USAID/ SYSTEMS FOR BETTER HEALTH QUARTERLY PROGRESS REPORT

APRIL – JUNE 2016

July 2016

This publication 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.

SBH Quarterly Progress Report April – June 2016

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

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 SBH Quarterly Progress Report April – June 2016

Table of Contents

Acronyms ...... 1

Executive Summary ...... 3

1. Introduction ...... 4

2. Progress by Task ...... 5 2.1 Task One: Design, implement and monitor national level interventions to strengthen health stewardship by the Ministry of Health ...... 5 2.1.1 Sub-task 1.1: Strengthen Human Resources Planning and Management ...... 5 2.1.2 Sub-task 1.2: Improve health care financing and public financial management ...... 7 2.1.3 Sub-task 1.3: Strengthen MOH capacity to oversee delivery of key health programs ...... 9 2.2 Task Two: Design, implement, and monitor interventions to strengthen program management capabilities of provincial and district teams ...... 12 2.2.1 Sub-Task 2.1: Strengthen program management capacity ...... 12 2.2.2 Sub-Task 2.2: Improve technical capacity of provincial and district health teams to deliver quality health services in facilities ...... 16 2.3 Task Three: Support the Government and Community-Based Organizations to increase the quality, availability, and use of health services...... 18 2.3.1 Sub-Task 3.1: Improve the capacity to deliver quality health services in the community ...... 18 2.3.2 Sub-Task 3.2: Strengthen linkages between the facility and the community ...... 19 2.4 Cross-Cutting Technical Areas ...... 20 2.4.1 Grants under Contract ...... 20 2.4.2 Research, Monitoring and Evaluation ...... 20 2.4.3 Knowledge Management ...... 21 2.4.4 Gender ...... 21

3. Project Management ...... 22 3.1.1 Finance and Administration ...... Error! Bookmark not defined. 3.1.2 Overall Budget and Expenditures ...... Error! Bookmark not defined. 3.1.3 Personnel ...... Error! Bookmark not defined. 3.1.4 Subcontracts ...... Error! Bookmark not defined. 3.1.5 Management Processes and Systems ...... Error! Bookmark not defined.

USAID Systems for Better Health ▌pg. ii SBH Quarterly Progress Report April – June 2016

4. Success Stories ...... Error! Bookmark not defined.

5. Challenges and Solutions ...... 23

6. Progress on Links to Other USAID Programs and Government of Zambia Agencies ...... 24

Annex 1: Performance Indicator Tracking Table ...... Error! Bookmark not defined.

Annex 2: List of Selected Health Facilities ...... Error! Bookmark not defined.

Annex 3: Summary of Training Data ...... Error! Bookmark not defined.

Annex 4: Status of Key Deliverables ...... Error! Bookmark not defined.

Annex 5: Short-term Technical Assistance Plan for Next QuarterError! Bookmark not defined.

USAID Systems for Better Health ▌pg. iii SBH Quarterly Progress Report April – June 2016

Acronyms

AMEP Activity Monitoring and Evaluation Plan ART Antiretroviral Therapy BRITE BroadReach Institute for Training and Education CBO Community-based Organization CHA Community Health Assistant CHAI Clinton Health Access Initiative DHIS2 District Health Information System Version 2 DHO District Health Office DMO District Medical Officer EmONC Emergency Obstetric and Neonatal Care GFP Gender Focal Point HCF Health Care Financing HCFP Health Care Finance and Planning HMIS Health Management Information System HRH Human Resources for Health HRHSP Human Resources for Health Strategic Plan HRIS Human Resources Information System HSS Health Systems Strengthening M&E Monitoring and Evaluation MCH Maternal and Child Health MOH Ministry of Health NCHW National Community Health Worker NFNC National Food and Nutrition Commission NGO Non-governmental Organizations NHA National Health Accounts NIPA National Institute for Public Administration NTOP National Training Operational Plan PA/e-PA Performance Assessment/electronic Performance Assessment

USAID Systems for Better Health ▌pg. 1 SBH Quarterly Progress Report April – June 2016

PEPFAR President’s Emergency Plan for AIDS Relief PMO Provincial Medical Officer PHO Provincial Health Office PMP Performance Management Plan QI Quality Improvement RBF Results-based Financing RMNCH Reproductive, Maternal, Neonatal, and Child Health RMNCAH Reproductive, Maternal, Neonatal, Child and Adolescent Health SBH Systems for Better Health SCM Supply Chain Management SHI Social Health Insurance SMAG Safe Motherhood Action Groups SMGL Saving Mothers Giving Life TWG Technical Working Group ZMLA Zambia Management and Leadership Academy

USAID Systems for Better Health ▌pg. 2 SBH Quarterly Progress Report April – June 2016

Executive Summary

This Quarterly Progress Report for the USAID Systems for Better Health (SBH) activity covers the period of April 1st through June 30th, 2016. The quarter was marked by significant progress in establishing the project’s activities. SBH recruited a total of 33 new staff members during the quarter bringing the total number of SBH personnel to 62, and seconded to the Ministry of Health (MOH), the first of two HMIS Specialists as well as the Health Care Finance and Planning Specialist. During the quarter, SBH technical teams held consultative meetings with MOH personnel and supported strategic activities such as the Provincial and District Integrated Meetings to strengthen program management in the district and review district and facility performance. SBH successfully conducted capacity assessment with senior MOH province, district and hospital leaders. The assessment examined five performance management systems by assessing: a.)the policies, guidelines, tools, b.)the people skills, knowledge and attitudes, c.) the processes and tools, and d.) the implementation structures. The Supply Chain Specialist conducted a targeted capacity assessment in twelve health facilities to develop tools strengthen systems and improve supply chain management in the target facilities. The project led USAID partner coordination meetings at both national and provincial levels to report partner activities and service delivery data, as well as to prepare for the MOH planning launch. SBH received Ethical Review Board approval to conduct the community capacity assessment and planned to execute the field work in July. SBH partner BroadReach Institute for Training and Education, collaborated with the National Institute for Public Administration to revise the Zambia Management Leadership Academy training curriculum and conducted the first training sessions for program officers from Lusaka and Central Provinces. These activities and others detailed in this report, contributed to SBH’s upward trend towards achieving some of the key Year One deliverables. SBH expects a continued increase in activity at the provincial, district, and community levels in the coming months, now that the project personnel are in place, the infrastructure is better established, and the project has built the necessary connections with the central and the sub-national levels of the MOH.

USAID Systems for Better Health ▌pg. 3 SBH Quarterly Progress Report April – June 2016

1. Introduction

The five-year USAID Systems for Better Health (SBH) activity in Zambia was awarded to Abt Associates Inc. in October 2015. Abt is implementing SBH in collaboration with partners American College of Nurse-Midwives (ACNM), Akros Inc., BroadReach Institute for Training and Education (BRITE), Initiatives, Inc., Imperial Health Sciences (IHS) and Save the Children. The goal of SBH is to improve health outcomes for Zambians by strengthening systems that underpin the delivery of high quality health services, and increasing the utilization of high impact health interventions at district and community levels. The expected outcomes of the activity are: 1. More effective national level health stewardship; 2. Improved capacities of provincial and district health teams to perform program management functions; 3. Increased quality and availability of priority health services at the community level in targeted districts; and 4. Increased utilization of key public health interventions. The project has the following specific objectives:

 Retention of patients on antiretroviral therapy (ART) increased to at least 85 percent in targeted districts;

 Couple years of protection increased by 10 percent in targeted districts;

 Proportion of deliveries with assistance from a medically trained provider increased by 20 percent in targeted districts; and

 At least 80 percent of children aged 12 to 23 months fully immunized in targeted districts. This Quarterly Progress Report summarizes the progress and achievements during the project’s second full quarterly reporting period, April to July 2016. The narratives under each sub-task include only activities where significant progress was made during the reporting period. The summary tables for each sub-task include a brief description of the status of all activities.

