Selection of Target Districts Revised Report

SYSTEMS FOR BETTER HEALTH

Project Implementation Working Paper

March 2016 This project implementation working paper was produced for review by the United States Agency for International Development. It was prepared by Abt Associates for the USAID Systems for Better Health activity. Selection of Target Districts

Contract/Project No.: Task Order No. AID611-TO-16-00001 Contract No. AID-OAA-I-14-00032

Submitted to: William Kanweka, Contracting Officer’s Representative USAID/Zambia

Prepared by: Abt Associates

In collaboration with: American College of Nurse-Midwives Akros Inc. BroadReach Institute for Training and Education Initiatives Inc. Imperial Health Sciences Save the Children

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

USAID Systems for Better Health ▌pg. i Selection of Target Districts

USAID Systems for Better Health ▌pg. ii Selection of Target Districts

Table of Contents

Acronyms ...... iv

1. Introduction ...... 5 1.1 Background regarding target districts ...... 5 1.2 SBH activities at each level of the health system ...... 6

2. Approach to selection of target districts ...... 7 2.1 Factors proposed to guide selection of target districts ...... 7 2.2 Method of identifying districts matching the selection factors ...... 8 2.2.1 Donor Preference ...... 8 2.2.2 Workforce in comparison to the establishment list ...... 8 2.2.3 Facilities ...... 9 2.2.4 Comparison of Key HMIS Indicators...... 9 2.2.5 Stakeholders working in the district...... 10 2.2.6 Total scores ...... 10

3. Central Province selection of target districts ...... 11

4. Copperbelt Province selection of target districts ...... 13

5. Eastern province selection of target districts ...... 15

6. Lusaka Province selection of target districts ...... 16

7. Southern province selection of target districts ...... 17

USAID Systems for Better Health ▌pg. iii Selection of Target Districts

Acronyms

DATIM Data for Accountability, Transparency, and Impact DHIS2 District Health Information System Version 2 DMO District Medical Officer or District Medical Office EHT Environmental Health Technician GRZ Government of the Republic of Zambia HMIS Health Management Information System HRH Human Resources for Health MOH Ministry of Health PEPFAR United States President’s Emergency Plan for AIDS Relief PMO Provincial Medical Officer or Provincial Medical Office SBH Systems for Better Health Project USAID United States Agency for International Development ZISSP Zambia Integrated Systems Strengthening Project

USAID Systems for Better Health ▌pg. iv Selection of Target Districts

1. Introduction

The United States Agency for International Development’s (USAID) five-year Systems for Better Health (SBH) in Zambia activity seeks to improve health outcomes for Zambians, SBH will be implemented by Abt Associates Inc. (Abt) and its partners Akros Inc., American College of Nurse-Midwives, BroadReach Institute for Training and Education, Imperial Health Sciences, Initiatives Inc., and Save the Children from October 2015 to October 2020. The goal of USAID’s five-year Systems for Better Health activity is to improve health outcomes for Zambians by strengthening systems that underpin the delivery of high quality health services. The activity also seeks to increase the utilization of high impact health interventions. In twenty target districts within five provinces, Systems for Better Health will assist the Ministry to:  Increase retention of HIV patients on antiretroviral therapy to 85 percent,  Increase the use of modern contraceptives by 10 percent,  Increase the proportion of deliveries assisted by a medically trained provider by at least 20 percent,  Increase the proportion of fully immunized children aged 12 to 23 months to at least 80 percent, and  Reduce the prevalence of stunting among children under five by 15 percent.

To achieve these objectives, the Systems for Better Health project will provide technical, financial, logistical and administrative assistance to the Government of the Republic of Zambia (GRZ) at the national level and in five provinces and twenty target districts. The project will also work to strengthen the capacity of non-governmental and community-based organizations (NGOs and CBOs) to foster healthy behaviors and to deliver selected health services in remote areas. The purpose of this implementation working paper is to describe the process which the SBH project followed to reach agreement with the Provincial Medical Offices regarding selection of the target districts.

