Through the provincial malaria review and death audit meetings, there was a consensus that the provincial and district offices need to calculate the threshold values and give them to facilities at the beginning of the malaria season so that facility staff can plot their graphs on time.  Timing of LLIN mass distribution campaign was after the peak malaria season: Future campaigns should be conducted just before the peak malaria season for impact.  VHW commodities: During the VHW supportive visits, ZAPIM worked with the district to ensure that VHWs without commodities were supplied with RDT kits, cotton wool, latex examination gloves, Sharps boxes and malaria medicines. The health centers are encouraged to continue supplying VHWs with adequate commodities.

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 VHW stock documentation: The documentation of stock in VHW registers is still a challenge with most not recording the opening and closing stock. ZAPIM emphasized these issues in the trainings and supportive visits. Health facility staff were encouraged to monitor and support VHWs more closely on these issues. ZAPIM staff will continue to train VHWs on this to ensure they are proficient and routinely document stock correctly.  Health facility staff support for VHWs. In 50% of the facilities visited during supportive supervision visits, staff were not meeting with VHWs when they came to clinics with their monthly reports. ZAPIM continues to orient facility-based health workers on VHW supervision and encourages them to create time for this. The DNOs in the affected districts were encouraged to ensure that clinic staff were effectively supporting VHWs.  NDS mosquito bioassays: National Institute of Health Research (NIHR) did not have enough mosquito colonies to conduct bioassays for the month 36 NDS. ZAPIM and NIHR arranged for the bioassays to be done at DeBeers Laboratory in Chiredzi.  Nurse involvement in elimination training. ZAPIM noticed that nurses had limited involvement in the trainings for enhanced surveillance in Lupane District, while an emphasis was placed on EHTs. This has resulted in challenges with the implementation of case investigations, active case finding, and the adequate supply of commodities to EHTs. ZAPIM discussed the issues with the province and district staff and agreed to involve nurses in future trainings and foster better elimination work collaboration between the two professionals.  EHT clinical skills. EHTs experience challenges in doing newly-required clinical work in the community for which they are untrained, such as preparing blood slides for microscopy examination for malaria parasites. ZAPIM-supported trainings emphasized skill development with thorough RDT simulations and practical sessions to help participants carry out these activities.  Limited access of entomology equipment to EHTs: Entomology equipment was mainly kept at district level yet the EHTs need to use them on a daily basis. This included even simple items like magnifying glasses. The DEHO was encouraged to decentralize the entomology equipment to ensure that the EHTs are able to carry out the entomology work.  Operating Environment: The volatile and complex operating environment as described in the background section of this annual report, coupled with the delayed release of Year 4 funding and anticipated delay of funding for Year 5 meant some planned activities were either delayed or could not be implemented in Year 4.  SBCC subcommittee meeting scheduling and funding: Convening of subcommittee meetings was are highly dependent on the NMCP programming year. While ZAPIM planned and was ready to support the NMCP on the technical meetings that guide SBCC programming nationally, mutual prioritization was not possible. In future ZAPIM should place the onus of convening these meetings on NMCP and depend on GFTAM funding to support the meetings.  Fuel access in the field. Lupane District experiences challenges obtaining petrol for EHTs to carry out community activities for elimination and servicing of motorbikes. The district was encouraged to continue lobbying for these through the MoHCC structures, which are primarily responsible for fuel access. ZAPIM will assist in some cases if the fuel is used for specified, well- defined malaria elimination actives and with proper accountability. The challenges with supporting this are in ensuring that the support is used for malaria activities and that issued coupons can be redeemed into liquid fuel in the field.

ZAPIM has experienced challenges exchanging coupons for liquid fuel in the field due to limited outlets fuel outlets. The project has resorted to using jerry cans to carry extra fuel for field work, which has resulted in limited reach in some communities. The project acquired more jerry cans in Year 4 and acquired some coupons from a second supply (Petrotrade) in addition to the usual supplier (Redan).