USAID Systems for Better Health ▌pg. 4 SBH Quarterly Progress Report April – June 2016

2. Progress by Task

2.1 Task One: Design, implement and monitor national level interventions to strengthen health stewardship by the Ministry of Health

During Year One, SBH aims to lay the foundation for evidence-based interventions to strengthen health stewardship at the central Ministry of Health (MOH). Interventions will be based on existing MOH policy documents, systems and processes to support Human Resources for Health (HRH), Health Care Financing (HCF), and health program management by the MOH. SBH has a three-pronged approach for Task One activities: 1. Support the development, review, implementation, and monitoring of key MOH strategies and plans; 2. Strengthen the implementation of existing systems and processes; and 3. Conduct baseline assessments to identify key gaps in service delivery and management capacity that can be addressed through project technical and material assistance. 2.1.1 Sub-task 1.1: Strengthen Human Resources Planning and Management The goal for Year One is to strengthen MOH capacity at central level to plan for and manage HRH by: supporting the development and implementation of key strategic plans; strengthening midwifery education; providing technical assistance to the MOH HRH Technical Working Group (TWG); and supporting HRH information and performance monitoring systems.

Strengthen midwifery education to support implementation of the National Training Operational Plan (NTOP) SBH is working to strengthen pre-service education by working with midwifery schools to procure medical models, strengthen skills labs, and prepare tutors to train students more effectively through demonstrations and simulations. The Systems for Better Health project is supporting three schools which received support under the Zambia Integrated System Strengthening Program by mentoring the tutors to strengthen the skills to conduct demonstration and simulations with student midwives. The project has begun to procure equipment and supplies for the skills labs in the four new Schools of Midwifery at University Teaching Hospital, Kabwe, Mufulira, and Monze. The SBH Senior Technical Advisor from the American College of Nurse Midwives (ACNM) and the Senior Manager of Health Programs visited the three ZISSP-supported midwifery schools in Kitwe, Chikankata and Livingstone to provide technical support to the tutors to integrate the use of skills labs in the midwifery curriculum. Tutors at Kitwe midwifery school continue to be proactive in integrating skills lab demonstrations and simulations into their lessons. The ACNM advisor recommended additional support for Kitwe midwifery school to make it a center of excellence and possibly a national training site. In Livingstone, the simulation lab at the school was under-utilized, not well organized and not readily accessible to students. The advisor held a meeting with the entire faculty to identify solutions to the problems and to develop an action plan with responsibilities and timelines. She recommended another follow-up visit to the school to support and strengthen management and the use of the skills lab. SBH tasked the Reproductive Maternal Neonatal Child and Adolescent Health (RMNCAH) Specialist for Southern Province to make frequent visits to support implementation action plan.

USAID Systems for Better Health ▌pg. 5 SBH Quarterly Progress Report April – June 2016

The ACNM advisor found a severe shortage of midwifery tutors at Chikankata Midwifery School where one tutor teaches midwifery, nursing supported by e-learning, and general nursing. Despite the tutor’s heavy workload, the skills lab was well organized and utilized by students. The advisor recommended that the midwifery tutor and clinical instructor be invited to the training of trainers simulation workshop planned for September 2016. She suggested that SBH could offer further support by procuring reading materials and books for the schools’ libraries. The project will provide this support.

Improve National Community Health Worker (NCHW) Strategy and Community Health Assistance (CHA) Program implementation The SBH Community Health Specialist and the Senior Technical Advisor from ACNM conducted an assessment of the CHA schools in Ndola and Mwachisompola in June to design a package of materials and training for the skills lab and library in the CHA schools. SBH will provide appropriate learning resources and strengthen the skills labs in both CHA schools. The SBH NGO Capacity Building Specialist participated in the review of the CHA curriculum which assessed the gaps between the CHA training curriculum and their actual field work and made recommendations. A 2015 evaluation carried out by the Clinton Health Access Initiative revealed that CHA students found some modules difficult, and the CHAs deployed to health posts reported that they were doing tasks for which they had not been prepared during the one-year training. The curriculum review workshop reminded participants that the main reason for the CHA strategy was to provide preventive, promotive and minor curative services in the community. As a result, CHAs are expected to spend 80% of their time in the community and only 20% at the health post. Both the stakeholders and the curriculum reviewers raised concerns about situations in which the community has expected some CHAs to assist with deliveries because the community is not aware of the limitations of the CHA’s training. The review meeting concluded that the CHA curriculum should remove the component related to deliveries; instead the curriculum will include a safe motherhood component that addresses identification of danger signs during pregnancy. The meeting further recommended that since CHAs are not trained to administer injections or to provide immunizations, they should not deliver injectable family planning methods such as Depo-provera and Noristerat. Table 1. Summary of Year One Benchmarks for Sub-task 1.1 Achievements Expected Year One Benchmarks this Quarter Second Program Specialist to support the Ministry Technical Working SBH identified the Groups to develop, disseminate and foster implementation of guidance HRH Specialist in documents this period and is HRH TWG and subgroups hold all of their planned meetings. Meetings are completing the effective in fostering efficient coordination among sector participants and recruitment process. promote accountability for implementation and monitoring of strategic and The candidate operational plans. requires USAID salary approval. Develop Human Resources for Health Strategic Plan (HRHSP) Support to 2017-2022 HRHSP developed, finalized, and disseminated with MOH leadership. development of HRHSP is clear, realistic, and responsive to Zambia’s most critical HRH Ministry of Health bottlenecks affecting service delivery. Strategic Plan. Develop NTOP No activities this New NTOP reviewed and finalized with MOH leadership. NTOP is clear, quarter realistic, and responsive to Zambia’s most critical health worker training gaps affecting service delivery.

USAID Systems for Better Health ▌pg. 6 SBH Quarterly Progress Report April – June 2016

Strengthen Midwifery education to support implementation of the NTOP SBH is procuring New midwifery tutors and clinical instructors with capacity to use skills equipment and laboratories and simulation centers for instruction. Skills laboratories used training midwifery more effectively to prepare midwives for practice. school tutors in seven schools. Improve NCHW Strategy and CHA Program implementation SBH developing plans MOH HRH TWG has identified the information required to improve the to support CHAs implementation of the NCHW Strategy, and a draft concept paper is developed with skills labs and for research or evaluation needed to address implementation challenges. SBH resource materials. has defined and begun to implement solutions for the identified challenges in all project target districts where CHAs are posted. Assist monitoring of implementation of Human Resources Information No activities this System (HRIS) and Performance Management Plan (PMP) quarter (MOH HRH Directorate carries out two performance review meetings to assess guidance required on progress in the implementation of the HRIS and PMP. Clear steps are defined in HRIS) the process to improving HRIS and PMP implementation.