1.1 Background regarding target districts

SBH activities will contribute to improvements at all levels of the health system. Task One activities prioritize national level improvements and systems strengthening. Tasks Two and Three prioritize the provincial, district, and facility levels. SBH will work in a total of five provinces (Central, Copperbelt, Eastern, Lusaka, and Southern). Within each selected province, SBH will target four districts, for a total of 20 target districts. SBH worked in collaboration with the Provincial Medical Offices (PMOs) to select the target districts in late January and early February 2016. SBH intends to implement district activities using a phased approach – SBH will initially begin its work intensively in ten districts. This initial phase of assistance will last 18 to 24 months and will culminate in a gradual withdrawal of intensive support and “transition,” when agreed-on performance targets are met and DMOs and facilities demonstrate improved capacity to maintain a high level of performance. As SBH reduces support from the initial set of target districts, we begin intensive support to the second set of ten districts. Phasing support for the SBH districts will allow for cost-effective, targeted use of project resources to strengthen health systems performance and health outcomes in all targeted districts during the life of the project.

Selection of Target Districts Once SBH target districts are selected, SBH will focus on approximately 15 targeted health facilities and their catchment communities within each district, and will reach about 300 health facilities and communities.

1.2 SBH activities at each level of the health system

The Systems for Better Health project will focus on three tasks as described below. Tasks Two and Three will be performed in the target provinces and target districts. Task One: Design and implement national level interventions to strengthen health stewardship by the Ministry of Health (MOH) The project will provide technical assistance to strengthen MOH systems and skills to plan, implement, monitor health programs and evaluate performance. Project support under this task includes: strengthening human resource planning and management; improving health care financing and public financial management; and strengthening MOH systems for assuring the delivery of high quality health services and for coordinating stakeholders. Task Two: Design and implement effective interventions to strengthen program management at provincial and district levels The project will assist the Ministry to strengthen linkages between the central MOH and the Provincial Medical Offices (PMOs); between PMOs and District Medical Offices (DMOs); and between DMOs and health facilities. The project’s support focuses on strengthening the leadership and management systems, tools and skills of the PMO and DMO teams in order to improve planning, implementation, supervision, monitoring and evaluation. In addition, Systems for Better Health will strengthen clinical skills with a focus on high-impact health interventions including: maternal, neonatal, child, and adolescent health, family planning, HIV, and nutrition. Task Three: Assist the GRZ and local organizations to increase the quality, availability and use of priority health services at the community level In line with Zambia’s decentralization plan, the Systems for Better Health team will work to increase the skills of district and facility level staff to plan, implement, monitor and evaluate effective community health programs. The project will assist health facilities to engage communities in planning for health services, reviewing performance, and participating in quality improvement teams. Working in collaboration with NGOs, CBOs, and the MOH, the project will give grants to support social and behavior change communication to generate demand for and support of quality health services at community level.

Selection of Target Districts

2. Approach to selection of target districts

In 2010 and 2011, the Zambia Integrated Systems Strengthening Project selected target districts in consultation with the MOH central level and the Health Care Finance Technical Working Group. The process was very time consuming. The SBH team proposed to USAID and to the Ministry of Health Permanent Secretary (PS) and Directors that the target districts for SBH be selected in by the Provincial Medical Office team in consultation with SBH managers. Both USAID and the MOH agreed that this strategy would be acceptable and would be likely to be more efficient and result in a better relationship between the project and the PMO team.