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ANNEX A: SHORT-TERM TECHNICAL ASSISTANCE

Project staff provided the following short-term technical assistance (STTA) during Year 4:

Name Position Dates Scope of Work Ekpenyong Ekanem ZAPIM M&E Specialist, April 1-13, 2019 and Provide technical Abt Associates May 2-4, 2019 assistance in NDS at month 36 data analysis and development of SM&E Training Manual Jeanne Koepsell Save the Children CCM May 20-22, 2019 Provide technical Advisor, Digital Health support to CCM and Innovation Lead activities Chantelle Allen Jhpiego Quality June 09-15,2019 Provide technical Improvement Advisor support for case management (malaria clinical mentorship and Y5 work plan development) and development of EPR training package Ffyona Patel ZAPIM Technical July 7 – 12, 2019 Provide technical Program Officer, Abt support to the project Associates including Year 5 workplan development. Kinsen Talukder ZAPIM Project Finance July 21 – 26, 2019 Provide finance and Analyst, Abt Associates administrative support including Year 5 budget formulation

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ANNEX B: PMP INDICATOR/YEAR 4 MILESTONE MATRIX

# Indicator/ Type Targets/ Results Comments/ Next Steps Milestone Benchmarks Problems Encountered Baseline Oct 2018 YR 4 Year 4 Percent of (year and – Sept Results Cumulative Annual Target source) 2019 Results Achieved CM Number of malaria PMP 392 N/A 353 353 Not applicable The baseline and Scale up malaria deaths (HMIS (N/A) results are national. interventions and also 2016) Cumulative deaths continue to support malaria from ZAPIM death investigations in the Districts/Provinces affected provinces. were reported from Matabeleland North (5)- Lupane (1) and Binga (4), Mashonaland Central (39)- Centenary (4), Guruve (8), Mazowe (1) , Mbire (6), Mt darwin (9), Rushinga (4) and Shamva (7), Mashonaland East (54)- Goromonzi (1), (4), Hwedza (2) , Mudzi (26), Murewa (8), Mutoko (8) and UMP (5)

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CM Incidence of PMP 17/1,000 N/A 21/1,000 N/A ZAPIM supported ZAPIM continues to priotize malaria (HMIS provinces, high-impact interventions to 2016) Mashonaland Central contribute to the reduction of and Mashonaland East malaria districts experiencing were amongst the three malaria outbreaks. provinces that reported high number of cases. The most affected ZAPIM supported districts were Mudzi, Goromonzi, Mt Darwin, Mbire, Bindura, Centenary, and Mutoko. These districts were suspected to be experiencing malaria outbreaks. 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 Manicaland to received two 2012) MIS. determine the causes for the or more doses of low uptake of IPTp. ZAPIM Intermittent continued to rely on Preventive assessment findings and Treatment of recommendations to improve Malaria in the program Pregnancy (IPTp) during ANC CM Proportion of PMP 68.8% N/A 50% 50% N/A 50% is according to the The indicator is not well under-five children (MIS 2015 ZDHS. The new reported in the 2016 MIS who sought 2012) National Malaria preliminary report and treatment within Strategic Plan is being therefore the 2015 ZDHS 24 hours of onset costed and will inform report has been used as a of fever the targets. reliable source document. CM Percentage of PMP 99.8% 100% 100% 100% 100% Need to encourage The HFs and community suspected malaria (HMIS communities that any health workers (CBHWs) cases that receive 2016) suspected malaria case should continue to exhibit a parasitological should be tested. high compliance and test acceptable practices.