2.1.2 Sub-task 1.2: Improve health care financing and public financial management In Year One, SBH will promote improved financing for health by supporting the MOH to develop and implement key health financing strategies and initiatives. SBH will also help the MOH to improve systems for financial management, and to produce and use financing data to inform planning and decision making.

Second Program Specialist to support the Ministry Technical Working Groups to develop, disseminate and foster implementation of guidance documents This quarter, the Health Care Finance and Planning (HCFP) Specialist joined the project and reported to the Ministry of Health Directorate for Policy and Planning. Mr. Kansembe is on a leave of absence from the Ministry of Health and recently worked in the Directorate of Technical Services. Prior to joining the Directorate of Technical Services, Mr. Kansembe worked for many years in the Directorate of Policy and Planning and has vast experience and understanding of health systems in the Zambian Ministry of Health.

Build MOH capacity to produce and use data The SBH Senior Manager of Health Systems Strengthening (HSS) worked with the National Health Accounts (NHA) team to draft the NHA report for the period from 2011to 2012. The Senior Manager of HSS and the HCFP Specialist collaborated with the Abt NHA expert and the MOH Policy and Planning Directorate and the University of Zambia (UNZA), Department of Economics to write and review the final report. The MOH and UNZA NHA teams are currently reviewing the report before it is presented to the Health Care Finance Technical Working Group. The report will be a resource document for the next national health strategic plan and the healthcare financing strategy.

Build public financial management capacity The MOH Directorate began to revise the planning handbooks in April in a workshop funded by UNICEF, and a subsequent meeting in May funded by SBH. The SBH Director of Research Monitoring and Evaluation, the Senior Manager of Health Systems Strengthening, and the HCFP Specialist assisted a team from the MOH Policy and Planning Directorate to revise five MOH planning handbooks and develop one new handbook. The five revised planning handbooks provide instructions and templates for: Health Centers and Communities, District Health Offices, Hospitals, Training Institutions, and the Central Ministry.

USAID Systems for Better Health ▌pg. 7 SBH Quarterly Progress Report April – June 2016

The team created a new planning handbook for the Provincial Health Office (PHO) because the Provincial Medical Officers previously developed their plans using the Central MOH handbook and asserted that the MOH templates were not suited to the PHO requirements. The MOH expects to give drafts of the revised handbooks to the provinces, districts, and health facilities during this year’s planning cycle and invite their comments. During the planning handbook review meeting, the MOH planning team proposed a new approach to initiating the annual planning process. Because the Ministry uses a medium term expenditure framework (MTEF), the team recommended that the MOH conduct a full launch once every three years. In the second and third years of the MTEF, the team suggested that the Central MOH use the Policy Meeting as a forum to define health priorities and initiate the planning cycle. The group further suggested that the provincial planning launches need not occur in the second and third years of the MTEF cycle. Instead, the districts would develop their plans following the MTEF priorities and the province would hold only a review meeting with its districts to finalize their plans. Ultimately, the MOH decided that the new handbooks and proposed changes to the planning cycle should be implemented in 2017 to allow further time to build consensus at all levels before making final changes to the processes. In the final month of the quarter, the SBH Senior Manager of Health Systems Strengthening (HSS), the seconded HCFP Specialist, the Senior Manager of Provincial Programs and the Senior Manager of Health Programs provided technical support to the MOH development of technical planning updates for the medium term expenditure framework period of 2017-2019. The SBH team provided input to the design of the template for the technical updates, and contributed to the identification of priority focus areas and performance targets for this MTEF period. The technical updates provide the lower levels of the health system with guidance on priorities and articulate national targets. The updates were disseminated at the national planning launch on June 30th. SBH personnel also provided technical and financial support to the MOH to initiate the development of the National Health Strategic Plan (NHSP) for the period 2017-2021. SBH team members participated in the thematic groups for primary health care and community services, health care financing, leadership & governance, HRH, and maternal, child, neonatal and nutrition. The discussions reviewed information on the current situation, identified core strategies, and proposed indicators for monitoring the implementation plan. In addition, the SBH HCFP Specialist provided overall guidance to the thematic groups on the process and shared the template for presentations from the thematic groups. The next stage will be to engage consultants to edit and consolidate the draft NHSP plan before consultative meetings with key stakeholders at national, provincial, and district levels. SBH is working with the Policy and Planning Directorate to identify the required consultant skills and plans to provide technical support to the Directorate.

Table 2. Summary of Year One Benchmarks for Subtask 1.2 Achievements this Expected Year One Benchmarks Quarter Second Program Specialist to support the Ministry to develop, HCFP Specialist seconded disseminate and foster implementation of guidance documents HCF TWG and subgroups hold all of their planned meetings. Meetings are effective in fostering efficient coordination among sector participants and promote accountability for implementation and monitoring of strategic and operational plans. Finalize the HCF Strategy No activities this quarter HCF strategy revised and finalized based on current data, led by the MOH.

USAID Systems for Better Health ▌pg. 8 SBH Quarterly Progress Report April – June 2016

The strategy includes a two-year action plan with concrete activities, responsibilities, timeframes, and budgets. Finalize HIV and health resource mobilization strategies No activities this quarter A sub-group to the TWG is formed and functioning to focus on the strategy. The sub-group has defined the actions and expertise necessary to complete the strategy, agreed on a timeline, and achieved effective coordination among partners to support strategy design and implementation. Support development of Social Health Insurance No activities this quarter Technical input provided to National Social Protection Bill. MOH staff knowledge and understanding of benefits of social health insurance improved. Build MOH capacity to produce and use data SBH supported data analysis to MOH has a clear, feasible plan for institutionalizing health accounts. Latest produce preliminary findings health account data and analyzed and report finalized with MOH leadership. and draft report for the NHA MOH capacity to carry out health accounts is improved. 2011 - 2012 period. Build public financial management capacity Supported Directorate of MOH and Ministry of Finance have identified changes that could be made in Policy and Planning to develop the near term to improve performance of planning, budgeting, and financial templates for technical management tasks. Training package on public financial management refined. updates. Mentoring module on the public financial management reform initiative in the Zambia Management and Leadership Academy (ZMLA) curriculum improved. Feasibility of delivering this module to PMO and DMO personnel not enrolled in ZMLA determined. Assess potential for project support of Results-Based Financing (RBF) No activities this quarter SBH has consulted with stakeholders on the status of RBF and opportunities for expansion. As appropriate, SBH is providing technical assistance to the Government of Zambia and World Bank on the expansion of RBF.

2.1.3 Sub-task 1.3: Strengthen MOH capacity to oversee delivery of key health programs In Year One, SBH will assist the MOH to strengthen stewardship at the central level. The project will begin with a capacity assessment to guide its capacity building activities. SBH will second technical specialists to the MOH as part of the strategy to strengthen key MOH systems, processes, tools, and training materials.