2.1 Factors proposed to guide selection of target districts

Members of the project management team visited each of the five provinces in late January and early February to discuss the selection of target districts. These meetings are described in more detail in section three of this report. The SBH team introduced five factors to be considered by the PMO team during the discussion on target districts. The two teams aimed to reach consensus on the 4 target districts in each province. The five factors were:  Donor preference for specific districts  The availability of human resources at DMO level to serve as managers, trainers and mentors, as well as human resources at the facility level to deliver services  The number of facilities in the district  Performance of the district on two HMIS indicators plus the number of people enrolled in ART  The number of stakeholders working in the district. The SBH team invited the PMO team to add other factors and to present information on those factors. Using the factors described above, SBH requested that the PMO team consider selecting districts which:  Respond to the donor priorities by including the SMGL and the priority districts for the President’s Emergency Plan for AIDS Relief (PEPFAR) program.  Have a high proportion of the establishment list filled for the positions of Medical Officer, Medical Licentiate, Clinical Officer, Registered Nurse and Registered Midwife since these cadres will play an important role in mentoring, training, and managing other frontline health workers.  Have a high proportion of the establishment list filled for the positions of Enrolled Nurse, Enrolled Midwife, and Environmental Health Technician since these people will be responsible for delivering services and will be the focus of capacity building efforts.  Have a large number of facilities in comparison to other districts.  Show poor performance on the HMIS indicators for full immunization coverage and skilled attendance at birth while also having high levels of ART enrollment.  Have a large number of partners or stakeholders to coordinate.

Selection of Target Districts

2.2 Method of identifying districts matching the selection factors

The SBH team reviewed the annual plans of all districts from the five provinces to create simple tables that allowed comparison of the districts according to five selection factors proposed by SBH. In order to enable simple comparison, the team converted all indicator proportions or values into a score using a three point scale. One third of the facilities which had the best performance for each indicator received three points; the next third of facilities with intermediate performance received two points, and the final third of facilities with lower performance received one point. When facilities were tied in a specific characteristic, the project expanded the tier with the tied score by one member in order to allow the tied facilities to receive the same score on the three point scale. After scoring each district on the five factors, the team added the scores for each facility across the factors to arrive at a total score. SBH ranked the total scores from highest to lowest to show the districts with the closest match to the selection factors. Below, we describe the approach used to create a score for each selection factor. 2.2.1 Donor Preference This is the most important of the five factors. SBH advocated strongly for PMO teams to select districts which are preferred by the donor. This includes the twenty-three priority districts for the US President’s Emergency Plan for AIDS Relief (PEPFAR), and five priority districts for the Saving Mothers Giving Life (SMGL) endeavor. The PEPFAR priority districts are those which the US Government estimates to have a larger gap between the number of individuals currently enrolled in care and treatment and the number of people estimated to be eligible for enrollment. The PEPFAR priority districts are distributed as follows:  Eight of Central province’s twelve districts are priority districts.  Six of Copperbelt province’s ten districts are priority districts.  Six of Lusaka province’s seven districts are priority districts.  Two of Southern province’s thirteen districts are priority districts. The priority districts for the SMGL endeavor are distributed as follows:  Kabwe district in Central province is an SMGL district and also a PEPFAR priority district.  Chipata, Lundazi, and Nyimba districts in Eastern province are SMGL districts.  Luangwa district in Lusaka province is an SMGL district and also a PEPFAR priority district.  Livingstone district in Southern province is an SMGL district and also a PEPFAR priority district. In addition, Choma, Kalomo, Pemba, and Zimba districts in Southern province are SMGL districts. To score the donor preference selection factor, SBH awarded three points to all districts which were either PEPFAR priority districts or SMGL districts. In case a district was both SMGL and PEPFAR priority, it still received three points. 2.2.2 Workforce in comparison to the establishment list SBH assumes that our efforts to improve health outcomes will be most successful where there are a sufficient number of personnel in the District Medical Office and district hospital or training institutions to be trained as trainers and mentors so that the district has its own trainers and mentors. This would also boost the already established district Clinical Care Teams. The project will support DMO teams to build the capacity of workers in the facilities.