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CBHWs are adhering to the guidelines. CM Percentage PMP 93% 100% 100% 100% 100% The indicator only The results show that the of confirmed (HMIS captures ACTs given; level of access to treatment malaria cases that 2016) other anti malarial of deserving cases for first- receive first-line medicine given to line treatment increased in antimalarial complicated cases are quarter. treatment not documented in the according to DHIS2 system. national policy CM+CCM Number of health PMP 896 760 538 538 71% 183 health facility Additional health workers will workers (including (Year 1 workers, 317 VHWs be trained in Year 5. VHWs) trained in ZAPIM and 38 VHW peer malaria case Annual supervisors were management Report) trained CM. The target (ACT, MiP/IPTp, was not achieved due RDT, microscopy, to inadequate funding. medicine management) CM Number of PMP 0 (2016) 15 9 9 60% Prioritized mentorship To be integrated into planned malaria- program during the mentorship program in Year related SS of year. 5. health facility workers conducted CM Number of PMP 0 (2016) 15 15 15 100% All districts plans feed As part of the outbreak districts with into the provincial response initiative, ZAPIM outbreak plans. will continue to support all response plans districts to ensure they have robust plans to quickly respond to any outbreaks. ZAPIM supported the production of the EPR guidelines. In Year 5, ZAPIM will support training of RRT members in selected districts. It is anticipated that this will go a improve the

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quality of the outbreak response plans. CM Functional training Year 4 0 (2016) 1 1 1 100% Database was Database to be maintained database mileston maintained throughout beyond the life span of the (TrainSMART) for e the year. project. current and future trainings CM NMCP CM/MiP Year 4 1 (2016) 2 0 0 0% Rescheduled for Q1- ZAPIM will continue to subcommittee mileston Year 5. engage NMCP so that quarterly meetings e subcommittee meetings are supported held as planned. CM Malaria case and Year 4 0 (2016) 1 1 1 100% Report was finalized Need to follow up on the drug consumption mileston and key results implementation of the assessment e disseminated at recommendations. findings different forums. disseminated CM Number of staff Year 4 0 (2016) 200 0 0 0% Deferred to Year 5 To be implemented in Year trained in CM/MIP mileston because of inadequate 5. reached with SMS e funds. information reminders and quizzes CM Supportive Year 4 0 (2016) 500 500 500 100% ZAPIM did not support ZAPIM will support review of supervision tools mileston the printing of revised any relevant tools in Year 5 and job aids e treatment charts as per recommendations reviewed and because of inadequate from SS and mentorship updated with funds. program. NCMP CM Number of on the Year 4 0 (2016) 3 6 6 200% 25 health facilities were Need to continue updating job mentorship mileston visited, with a total of action plans based on visits to six e 98 health workers discussions and proposed districts mentored. actions to be taken. conducted CM Number of Year 4 0 (2016) 2 1 1 50% The review meeting Need to follow up on the mentorship review mileston focused on the recommendations of the meetings e approach that was meeting. conducted used and highlighted areas where mentees

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and mentors need additional training or skills building CM External Year 4 0 (2016) 1 0 0 0% This will be guided by To be guided by the mentorship mileston the recommendations recommendations from the assessment e from the mentorship mentorship review meeting. conducted review meeting. CM Number of malaria Year 4 2 (2016) 6 3 3 50% One meeting was Need to follow up on the death mileston conducted in each recommendations of the investigation/ e province. The target meeting. More death audit malaria death was not achieved due meetings to be conducted in audit meetings to inadequate funding. Year 5. with NMCP, hospitals and PMDs, DMOs, and Matrons in attendance CCM Number of facility- Year 4 0 (2016) 25 18 18 72% The orientation These will act as focal based health mileston targeted selected persons for VHW supervision workers oriented e health workers from at their respective centers. on supportive health facilities in UMP supervision District. process and tools CCM Number of VHWs Year 4 0 (2016) 280 203 203 73% Follow up VHWs in four Additional VHWs will be and potential mileston districts, Centenary, followed up in Year 5. VHW peer e Goromonzi, Mudzi and supervisors UMP. Other VHWs followed up (post- could not be followed training follow-up) up in the last quarter of the year because of inadequate funds. CCM Number of Year 4 0 (2016) 3 0 0 0% Deferred to Year 5 To be implemented in Year meetings with mileston because of inadequate 5. School Health e funds. Coordinators conducted as part of post-training follow-up