Strengthen MOH performance monitoring and improvement SBH supported training of MOH central and provincial program officers in the electronic Performance Assessment (e-PA) tool. SBH supported five MOH Clinical Care Specialists and five Planners plus SBH personnel from the four of the project’s five target provinces. The training was organized by the MOH Directorate of Technical Support Services with support from the Clinton Health Access Initiative (CHAI). The SBH Director of Technical Support, the Quality Improvement Specialist, the Senior Manager for Provincial Programs, and Clinical Care Specialist for Southern Province supported the MOH to hold a meeting to review the national mentoring program and guidelines. The main objectives of the meeting were: to review the national mentorship framework and arrive at consensus on a common framework that would be supported by all stakeholders; to build consensus on the format of mentorship tools,

USAID Systems for Better Health ▌pg. 9 SBH Quarterly Progress Report April – June 2016 aggregation tools, and report/dashboard structure for monitoring mentorship activities, and to draft an MOH road map for sustainable scale-up of mentorship. SBH will further support the MOH to complete the review process for the mentorship guidelines and to develop electronic mentorship tools. SBH is designing and beginning implementation of a pilot that will support HIV-positive children and adolescents on Anti-Retroviral Therapy (ART) by monitoring care in the facility and strengthening linkages between the health facility and the community. The pilot will support adherence to treatment HIV-positive children and adolescents and refer children and families to social support services to enhance the quality of life for these children. In this period, SBH finalized the pilot concept and developed a detailed implementation plan for the remainder of 2016. Save the Children is leading the implementation of the pilot and continued to recruit for two positions that will lead program activities. The SBH Senior Manager of Provincial Programs, the Health System Specialist for and the HIV Specialist from Save the Children participated in the MOH retreat to develop an HIV case finding and linkage strategy for children and adolescents. The team worked with the MOH and other partners to draft the maternal and child health and community components of the strategy. SBH contributed to a meeting held to monitor progress under the Accelerating Children’s HIV/AIDS Treatment Initiative. The Senior Manager of Provincial Programs provided an update on the pediatric antiretroviral therapy job aids being developed with CHAI, University Teaching Hospital, and the Zambia Prevention Care and Treatment IIB project.

Strengthen national training materials to support implementation of nutrition policies The SBH Nutrition Specialist contributed to a meeting of the Micronutrients Subcommittee of the Maternal, Adolescent, Infant and Young Children Nutrition (MAIYCN) Technical Working Group. She proposed that the MOH create a database for trainers, health workers, and community volunteers by province and district to help identify training needs at each level. The MOH is developing the database. The Nutrition Specialist met with the UNICEF nutrition team and then with the Scaling-Up Nutrition Fund team leader from CARE International to discuss support to the National Food and Nutrition Commission (NFNC) and the MOH. The organizations will collaborate on training and to review guidelines and training materials for MAIYCN, Growth Monitoring and Promotion and Integrated Management of Acute Malnutrition. In this quarter, SBH engaged with United Nations Children’s Fund (UNICEF) and NFNC to discuss development of the National Food and Nutrition Strategic Plan. The team agreed to begin by reviewing the current strategic plan and developed a schedule. SBH subsequently supported a stakeholder meeting led by the NFNC to plan for the National Food and Nutrition Strategic Plan for 2017-2021. Participants included UNICEF, World Food Program, CARE International and other non-governmental stakeholders, as well as representatives from the Ministries of Health, Gender, Education, and Agriculture. SBH will support a meeting for Permanent Secretaries (PS) of the four ministries as an urgent activity resulting from this meeting. The purpose of the meeting with PS group is to support the Ministries with technical guidance on how to include nutrition activities in their strategic plans. The SBH Nutrition Specialist participated in an NFNC-sponsored stakeholder consultation meeting which shared the findings of the consultant engaged by NFNC who helped to prepare a nutrition chapter for the 7th National Development Plan (NDP). Representatives from eleven stakeholder organizations attended the meeting and resolved that there was need to further refine the consultant’s findings to align them with the thematic areas of the 7th NDP framework. The meeting emphasized the need to develop policy briefs which can be used to engage the Permanent Secretaries and the Directors from various sectors to get these sectors to include nutrition related elements as they prepare sector- specific chapters for the NDP document.

USAID Systems for Better Health ▌pg. 10 SBH Quarterly Progress Report April – June 2016

Strengthen District Health Information System (DHIS) 2 and Health Management Information System (HMIS) at the national level The SBH partner Akros seconded one HMIS Specialist to the MOH M&E Unit this quarter. The specialist will support development of user-friendly reports from HMIS and help the M&E unit to strengthen information use. During the quarter, SBH met with the MOH Monitoring & Evaluation Team and representatives from Clinical Care, Maternal and Child Health, and Quality Improvement to present an overview of the project and explain how SBH proposes to support the MOH to strengthen data use. The MOH requested additional support for the development of: a Monitoring & Evaluation Strategic Plan; a policy on access to basic health information; scorecard reports; and hospital information systems using the District Health Information System 2 (DHIS2) platform. The MOH also wants to integrate nutrition data in the HMIS. SBH will align its work plan to incorporate some of the proposed MOH M&E priorities. SBH set dates in July, for two pivotal events requested by the MOH M&E Team: technical support to archive or delete unused or irrelevant data elements from the DHIS2 database; and a workshop to draft a policy for DHIS2 user rights and access. The M&E team sees these activities as a precondition for giving provincial and district program personnel access to the Health Management Information System on the DHIS2 platform. The SBH Community Health Specialist, M&E Analyst, and Akros Program Officer attended the Integrated Management of Childhood Illness Technical Working Group meeting at UCI secretariat in June. During the meeting the Chief Child Health Specialist briefed the group on the community DHIS2 orientation held in Kabwe, in May. Other issues discussed included the integrated community case management (iCCM) scale up plan, partner mapping, Essential New Born Care, and the revised ICCM TB/HIV package. These meeting updates will guide SBH to identify strategies that the MOH can adopt to operationalize DHIS2 at community level and strengthen technical working groups. Table 3. Summary of Year One Benchmarks for Sub-task 1.3 Achievements this Expected Year One Benchmarks Quarter Second Program Specialists to support the Ministry to develop, One of two HMIS Specialists disseminate and foster implementation of guidance documents seconded full-time to MOH M&E Specialists seconded, trained, and providing regular technical assistance Unit as of June 2016 to MOH programs. TWGs develop and execute effective meetings, work plans and technical products, and plan and implement international health days. Guidance documents identified, printed and disseminated. Design and conduct assessments of central MOH capacity No activity this quarter Assessment tool developed in close collaboration with MOH. Two assessments carried out, including description of areas that need improvement and recommendations for SBH support to improve. MOH’s Performance Assessment e-tool successfully piloted and revised.

USAID Systems for Better Health ▌pg. 11 SBH Quarterly Progress Report April – June 2016

Strengthen MOH performance monitoring and improvement Activities reported under Task At least two performance review meetings carried out. Meetings 2.1 will enable the project to include analysis of key indicators and produce clear recommendations contribute to better performance for improvement and stakeholder collaboration. QI TWG carrying out monitoring and improvement at regular meetings and provincial visits. Tools, protocols, and curricula national level. for specific health programs improved. Electronic tool for clinical tutoring developed and piloted. Strengthen national training materials to support implementation SBH contributed to review and of nutrition policies revision of the nutrition chapter th Three working meetings between the NFNC and the Ministry of of the 7 NDP. Agriculture convened where training materials, strategy and action plans are developed. Strengthen DHIS2 and HMIS at the national level SBH seconded the first of two HMIS specialists seconded to MOH and providing continuous technical HMIS Specialists to the MOH and assistance. Feasibility of electronic data submittal from health facilities introduced the project support to assessed. Mobile data capture forms and data dashboards for the M&E team. Performance Assessment results on the DHIS2 platform developed.