Selection of Target Districts SBH is also more likely to attain the project objective in districts which have reasonable levels of health professionals in the health facilities. The project encouraged PMOs to select districts with the high or medium scores for human resource availability. The project reviewed the action plans of the districts in the five provinces in order to get information on the availability of DMO senior clinical personnel and facility health workers. At district level we compared the supply of medical officers and medical licentiates, clinical officers, registered midwives and registered nurses to the establishment list to calculate the proportion of available personnel in comparison to the establishment list. SBH followed the same approach to calculate the proportion of the establishment filled at the primary health facility level. We looked at the cadres of Zambia Enrolled Nurse, Zambia Enrolled Midwife, and Environmental Health technical which predominate at the rural health center level. Again we calculated the proportion of available personnel in comparison to the establishment list. In order to make the district data more easily comparable, we converted the proportions described above into simple numeric scores. Districts with less than 33% of the establishment filled in each group received a score of one point. Districts with 33 to 66% of the establishment filled received a score of 2 points, and districts with more than 66% of the establishment filled received a score of three points. We tallied the scores for the group of DMO senior personnel and a separate group of facility personnel to arrive at separate scores for the availability of personnel from the group that would lead training and capacity building and another score for the availability of personnel in health facilities that will be targeted for capacity building to enhance the quality of health services at primary level. The project suggested that PMOs select districts with the highest scores for human resource availability because this would promote greater impact. 2.2.3 Facilities Under the ZISSP project, many interventions were implemented in all of the provinces’ districts. Under SBH, the project will try to reach agreement with the PMOs that the project’s provincial staff will focus their efforts on the PMO team and the two target districts. This means that the province and district will glean the most direct and spillover benefits if SBH works in districts with larger numbers of facilities and higher patient volume. To facilitate analysis, we used the simple three point ranking system. We divided the number of districts in each province by three. When the number of districts was not evenly divisible by three, we ascribed any remaining districts to the lowest ranked group. For example, a province with 11 districts will have the two groups of three at the top of the scale, and one group of five with the lowest ranking. SBH used the annual plan data to determine the number of health facilities in each district. We then divided these into three groups. The group of districts with the largest number of facilities received a score of three points, the group with the smallest number of facilities received a score of one point, and facilities in the middle received two points. 2.2.4 Comparison of Key HMIS Indicators. The SBH team believes that the project could have more tangible impact if it works in districts with lower performance on the HMIS indicators. We used data from the Annual Plans to look at performance on of full immunization coverage for children 12 to 23 months, deliveries by a skilled provider, and number of people on ART.  Immunizations and deliveries with skilled attendants: We ranked the facilities into three groups for each of these indicators by giving a score of three points to the worst performers on the indicators for immunizations and skilled attendance at delivery, a score of two points to the middle group, and a score of one point to the best performers. In this

Selection of Target Districts instance, the scoring system is different than for the other indicators because lower performance gives a district more points.  ART enrollment: We gave a score of three points to the districts with the highest numbers of patients on ART, a score of two points to the middle group, and a score of one point to the districts with the lowest ART enrollment.  Total performance score. We totaled the scores for immunization, deliveries with skilled attendants, and ART enrollment. We then divided the total score by three to get the score for each district for this selection factor. We would prefer to pick districts with higher scores in this domain. 2.2.5 Stakeholders working in the district. Because SBH has a role to assist the district with partner coordination, we assume that the project can be most useful in districts which have many partners to coordinate. We gleaned data from the annual plan to rank districts into 3 groups. Those with the most partners received a score of three points and those with fewer a score of two points, and those with the least a score of one point. We would prefer to select districts with a larger number of partners. 2.2.6 Total scores As noted above, after scoring each district on the five selection factors, the team added the scores for each district across the five preferred characteristics to arrive at a total score. SBH ranked the total scores from highest to lowest to show the districts which fit the greatest number of preferences. The SBH team discussed this approach with each PMO team, shared the scores and discussed the PMO team preferences.