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CCM Number of training Year 4 0 (2016) 370 1,440 1,440 389% Copies printed in Q2 Additional copies will be manuals and job mileston were sufficient to cover printed as per need in Year aids (facilitators e the trained cadres in 5. and participant Q3. manuals, medicine supply and accountability register, RDT job aid and monthly reporting book) printed CCM Number of bi- Year 4 0 (2016) 16 3 3 19% Conducted in three Additional meetings will be annual district mileston districts only, conducted in Year 5. VHW review e Centenary, Mbire and meetings Mutoko. conducted (eight Implementation districts) affected because of the other competing activities and inadequate funds. CCM Number of items Year 4 0 (2016) 200 200 200 100% 200 medicine boxes Need to monitor the use of procured for the mileston were procured for all medicine boxes. VHWs (medicine e VHWs in Mbire District. boxes & torches) Three cabinets were lost within the district during transportation at the time of distribution. CCM Number of EHTs Year 4 0 (2016) 60 10 10 17% Piloted in Mbire, To be scaled up in Year 5. and nurses mileston Mutoko and UMP were supported to e selected motorized conduct VHW EHTs provided SS to supportive VHWs. supervision including LLIN CD CCM Number of Year 4 0 (2016) 1 1 1 100% Met with Wild 4 Life Need to follow up on areas coordination mileston and Isdell Flowers to to share or leverage meeting with other e discuss how resources Malaria Partners community activities on CCM can be coordinated

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LLIN Proportion of PMP 49% N/A 54% 54% N/A The figure of 54% is Need to assess the population that (MIS according to the MIS performance of the indicator slept under an 2012) 2016. through ZDHS/MIS that is insecticide treated scheduled for 2020 net the previous night LLIN Proportion of PMP 8% N/A 17.5% 17.5% N/A It is important to note Need to assess the children under-five (ZDHS (ZDHS (ZDHS the different performance of the indicator who slept under 2010-11) 2015) 2015) methologies used for through ZDHS/MIS that is an LLIN the 49.6% MIS and ZDHS. scheduled for 2020. previous night (MIS 33% 33% (MIS However, there is need to 2012) (MIS 2016) scale up the interventions 2016) which promote net usage among children. LLIN Proportion of PMP 49.1% N/A 36% 36% (MIS N/A Only 36% of women Need to assess the women of child (MIS (MIS 2016) slept under an LLIN the performance of the indicator bearing age who 2012) 2016) previous night, which through ZDHS/MIS that is slept under an was a substantial scheduled for 2020. LLIN the previous decrease compared to However, there is need to night the 49% in the 2012 scale up the interventions MIS. which promote net usage among women aged 15-49 years. LLIN Proportion of PMP 46.4% N/A 58% 58% (MIS N/A The baseline and Need to assess the households in (MIS (MIS 2016) results are national. performance of the indicator ZAPIM target 2012) 2016) through ZDHS/MIS that is districts with one scheduled for 2020. or more LLINs LLIN LLIN Continuous PMP 10 (Year 11 11 11 100% This was complimented To be done throughout the distribution 1 ZAPIM by the mass distribution year system rolled out Annual program in ZAPIM target Report) districts LLIN Net durability PMP 0 (2016) 1 1 1 100% The project the study The recommendations will study findings and submitted the final be adopted for future produced and report to PMI for distribution planning. recommendations approval. adopted for future

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distribution planning LLIN Number of PMP 0 (2016) 120 29 29 24% The target was not To be trained in Year 5 when trainers trained on achieved due to funds are available continuous LLIN inadequate funding. distribution LLIN Number of people PMP 1,358 1020 100 100 10% The target was not To be trained in Year when (LLIN Distributors) (2016) achieved due to funds are available trained in LLIN inadequate funding. routine/continuous distribution LLIN Number of Year 4 0 (2016) 330 348 348 105% The target was Ensure that the trainers trainers trained on mileston surpassed at no extra provide effective training. Mass LLIN e cost. distribution LLIN Number of people Year 4 0 (2016) 870 1,632 1,632 188% HFs engaged all the Ensure that the VHWs (LLIN Distributors) mileston VHWs in their area of distribute the LLINs in an trained in LLIN e operation instead of efficient manner. mass distribution working with the targeted 6 VHWs only. This was done at no extra cost to the project LLIN Number of LLINs PMP 573,950 816,225 725,569 725,569 89% A total of 725,569 Distribution will continue as distributed (mass (2016) LLINs were distributed. per need + CD) Of these, 624,458 were distributed through mass campaign and 101,111 through continuous channels LLIN Number of ANC PMP 0 (2016) 98 98 98 100% All ANC clinics All ANC clinics will continue clinics continue to implement to implement LLIN routine implementing LLIN routine distribution. LLIN routine distribution. distribution LLIN Number of vector Year 4 1 (2016) 2 0 0 0% Rescheduled for Q1- ZAPIM will continue to control mileston Year 5. engage NMCP so that subcommittee e subcommittee meetings are held as planned.