2.2 Task Two: Design, implement, and monitor interventions to strengthen program management capabilities of provincial and district teams

Task Two targets provincial and district level capacity to manage health programs and deliver quality health services. Activities under this task will benefit from the improvements achieved under Task One at the national level. The SBH approach to strengthen provincial and district capacities is similar to the approach at the national level in that it will be guided by participatory assessments and will focus on strengthening existing systems and processes. 2.2.1 Sub-Task 2.1: Strengthen program management capacity This sub-task will improve key MOH management capacities at the provincial and district levels that support effective delivery of quality health services. These include: designing, implementing, and monitoring health programs; annual planning; HRH management; use of data; performance monitoring; Quality Improvement; and supply chain management.

Second program specialists By the second quarter, SBH had identified candidates for all seconded positions at province level except two Eastern Province positions for the Clinical Care Specialist (CCS) and RMNCAH Specialist. The project also identified candidates for the seconded district positions except the Health Systems Specialist for Petauke. Although the project had sufficient recruits to fill the Central, Copperbelt, Lusaka, and Southern province and district teams by the end of the quarter, the Copperbelt CCS, the Livingstone SMGL Coordinator, and the Monze HSS were due to report after the end of the quarter. The drivers and vehicles will reach several province and district offices in the third quarter.

Design and conduct assessments of provincial and district MOH capacity This quarter, the SBH Research, Monitoring, and Evaluation team and the Capacity Building and Gender Leader led two capacity assessment workshops for 140 senior MOH Officers from four target provinces, nine districts, four central hospitals and three provincial hospitals to examine the implementation capacities of five performance management systems. The performance management

USAID Systems for Better Health ▌pg. 12 SBH Quarterly Progress Report April – June 2016 systems included: Planning, Performance Assessment, Performance Review Meetings (Provincial and District Integrated Meetings), Quality Improvement, and HMIS. SBH chose to assess these performance management systems because they will be a focus of project support. The workshop was designed to collect information from the PMO/DMOs as implementers of the five performance management systems and their capacity to effectively implement these systems. The workshop participants systematically examined five systems to assess: a.) the existing MOH policies, guidelines b.) the people skills, knowledge, and attitudes c.) the processes, and tools d.) and the implementation structures. The participants included 4 of 5 Provincial Medical Officers, 9 District Medical Officers and 7 Hospital Medical Superintendents. The qualitative data from this assessment is being transcribed and analyzed in order to develop a report. The report will be used to guide SBH’s capacity strengthening interventions for the province, district, and facility levels for systems and people.

Strengthen MOH performance monitoring and improvement Performance Review Meetings and HMIS data use In order to strengthen capacity for program performance management, SBH supported Performance Review Meetings (District Integrated Meetings) for Shibuyunji, Mkushi, Kabwe, Kitwe and Mufulira districts and the Copperbelt Provincial Integrated Meeting. During the meetings the teams focused on reviewing performance indicators against national MOH targets and adherence to national standards using data from the health management information system (HMIS) and findings from the Performance Assessment. In addition, the province and districts used the performance review of priority indicators meetings to identify health service and systems gaps to prepare for their annual planning cycle. For Kabwe, Kitwe and Mufulira, SBH partner Akros oriented DHO and facility staff on data analysis during the meetings. The SBH HMIS Specialist and Program Managers from Akros participated in two District Integrated Meetings (DIMs) in Shibuyunji and Mkushi and one Provincial Integrated Meeting in Kitwe. The team identified strengths and gaps in the current meeting agenda, presentation templates, and the knowledge and skills of facility, district, and province personnel in relation to DHIS2 and data use. The team used this information to design a DIM agenda, presentation templates, and data analysis practical training workshop. The team piloted the data analysis workshop with 3 districts during their DIM meetings at the end of June. The workshops engaged 110 participants. SBH will refine and repeat the data analysis workshop in the remaining provinces and districts during the second round of 2016 Performance Review Meetings. This activity also contributes to strengthening HMIS at sub-national level. In Shibuyunji district SBH is supporting all the 9 facilities, and the proportion of institutional deliveries in the first quarter of 2016 was 48%, which is well below the national target of 60%. Among the health centers the proportions ranged from 11% at Mwembezhi Rural Health Centre (catchment population of 12,411) to 73% at Nampundwe Health Centre (catchment population of 14,371). Participants noted that first antenatal attendance at 14 weeks declined from 9% in 2015 to 3% in the first quarter of 2016. This also contributed to low coverage of three doses of Intermittent Preventive Treatment for malaria in pregnancy in the district. Participants attributed both the low institutional deliveries and first antenatal attendance at 14 weeks to weak community engagement and inadequate outreach activities by health centers. At Mwembezhi RHC, HIV testing at the first antenatal attendance was 67%, which is far below the national target of 90%. In addition, clients tested at MCH clinic were not entered in the HTC Register. SBH will support Shibuyunji to strengthen health systems that will address the current low level performance in these indicators including community-health facility linkages, quality improvement and mentorship activities in Shibuyunji District. The HSS for collaborated with his DHO counterparts to organize and hold the District Performance Review Meeting. During the meeting, participants identified challenges with inactive district and facility QI committees, poor data management, weak community partnership, PA and TSS not

USAID Systems for Better Health ▌pg. 13 SBH Quarterly Progress Report April – June 2016 prioritized at facility level and delay in starting the planning process at facility level. The meeting noted from the data that the district was having an upward trend in maternal deaths. In 2014 and 2015, the district had 12 and 25 maternal deaths respectively while for the first quarter of 2016 facilities have already reported 16 maternal deaths. SBH is supporting the district to analyze the problem and implement solutions. The SBH RMNCAH specialist worked with her PHO counterparts to organize and conduct the Provincial Performance Review (Provincial Integrated Meeting) for the final quarter of 2015 and first quarter of 2016. SBH and other partners funded the meeting. Some of the key issues discussed were that Kitwe and Mufulira the two SBH target districts were among the districts with lower performance on first antenatal attendance coverage, institutional deliveries, immunization coverage, and family planning utilization. The meeting noted that in the last quarter of 2015, Kitwe Central Hospital reported 57 maternal deaths while Ndola Central Hospital reported 27 deaths. The meeting resolved to pair Kitwe and Ndola Central Hospital in order for the former to learn good practices from the latter. The most common causes of maternal deaths at Kitwe Central Hospital were: postpartum hemorrhage (13), eclampsia (13), severe sepsis (11), and antepartum hemorrhage (6). Ndola Central hospital reported 4 deaths due to postpartum hemorrhage, 1 death due to eclampsia, and 6 deaths due to antepartum hemorrhage. The meeting agreed to intensify EmONC mentorship at Kitwe Central Hospital. The SBH team will work in collaboration with PHO counterparts and other partners to strengthen MDSR committees and meetings through the use of quality improvement approaches including mentorship. Strengthening Management & Leadership Capacity SBH partner BroadReach Institute for Training and Education worked with the National Institute for Public Administration trainers and the MOH to revise the Zambia Management Leadership Academy (ZMLA) training curriculum. The team strengthened the financial management module by including an overview of budgeting processes, forecasting, and the functions of the budget committee. The team also realigned the flow of information in all the other modules in the curriculum. SBH conducted the first of four training sessions for program officers from Lusaka and Central Provinces. The training included 72 participants split into two cohorts. Participants are developing their group and individual quality improvement projects with a special focus on the SBH indicators. The two cohorts will graduate in September 2017. Strengthening Supply Chain Management To support Supply Chain Management (SCM), the SBH SCM Specialist and the Provincial Pharmacists assessed the provincial and district quality improvement and clinical care teams, and noted that pharmacy and laboratory personnel are already part of these committees at both levels. However, many of these committees have become inactive because of funding challenges and need to be revitalized. The SCM Specialist also provided technical input to the 2016 MOH National Contraceptive Quarterly Forecasting and Quantification Review Meeting. Partner Coordination SBH supported the Lusaka Provincial Health Office Partner Coordinating Group to hold a provincial partners’ meeting to improve partner coordination. The meeting was the first of its kind and had 73 partners in attendance. The aim of the meeting was to coordinate and report partner activities and service delivery data. The province shared draft terms of reference with participants and invited comments. The PHO intends to hold similar meetings quarterly. Performance Assessment and Technical Support Supervision During the Performance Assessment (PA) at Mansa General Hospital in , the SBH Saving Mothers Giving Life (SMGL) coordinator and her MOH counterparts found that only 59 percent