Selection of Target Districts

3. Central Province selection of target districts

The Central PMO team met the SBH team in Kabwe on District Score January 25, 2016. The team from the Central Province Medical Office included: Dr. Rosemary Mwanza, Provincial Medical Kabwe 16.66 Officer; Dr. Beatrice Kafulubiti Clinical Care Specialist; Eva Wonani, Principal Nursing Officer – Standards; Clemmy Kapiri Mposhi 16.5 Sooka, Principal Nursing Officer – Maternal and Child Health; Mumbwa 14.66 Stabes Mpokota, Senior Health Education Officer; Teddy Wakunuma, Acting Chief Environmental Health Officer; Gloria Chisamba 14.33 Silondwa, Senior Health Information Officer; Stephen Sichamba, TB/HIV Liason Officer, Benedictus Mangala, Planner; Mkushi 13.75 Sydney Nakubaya, Planner; and Webster Chisaka, Senior Human Resources Management Officer. Chibombo 13.33 The team from SBH included Dr. Elijah Sinyinza, Chief of Party Serenje 13.08 (COP), Dr. Victoria Musonda, Director Technical Support, Kathleen Poer, Deputy Chief of Party (DCOP); Dr. Kenny Itezhi-tezhi 10.75 Kapembwa, Senior Manager for Provincial Programs; and Emily Moonze, Senior Manager for Health Systems Strengthening. Chitambo 9.5 The SBH team developed a total score for all the districts in Luano 8.08 Central province to reflect five factors described above. The SBH team discussed this approach with the PMO team, shared Ng’abwe 5.08 the scores and discussed the PMO team preferences. The adjacent table shows the scores for Central Province. The PMO team selected the districts highlighted in color in the table. Work will begin first in the districts highlighted in green. The team cited the following factors as important in their decision:  Kabwe has the large population and the highest number of patients on ART. It receives referrals from the entire province, thus it needs support.  Kapiri Mposhi has a large population, many facilities and is the parent of Ng’abwe district. The province hopes that Ng’abwe district will receive some spill over benefits.  Chisamba has challenges with maternal health indicators and is a referral site for other districts.  Mkushi was preferred to Mumbwa because the province currently has some management challenges in Mumbwa. In addition, the PMO team hopes that there will be some “spill over” benefits for the new district of Luano which was once part of Mkushi and receives help from the parent district. During the two hour meeting the team discussed the following topics related to the district selection. The minutes from the meeting capture additional topics discussed.  The PMO team requested that wherever possible the new districts receive spill over benefits from the program implementation in the target districts.  Some participants disagreed with the idea that the SBH district selection scoring method gave preference to districts with large numbers of partners. SBH explained that this is because of the partner coordination role that has been given to SBH by USAID.

Selection of Target Districts  Some participants expressed concern that the PEPFAR priority districts are already performing better than the remote, rural, and new districts.  Participants expressed the view that the data from Serenje on people enrolled on ART must be an error because Serenje enrollment definitely does not exceed Kabwe enrollment. SBH agreed that there could be an error either in our data entry, or possibly in the copy of the district annual plan which we received. After a quick review, we observed that even if the absolute number of patients on ART is in error, Serenje would still have received a high score on this variable because its ART patient numbers are still in the top third among the province’s districts.  The PMO team received the ranking provided by SBH as a useful guide for discussion. Some participants felt that the deprivation index would have led to different choices which would benefit the new districts with very little partner support. However, the team felt that the method was scientific and had rigor.  The PHO team agreed to accommodate and integrate SBH staff.

Selection of Target Districts

4. Copperbelt Province selection of target districts

The Copperbelt PMO team met the SBH team in Ndola on District Score January 26, 2016. The team from the Copperbelt Province Medical Office included: Dr. Liyapa Sikazwe, Clinical Care Kitwe 16.68 Specialist and Acting PMO; Dr. Kennedy Chibwe Alison, Acting Communicable Disease Control Specialist; and Ndola 14.73 Mumba Tembo, Senior Planner. Chililabombwe 13.38 The team from SBH included Dr. Elijah Sinyinza, Chief of Party (COP), Dr. Kenny Kapembwa, Senior Manager for Mufulira 13.27 Provincial Programs; and Emily Moonze, Senior Manager for Health Systems Strengthening. Chingola 12.18 The SBH team developed a total score for all the districts in Luanshya 12.17 Copperbelt province to reflect five selection factors. The SBH team discussed this approach with the PMO team, Kalulushi 12.16 shared the scores and discussed the PMO team preferences. The adjacent table shows the scores for Copperbelt Lufwanyama 11.1 Province. Mpongwe 9.13 The PMO team selected the districts highlighted in color in the table. Work will begin first in the districts highlighted in Masaiti (data missing) 1.75 green. The team cited the following factors as important in their decision.  Kitwe district is in need of systems strengthening support.  The Mufulira district team needs capacity building for leadership and governance  Chililabombwe district faces a high HIV burden due to cross-border activities.  Chingola district is in need of systems strengthening support. During the two hour meeting the team discussed the following topics related to the district selection. The minutes from the meeting capture additional topics discussed.  The PMO team requested that if possible Luanshya district receive “spill over” support as the program implements Zambia Management and Leadership Academy Training, Quality Improvement, and Clinical Mentoring activities.  The PMO team accepted the district selection guide proposed by SBH; however, the PMO would have liked the project to consider taking a district with a lower score such as Lufwanyama or Luanshya. None of the rural districts receive support from the Millennium Development Goal Initiative (MDGi) program.  The PMO team did not propose Ndola as an SBH target district because it already has many partners including MDGi.  The Copperbelt team indicated that there is space in the PMO’s offices for the SBH CCS and RMNCH Specialist. The districts will be advised to prepare for the Health Systems Specialist. The PHO team requested that SBH procure workstations and equipment for the seconded staff.