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meetings supported SBCC SBCC repository PMP 0 (2016) 1 0 0 0% This falls under the ZAPIM will no longer support (on-line data portfolio of the the activity. base) of malaria mainstream MoHCC. messages and delivery methods established SBCC Number of PMP 1066 803 554 554 69% The trainings focused Additional trainings will be persons trained in (2016) on CAC Explore health conducted in Year 5. SBCC issues and setting priorities as well as CAC Evaluate Together. SBCC Rapid PMP 0 (2016) 1 1 1 100% The project worked The report is expected to assessment- with NMCP to review inform future programing as Knowledge, and refine the report. per findings from the Attitude and assessment. Some of the Practice Surveys findings were also used of the Mbire during the development of community Year 5 work plan. completed SBCC Commemoration Year 4 1 (2016) 1 1 1 100% Press conference was ZAPIM will continue to of the SADC mileston held together with the support future Community e Minister of Health and commemorations. Malaria Day Child Care supported SBCC World Malaria Day Year 4 3 (2016) 3 3 3 100% World Malaria Day ZAPIM will continue to Campaign mileston commemorations were support future supported in 3 e supported at national commemorations. provinces level and in three ZAPIM supported provinces. SBCC SBCC materials Year 4 0 (2016) 3 3 3 100% Project printed LLIN ZAPIM will continue to and tools in local mileston promotional leaflet, My support material production languages e net, My life. Support for different thematic areas. (including leaflets was also rendered & posters) for towards the

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LLINs, CM & development of SBCC printed and materials for disseminated elimination for Lupane District. SBCC National level Year 4 0 (2016) 1 1 1 100% ZAPIM continued to The survey and rebranding malaria branding mileston support the NMCP to workshop were deferred to initiative to e prepare for the Year 5. ZAPIM will continue operationalize strategic re-branding to be a key partner in strategy 7 of exercise. NMCP supporting this process in Malaria deferred the rebranding Year 5. Communication workshop to Year 5 Strategy SBCC Number of Year 4 0 (2016) 3 0 0 0% No budget for this ZAPIM will provide technical provincial cross- mileston activity support when necessary border e collaboration meetings on SBCC community change SBCC Number of radio Year 4 0 (2016) 60 0 0 0% The development of the To commence broadcasting spots produced mileston radio spots to support in October 2019 on three for sensitization e LLIN distribution was radio stations, namely on LLINS completed in the last National FM (27 slots), Radio campaign quarter. Zimbabwe (30 slots) and Diamond FM (24 slots). SBCC Number of radio Year 4 0 (2016) 60 33 33 55% These were aired on ZAPIM to continue spots produced mileston Diamond (22) and supporting as need arises for sensitization e National FM (11) on IRS campaign SBCC Number of Year 4 0 (2016) 12 10 10 83.3% Forums used to Continue using the CAC advocacy mileston discuss the disease approach to reach out to as meetings with e burden in the area, many community community analyzed areas most stakeholders as possible. stakeholders on affected, and identified LLIN use and possible actions to be IPTP uptake taken conducted