USAID Systems for Better Health ▌pg. 14 SBH Quarterly Progress Report April – June 2016 of women in labor were monitored using partographs. This was attributed to inadequate supervision and high patient volume. The SMGL coordinator and the Provincial Medical Office (PMO) team will mentor hospital personnel on the use of the partograph. The PA also noted that Kasenengwa zonal and Kwenje rural health centers were among the SBH supported sites where key registers were not corresponding with the HMIS report and the latter HC had a critical shortage of midwives and other personnel. The action plan at Kwenje had also not been revised in a long time while Chiparamba RHC did not even have an action plan and two of its NHCs were inactive. The TSS team guided health center personnel through data entry and HMIS reports and advised to use registers and not tally sheets as data sources. The TSS team showed the two health facilities how to review action plans. To revitalize inactive NHCs, the TSS team guided health center personnel to frequently visit communities and NHCs. A total of 15 health center staff and 27 support personnel (lay counselors) received mentoring support in the nine SBH supported health centers during the visit. In Chipata, the SBH HSS worked with his DHO counterparts to provide technical support to health facilities. The team supported the facilities to address performance gaps identified during the third and fourth quarter 2015 Performance Assessment (PA). The district teams visited 30 health centers which included 9 SBH target facilities. SBH supported facilities Chipangali, Kasenengwa and Chikando were among the health facilities identified with lower institutional deliveries and antenatal coverage of below 60% during PA. The TSS teams advised facility staff to hold monthly NHC meetings and health center data review meetings. SBH will support NHC meetings, HCAC meetings and facility mentorship. Table 4. Summary of Year One Benchmarks for Sub-task 2.1 Achievements this Expected Year One (2016) Benchmarks Quarter Second program specialists SBH identified Clinical Care All seconded staff established and providing continuous technical Specialists for Copperbelt and assistance to their counterparts. Eastern Province. Design and conduct assessments of provincial and district Conducted the first capacity MOH capacity assessment workshop with four provinces with the Two assessments carried out in each target province and district, and exception of Southern action plans developed for improvement, including areas where SBH Province. can contribute with support. Strengthen MOH performance monitoring and improvement Recruited and conducted first Two provincial-level performance review meetings and two district- ZMLA courses for 72 level meetings carried out; 128 health managers trained in leadership participants and management in collaboration with ZMLA; e-tool for Performance Assessment implemented; Performance Assessment system and HRIS Supported 5 DHOs and 1 scaled up; QI structures established or refreshed; supply chain system PHO to hold their in target districts assessed, and SBH and MOH counterparts Performance Review Meetings. collaborating to address identified issues. Strengthen DHIS2 and HMIS at sub-national level Developed template for the All users in PMOs and DMOs trained in DHIS2 and HMIS. SBH District Integrated Meeting collaborating with DMO to provide routine HMIS supervision visits to which includes HMIS data from facilities and supporting quarterly data quality assessments. Capacity of DHIS2. Designed data use PMOs and DMOs to generate and use quality data improved. training for the District Health Office. (reported under Performance Review Meetings)

USAID Systems for Better Health ▌pg. 15 SBH Quarterly Progress Report April – June 2016

2.2.2 Sub-Task 2.2: Improve technical capacity of provincial and district health teams to deliver quality health services in facilities During the period under review, SBH continued to apply a number of strategies to improve the technical capacity of provincial and district teams to deliver quality health services, including: provision of technical assistance and training, strengthening MOH structures and skills for performance monitoring and improvement, and strengthening supply chain systems.

Second program specialists By the end of the quarter, SBH had recruited SMGL Coordinators for all provinces except Eastern and for all districts except Lundazi and Luangwa. The district coordinator for Livingstone was due to join after the end of the quarter.

Improve the MOH structures, systems, tools, and skills for performance monitoring and performance improvement Maternal and Newborn Health Overall, SBH is supporting Saving Mothers Giving Life activities in 14 target districts in five provinces. The SMGL Coordinator for Luapula Province collaborated with PMO counterparts in SMGL districts to prepare for the Provincial Maternal Death Surveillance and Response (MDSR) Review Meeting in June. The team agreed on concrete next steps to strengthen prevention of maternal deaths based on the MDSR. Based on the final 2015 Performance Assessment findings, the SBH Luapula Province SMGL Coordinator and Principal Nursing Officer for maternal and child health visited Chembe district to mentor personnel on Emergency Obstetric and Neonatal Care (EmONC). The team visited four health centers and mentored seven health workers and two CHAs in essential newborn care and the use of partographs. SBH will continue to support EmONC mentoring in four SMGL districts in Luapula Province. In , the SMGL Coordinator supported the District Health Office to revitalize the District MDSR Technical Committee, and worked with the Safe Motherhood 360+ project to assess 21 health facilities to establish a baseline on EmONC services. The SBH Clinical Care Specialists and Reproductive, Maternal, Neonatal, and Child Health Specialist for Central Province participated in the Provincial MDSR Meeting held in Kabwe. Participants reviewed 86 maternal deaths that occurred in 2015. Participants learned that most health facilities and districts were not reviewing the maternal deaths. This review also found that 80 percent of the maternal deaths occurred at health facilities and the rest were community deaths. Thirty-seven percent of the deaths occurred in SBH-supported districts. In Kabwe district, the 16 reported deaths occurred at Kabwe General Hospital. Most of the deaths in the province were attributed to obstetric hemorrhage while others were a result of abortions, hypertensive disorders, and puerperal sepsis. The maternal deaths increased by over 25% in 2015 compared to 2014. The meeting also reviewed perinatal deaths and still births. In 2015, Central Province had 336 perinatal deaths and still births. Child Health Systems for Better Health provided technical and financial support to DHO teams to implement Child Health Week activities in Kabwe, Mkushi, Kitwe, Mufulira, Monze, Livingstone and Chipata districts. The SBH CCSs, RMNCHSs, HSSs and SMGL coordinators worked with their MOH counterparts to hold child health week preparatory meetings. During the meetings the teams reviewed the previous child health week performance, shared best practices, addressed the challenges and planned for the implementation of the first 2016 Child Health Week. In addition to the preparatory meetings, the SBH