Selection of Target Districts  The PMO team requested that the project develop a written agreement about the seconded staff. The two teams agreed to develop operational guidelines which will explain how the SBH and GRZ team will work with each other.

Selection of Target Districts

5. Eastern province selection of target districts

The Eastern PMO team met the SBH team in Kabwe on District Score January 28, 2016. The team from the Eastern Province Medical Office included: Dr. Jairos Mulambya, Clinical Care Specialist; Lundazi 13.66 Luckson Simanwe, Senior Accountant; George K. Mulenga, Senior Human Resources Management Officer; Ovost Chooye, Chadiza 12.25 Senior Health Information Officer; and Samuel Chizalila, Provincial Nursing Officer – Standards. Mambwe 11.83

The team from SBH included Dr. Victoria Musonda, Director Nyimba 11.75 Technical Support, and Kathleen Poer, DCOP. The SBH team developed a total score for all the districts in Petauke 11.5 Eastern province to reflect five factors described above. The Chipata 11.41 SBH team discussed this approach with the PMO team, shared the scores and discussed the PMO team preferences. The Sinda 11.41 adjacent table shows the scores for Eastern Province. Vubwi 8.33 The PMO team selected the districts highlighted in color in the table. Work will begin first in the districts highlighted in green. Katete 5.33 The team cited the following factors as important in their decision:  Petauke is contributing significantly to maternal deaths in the province.  Chipata has the largest population and its high volume will contribute to the province’s overall performance if it achieves improvements.  Nyimba faces challenges in terrain and also with indicators, but was selected also because it is an SMGL district.  Lundazi faces challenges in terrain and also with indicators, but was selected also because it is an SMGL district. During the two hour meeting the team discussed the following topics related to the district selection. The minutes from the meeting capture additional topics discussed.  Some members of the provincial team proposed that Chipata and Lundazi should be supported in the first phase. Other PMO staff felt Petauke should be in the first phase because Petauke had a large share of the province’s maternal deaths in the past year. Later, the team arrived at the consensus that Chipata and Petauke needed to start first because it was high volume and if well supported could have some influence on the others through mentorship.  The CCS said partner coordination was a major challenge at both PHO and DHO levels.