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SBCC Number of SBCC Year 4 1 (2016) 2 0 0 0% Rescheduled for Q1- ZAPIM will continue to Sub-Committee mileston Year 5. engage NMCP so that meetings e subcommittee meetings are conducted held as planned. Eliminatio Number of health Year 4 0 (2016) 25 24 24 96% The participants were Training will enhance the n workers trained in mileston drawn from Lupane capacity of health workers to enhanced e District where ZAPIM is effectively carry out malaria surveillance supporting elimination elimination activities in the work district Eliminatio Number of Year 4 0 (2016) 25 25 25 100% The training gave The skills will be essential for n environmental mileston cadres the theoretical routine vector surveillance health workers e and practical skills they for elimination and response trained in need for active vector to malaria cases entomology surveillance of breeding sites and adult vectors within their communities Eliminatio Number of Year 4 0 (2016) 25 25 25 100% The project supported Trained health workers are n environmental mileston the training of 25 EHTs expected to map malaria health workers e from Lupane District on cases, vectors, vector trained in GIS GIS mapping for quality breeding sites, and malaria mapping of malaria transmission foci cases, vectors, vector breeding sites, and malaria transmission foci. Eliminatio Number of health Year 4 0 (2016) 25 25 25 100% The training equipped Trained health workers are n workers trained in mileston health workers with the expected to proactively and foci response e knowledge and skills reactively respond to needed to proactively potential and existing malaria and reactively respond transmission foci. to potential and existing malaria transmission foci—in accordance with the national guidelines for malaria elimination

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M&E Malaria M&E Year 4 0 (2016) 1 1 1 0% The project supported To finalize the facilitator’s training manual mileston a workshop which kick training manual and revised e started the process of participants’ manual in Year developing the malaria 5. SM&E training manual M&E Number of PMP 10 (2016) 90 0 0 0% The trainings will be To be implemented as soon districts and guided by the M&E as the M&E training manual health facility staff training manual to be is updated trained in M&E, finalized in Year 5 supportive supervision, epidemic alert protocols (EPR/IDSR) M&E ZAPIM M&E Year 4 0 (2016) 1 1 1 100% The M&E Database M&E Database will continue database updated mileston was updated on a to be updated throughout the e regular basis. projecet lifespan and to be used to monitor the performance of the project. M&E Number of Year 4 0 (2016) 6 3 3 50% A total of 32 health Additional districts and national, mileston facilities: Binga (4), health facilities to be covered provincial and e Hwange (6), Rushinga in Year 5 district data (6), Mt Darwin (6) and quality Mudzi (10) participated assessments in the DQAs. The target (DQAs) conducted was not achieved due to inadequate funding. M&E Number of Year 4 0 (2016) 6 3 3 50% The project all the The project will support provincial and mileston provinces to undertake additional malaria review district planning e malaria review meetings in Year 5. and review meetings. The target meetings was not achieved due conducted to inadequate funding. M&E M&E Plan for the Year 4 0 (2016) 500 500 500 100% The project supported The project will continue National Malaria mileston the printing and using different platforms at Strategy printed e distribution of the provincial and district level to and distributed SM&E Plan disseminate key document.

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M&E Revised EPR Year 4 0 (2016) 1,600 1,600 1,600 100% NMCP requested These were distributed to guidelines printed mileston ZAPIM to revise the partners and provinces at the and distributed e number of copies to be Annual Malaria Conference. printed The guidelines will guide the training of RRTs. M&E Number of district Year 4 0 (2016) 80 0 0 0% Deferred to Year 5 To be implemented in Year staff trained in the mileston because of inadequate 5. revised EPR e funds. guidelines M&E Malaria Research Year 4 0 (2016) 1 0 0 0% Discussions with To be implemented in Year Agenda mileston NMCP to develop the 5. developed and e agenda underway printed M&E Number of RDT Year 4 0 (2016) 1,000 1,160 1,160 116% Printed as per Distributed to all provinces registers for mileston provinces’ request as per need. VHWs printed e M&E Number of Year 4 0 (2016) 200 200 200 100% Agree with NMCP and VHWs started reporting to cellphones mileston national health their respective health procured to pilot e information department facilities from mid-August weekly mobile on parameters to be 2019. data reporting by reported. VHWs M&E Number of VHWs Year 4 0 (2016) 186 186 186 100% All active VHWs were VHWs started reporting to trained in weekly mileston trained to report to the their respective health mobile data e health facility on a facilities from mid-August reporting (through weekly basis. 2019. Non-active VHWs are SMS) likely to be targed for CCM training in Year 5. This will be followed by training in weekly mobile data reporting. Health facility staff prepared to lobby with HCCs to take over the initiative after the ZAPIM Project M&E Alternative to MIS Year 4 0 (2016) 1 1 1 100% Five options were The brief is intended to be developed and mileston identified and a short the starting basis for further explored e description of the discussions with the NMCP, approach for each PMI and other partners to