USAID Systems for Better Health ▌pg. 16 SBH Quarterly Progress Report April – June 2016 teams also supported DHOs to distribute the commodities, mobilize communities and to monitor activities during the week. Through the Child Health Week activities, children between 6-59 months old receive Vitamin A supplements and those aged 12-59 months are dewormed. The activity is an opportunity to provide other services such as growth monitoring and promotion, family planning, immunizations for those who have missed opportunities, tetanus toxoid, nutrition assessment and counseling for HIV and services for Prevention of Mother to Child Transmission (PMTCT). In Eastern province, SBH provided support for two national, one provincial, and one district personnel to monitor the Child Health Week activities. The team visited three districts – Chipata, Katete and Petauke; 6 facilities – Mnoro, Mshawa, Madziatuba, Mbinga, Katete Boma and Nyampande – and 2 outreach posts. At these sites, national level personnel conducted supervisor interviews, activity observations, and caregiver exit interviews The teams in Chipata and Mkushi observed disparities between health center catchment populations and head counts which resulted in most health centers recording coverage of over 100%. The disparities were attributed to the influx of people in some catchment areas. SBH provided technical and financial support to train 25 people from Nyimba, Chipata, and Lundazi districts of Eastern Province as trainers for Maternal Adolescent Infant and Young Child Feeding (MAIYCN). All participants successfully demonstrated their capacity as trainers. In a separate activity, the SBH Nutritionist supported two training events organized by the Eastern province Nutrition Officer to certify 39 health workers as trainers for MAIYCN in Eastern Province. Participants came from health facilities in Chipata, Katete, Lundazi, Petauke and Nyimba districts. Four master trainers – two from Lusaka and two from Eastern province – supported the training. Eastern province and its districts will use these new trainers to conduct MAIYCN training using funding from their Sida grant. Quality Improvement SBH supported the provincial health office in Southern Province to train 23 health workers from Monze and Livingstone in Quality Improvement (QI). Four SBH staff (CCS for Southern Province, HSS for Livingstone, RMNCAHs for Lusaka and Central Provinces) also participated. The main objective of the training was to equip participants with the knowledge and skills to enable them to identify health service delivery and systems gaps and apply QI principles to improve the quality of service delivery at their respective health facilities. The participants will form or revitalize the QI committees in their institutions and ensure that the institution includes QI activities in their 2017 action plans. SBH will work with MOH and other partners to support facility based coaching to ensure implementation and promote sustainability of QI. As a follow-up to the Quality Improvement training, the Health Systems Specialist for Livingstone worked with the District Planner to organize and revitalize the inactive District Health Office Quality Improvement Committee. The district plans to start by revitalizing the district QI committee and then the district QI committee will support the facilities to begin activities. The new district committee recommended that the QI training supported by SBH and the Quality Improvement for Data Use (QIDU) training supported by the Centers for Disease Control (CDC) should be harmonized since the district should have only one QI Committee. SBH will coordinate with USAID to propose that the QI and QIDU trainings be harmonized.

USAID Systems for Better Health ▌pg. 17 SBH Quarterly Progress Report April – June 2016

Table 5. Summary of Year One Benchmarks for Sub-task 2.2 Achievements this Expected Year One (2016) Benchmarks Quarter Second program specialists Seconded specialists are The SMGL Coordinators for all provinces and districts with the assisting provinces and districts exception of Eastern Province and Lundazi, and Luangwa districts. to strengthen clinical programs and performance. Use the results of the province and district capacity Capacity assessment data assessment to develop a data-driven capacity building plan gathered and being analyzed. Capacity development plan for clinical skills developed, and SBH, PMO and DMO teams collaborating to implement it. Improve the MOH structures, systems, tools, and skills for 56 health workers trained in performance monitoring and performance improvement QI. One district has revitalized its QI committee. QI committees and Clinical Mentoring teams revitalized; QI projects implemented in target districts and health facilities; PMO and DMO clinical trainers trained as mentors; EmONC and LAFP methods training sites equipped; health care providers trained on LAFP methods; health workers in select hospitals trained on maternal, adolescent, infant, and young child nutrition; and PMO and DMO reporting on implementation of NFNC Strategic Plan during provincial quarterly review meetings.

2.3 Task Three: Support the Government and Community-Based Organizations to increase the quality, availability, and use of health services

Task Three targets the ultimate levels where health services are sought and provided: in facilities and communities. It addresses both supply and demand for health services, including the critical link between communities and health facilities. SBH will focus on making community-level activities more resource efficient by targeting to address gaps where they exist in specific areas instead of providing a uniform "package" of community-level interventions. 2.3.1 Sub-Task 3.1: Improve the capacity to deliver quality health services in the community SBH will improve community participation in health and to help scale up health services in response to community needs. The project will also support community-level activities through social and behavior change communication to increase demand, enhance the availability of health services, and improve referral systems.

Design and conduct assessment of community capacity to provide quality health services During this quarter, the SBH Monitoring and Evaluation and technical teams collaborated to develop the Community Capacity Assessment protocol and tools. Following Zambia Ethics Review Board approval, SBH piloted the Community Capacity Assessment tool in Shibuyunji and Lusaka (urban) districts. The project will collect data for analysis in July in Eastern, Southern and Copperbelt provinces.

USAID Systems for Better Health ▌pg. 18 SBH Quarterly Progress Report April – June 2016

Community HMIS This quarter, the project supported an MOH–led consensus building workshop on the development of Community HMIS in June. The MOH M&E Unit will use CHAs as the main source of community level data. The CHAs will report on key indicators to be determined by the MOH and partners. The meeting participants proposed the data elements to include in the community level aggregation tool (HIA4.) SBH assisted the MOH to strengthen management and access of facility and community level data through SBH subcontractor Akros. The SBH Surveillance Manager conducted an assessment of health facilities and community level data access and use by interviewing health facility personnel in Central and Southern Provinces. This was carried out at the time when the provinces were in the process of entering data directly into DHIS2. The assessment identified the best practices and documented lessons learned from these sites. This information will be guide development of criteria for selection of a pilot district to initiate facility-level HMIS data reporting later in the year.