Selection of Target Districts

6. Lusaka Province selection of target districts

The Lusaka PMO team met the SBH team in Lusaka on District Score January 26, 2016. The team from the Lusaka Province Medical Office included: Dr. Malama, Provincial Medical Lusaka 18 Officer; Dr. Chilambo, Clinical Care Specialist; Inutu Mbangweta, Principal Nursing Officer – Standards; Doreen, Chilanga 16.66 Principal Dental Therapist; John Sichande, Accountant; Samson Lungu, Principal Planner; Betty Sikazwe, Senior Kafue 16 Health Education Specialist; Chakeme Mukwangole, Communicable Disease Control Specialist; Suzen Hanene, Chirundu 14.33 MGDi; Christine M. Imasiku, Principal Nursing Officer – Chongwe 13.91 Maternal and Child Health; and Peter Funsani, Treatment Coordinator. Luangwa 13 The team from SBH included Dr. Victoria Musonda, Shibuyunji 9.08 Director Technical Support, Kathleen Poer, DCOP; and Timothy Silweya, Community Health Specialist. The SBH team developed a total score for all the districts in Lusaka province to reflect five factors described above. The SBH team discussed this approach with the PMO team, shared the scores and discussed the PMO team preferences. The adjacent table shows the scores for Lusaka Province. The PMO team selected the districts highlighted in color in the table. Work will begin first in the districts highlighted in green. The team cited the following factors as important in their decision:  Lusaka district has the largest population, serious indicator challenges, and is the referral site for all other districts.  Shibuyungi district is one of two districts not supported through the MDGi program but it is a PEPFAR priority district with serious challenges that should respond well to support.  Luangwa district is a SMGL priority district and needs support for its maternal and child health programs.  Chirundu district faces challenges with HIV and is in need of systems strengthening. During the two hour meeting the team discussed the following topics related to the district selection. The minutes from the meeting capture additional topics discussed.  There was some debate on which two districts to be in the first phase. SBH had a strong preference to include Luangwa district in the first phase in order to assure access to transport for the SMGL coordinator.  The province wanted to start work in Shibuyunji in the first phase. In contrast, the project wanted to select Lusaka for phase one work because of the huge size of the district population and the complexity of its issues. This question was not fully resolved. SBH agreed to go back and look at the issue of transport to determine whether there could be any other solution for the vehicle for the SMGL coordinator.

Selection of Target Districts

7. Southern province selection of target districts

The Southern PMO team met the SBH team in Choma on District Score February 8, 2016. The team from the Southern Province Medical Office included: Boyd Mwangelwa, TB/HIV/ART Kalomo 13 Technical Officer CDC; Dr. Tina Chisenga- Acting Clinical Care Specialist; C.M. Kazila, Acting Principal l Nursing Sinazongwe 11.75 Officer, Maternal and Child Health; Prosperinne Walumba, Principal Nursing Officer, Standards, Chilembo Neroh, Choma 12 Acting Communicable Disease Control Specialist; Esnart M Juunza, proposed SMGL Coordinator for SBH. Kazungula 11.66 The team from SBH included Dr. Victoria Musonda, Moonze 11.08 Director Technical Support, and Kathleen Poer, DCOP. Pemba 10.16 The SBH team developed a total score for all the districts in Southern province to reflect five factors described above. Namwala 10.08 The SBH team discussed this approach with the PMO team, shared the scores and discussed the PMO team preferences. Zimba 9.66 The adjacent table shows the scores for Southern province. Siavonga 9.33 The PMO team selected the districts highlighted in color in the table. Work will begin first in the districts highlighted in Mazabuka 9.33 green. The team cited the following factors as important in their decision: Gwembe 9.08  Moonze district receives difficult maternity cases Chikankata 8.92 and experiences many maternal deaths. Livingstone (data missing) 8.33  Gwembe district is challenged by its remoteness and has poor indicators in several program areas.  Chikankata district was formerly part of Mazabuka. It has nine of the PEPFAR priority facilities which are currently reported as part of Mazabuka district because the PEPFAR database referred to as Data for Accountability, Transparency, and Impact (DATIM) has not yet been updated to link these facilities to their new district. According to the PMO team, Mazabuka is already extremely well supported through other PEFPAR programs.  Livingstone is an SMGL and a PEPFAR priority district but is also the referral center for the province. It will benefit from systems strengthening support. During the two hour meeting the team discussed the following topics related to the district selection. The minutes from the meeting capture additional topics discussed.  The two teams discussed the district scores calculated by the SBH team. The Southern PMO team agreed that the data was a helpful guiding point.  There will be a challenge of office space to accommodate the three staff earmarked for secondment. The container office block mounted by CDC which had been partitioned into four offices, which could be considered as an option for SBH to provide for its seconded staff to PMO.