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option and the decide on which option(s) to advantages, pursue. Once the internal disadvantages/limitatio partners have made a choice ns, and likely cost were on a method(s) to pursue articulated further, ZAPIM will develop a detailed proposal in Year 5. M&E Number of Year 4 0 (2016) 2 0 0 0% Rescheduled for Q1- ZAPIM will continue to Surveillance, M&E mileston Year 5. engage NMCP so that and OR Sub- e subcommittee meetings are Committee held as planned. meetings supported

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ANNEX C: YEAR 4 ACTIVITIES AFFECTED BY ANTICIPATED DELAYED RELEASE OF YEAR 5 FUNDING

THEMATIC AFFECTED ACTIVITY COMMENTS AREA CM  EPR training  ZAPIM intended to carry out training of 80 RRT members in October

 Supportive supervision  Matabeleland North requested support for SS but project could not provide

 CM subcommittee meeting support  NMCP planning to have this meeting in October. ZAPIM will not be able co-fund this activity with other partners  Death audit meetings  Managed one death audit meeting for each province instead of the planned 2 per province CCM  CCM training of VHWs  Mbire trainings x 2 groups postponed

 CCM post training follow up for Binga  Follow up was affected by changes in monetary policies. Then subsequently budget issues

 Supportive supervision  Only one visit conducted for Binga and Hwange districts instead of 2 visits to each of the 11 CCM supported districts

 VHW review meetings  Only 3 meetings held one per each district instead of the planned 16 (2 per district in 8 districts)

LLINs  Training of HWs and VHWs on CD of  91 HWs and 920 VHWs could not be trained LLINs

 Net follow ups after Mass Distribution  No follow up was done

 Community Leaders’ engagement meetings for LLINs uptake  None carried out

 District supportive visits  None carried out

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SBCC  Re-print malaria BCC communication  VHW Flipchart in Shona Language could not be facilitation tools for health personnel printed Commented [EM3]: Are all other activities postponed to Year and CBHWs in 1 district  All the activities will be implemented in Year5? 5

 Re-print copies of My net my life (20 000)

 Development of 1 Ndebele language leaflet on net use (translation of My net my life)

 Conduct a follow-on rapid assessment of Dipa la Malaria and replenishment of gadgets in Chapoto ward

 Fully develop malaria elimination material (partly – illustrator procurement deferred) Community  CAC Evaluate Together trainings for  All the activities will be implemented in Year 5 SBCC Mt Darwin (9 HCCs)and Shamva (13 HCCs)  Lupane CAC Elimination support trainings  Support Advocacy community dialogue meetings with leaders to promote LLINs utilization and uptake of IPTp.  Support post Angwa assessment dissemination of findings and roll out of short term interventions.  Documentation of CAC activities

Elimination  Supportive supervision for Lupane  The supportive supervision could not happen in district July as plan. It could not be done in September either.

 Elimination review meeting  The elimination review was scheduled for September and could not happen as the project could not carry out field activities in September. M&E/OR  One last round of DQAs in each All the activities are now earmarked for Year 5 province  One provincial malaria review meeting per province  Support training of RRTs in revised EPR guidelines-  Support SM&E Sub-Committee Meeting  Support printing and distribution of T12/ OPD Registers- MoHCC NHIS department yet to finalize them though

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