Table 6. Summary of Year One Benchmarks for Sub-task 3.1 Achievements this Expected Year One (2016) Benchmarks Quarter (Y1Q1) 2016 Second health system specialists to support the districts and health SBH has recruited and facilities to engage the communities placed Health Systems Technical specialists seconded and providing continuous technical Specialists in 8 of the 10 assistance to improve community-level activities. initial target districts. The project placed five of the eight planned SMGL coordinators. Design and conduct assessment of community capacity to provide SBH finalized the tools and quality health services methods for the Community Community health plans developed in ten communities. Assessment Capacity Assessment and designed and conducted, and results used to develop project assistance received Ethics Review plan for strengthening community delivery of health services. Board approval. Strengthen and integrate approaches to informing and engaging No activities this quarter communities to seek services Feasibility of approach assessed. If feasible, specific approach designed and volunteers trained. If not feasible, then alternative strategy identified. Improve supervision of Community Health Assistants SBH is communicating with Strategies designed in collaboration with other implementing partners CHAI to agree on areas of and MOH to solve the supervision challenges. Supervisors identified in collaboration to strengthen health facilities and trained. Advisory Committee meetings convened supervision. monthly where supervision is provided to Community Health Assistants. Test feasibility of community HMIS Participated in a workshop Community register developed in collaboration with stakeholders and with stakeholders and introduced on a pilot basis. Health facility staff using data from reached consensus on community registers in quarterly meetings with technical support from indicators to include in SBH. DMOs conducting Data Quality Audits. community aggregation forms.

2.3.2 Sub-Task 3.2: Strengthen linkages between the facility and the community SBH will strengthen facility-community linkages by supporting health facilities in the engagement of communities in health planning and QI processes. The project will also pilot interventions for supporting children and adolescents in HIV treatment. SBH will support the MOH to improve linkages between

USAID Systems for Better Health ▌pg. 19 SBH Quarterly Progress Report April – June 2016

CHAs, community health volunteers and health facility staff, and pilot a community-level information system to better monitor community-level activities.

Table 7. Summary of Year One Benchmarks for Sub-task 3.2 Achievements this Expected Year One (2016) Benchmarks Quarter Support health facilities in strengthening community capacity to No activities this quarter participate in health planning Health facility personnel and HCAC members from 150 facilities trained on health planning. Health plans developed and monitored during HCAC quarterly review meetings. Support QI projects No activities this quarter QI committees formed in target districts. Each committee implements at least one QI project that is monitored monthly for the first six months and thereafter quarterly. Test methods for supporting children and adolescents in HIV No activities this quarter treatment Pilot program designed, implemented, and assessed. Pilot design revised based on assessment and first set of community volunteers selected to begin training in Year Two.

2.4 Cross-Cutting Technical Areas

2.4.1 Grants under Contract During this quarter, the NGO Capacity Building Specialist prepared to orient Grants Support Teams (GST) in ten districts. Once trained, the GSTs will assist SBH to identify, select, manage and monitor non-governmental organization grantees. The first orientation will occur in in the second week of July. The Health System Specialists will participate in the Mkushi training and will then roll-out the training in their respective districts.

Table 8. Summary of Year One Benchmarks for Grants under Contract Expected Year One Benchmarks Achievements this Quarter (Y1Q1) Grants program design completed and Provincial SBH developed a Grants Support Team Grant Support Teams formed to evaluate orientation package proposals and make recommendations. Capacity building materials adapted to suit the grant program areas. Recommendations for grant awards made to USAID.

2.4.2 Research, Monitoring and Evaluation The SBH approach to performance RM&E is designed to be cost-effective, accurate, reliable, and timely. The SBH RM&E team will lead performance management and evaluation of project activities, routine performance reporting, and research and evaluation to measure the effects of SBH work and generate evidence within priority technical areas. The RM&E team works closely with the SBH Senior

USAID Systems for Better Health ▌pg. 20 SBH Quarterly Progress Report April – June 2016

Management Team and program staff to ensure that the SBH Activity Monitoring and Evaluation Plan (AMEP) guides project implementation, and that the program uses evidence to make decisions and modify approaches. During the quarter, SBH developed data collection tools for the indicators in the AMEP that was submitted to USAID in the previous quarter. The SBH AMEP includes outcome and output indicators for each interim result (by program task) associated with systems strengthening, service quality and utilization improvements. The AMEP is used as a management tool to serve both internal and external audiences over the life of the project. In addition, the project team uses the SBH AMEP to make mid- course corrections and adjustments as needed, provide lessons learned, and share new evidence with both internal and external stakeholders. During the quarter, some indicators have been deleted, replaced or revised. The SBH M&E team submitted the indicator matrix and Project Indicator Reference Sheets to enable USAID to establish the project’s DevResults reporting templates. The M&E team submitted the project’s 2016 semi-annual achievements and narrative reports for two indicators through the Data for Accountability, Transparency and Impact system. 2.4.3 Knowledge Management In the period under review, SBH completed the recruitment of the Knowledge Management Specialist, who collaborated with the technical teams to compile monthly and quarterly reports. 2.4.4 Gender During the quarter, SBH shared the gender integration strategy with the MOH Gender Focal Point Persons (GFPs) in the Directorate of Policy and Planning, to get their input. The MOH GFPs expressed interest in presenting to SBH the ministry’s progress on gender, in order to agree on areas of collaboration. However, MOH has requested more time to develop its presentation. The SBH gender integration strategy has been shared with all newly recruited SBH personnel during their orientation to ensure that gender is properly integrated into policy implementation at all levels. At community level, the SBH Community Capacity Assessment will help to identify gender barriers to healthy behaviors. The goal of SBH’s gender integration strategy is to contribute to reducing the gender-related barriers to the uptake of health services in Zambia. SBH will use project management strategies to ensure that the project introduces, implements, and monitors gender integration efforts. At the central MOH level, the SBH strategy focuses on collaborating with and building the capacity of the Gender Focal Point (GFP) and of other key stakeholders with the goal of integrating gender issues into the highest levels of policy-making, in health care financing, human resources, or clinical policies. At the provincial, district, and facility levels, SBH is extending this strategy to work with local-level GFPs – and in cases where they do not exist, helping establish one – to ensure that gender is integrated in implementation at all levels. SBH will also build capacity at the local levels to collect, analyze, and report gender- and age-disaggregated data to enable monitoring of gender integration efforts and provide evidence for effective gender-sensitive policy development. Finally, at the community level, gender will be a central element of SBH’s efforts. To improve equitable community participation in health, SBH has placed a strong focus on women and youth empowerment. SBH will leverage all social and behavior change communication activities to help challenge harmful gender norms in communities.

USAID Systems for Better Health ▌pg. 21 SBH Quarterly Progress Report April – June 2016

3. Project Management

The major focus of activities in this quarter was to strengthen office services, recruit personnel, and develop deliverables. The key accomplishments are presented below. 3.1.1 Finance and Administration During the quarter, the Finance and Administration team:  Opened a second bank account with Barclays Bank Plc for managing funds transfers for field activity implementation to ensure risk of loss is minimized,

 Obtained approval for a prefabricated office for the field staff in Southern Province PHO,

 Conducted an orientation for new employees to Abt financial policies and procedures,

 SBH received computer equipment and began configuration and distribution to all project staff,

 Procured furniture and equipment and distributed to field offices. 3.1.2 Overall Budget and Expenditures As of June 30th, 2016, SBH spent a cumulative total of $3,066,624 against obligations of $22,221,810.52. Cumulatively, SBH spent 5.7% of the total project estimated amount of $53,925,452. 3.1.3 Personnel  In the previous quarter SBH had 30 employees. During the reporting quarter, the project added 33 more employees and dismissed one staff member, the Procurement Specialist, for misconduct. As of June 30th, SBH has a total of 62 staff members including five senior managers, 31 program personnel and 26 finance and administrative personnel. One candidate, SMGL for who was scheduled to report in June has not reported. In addition, the project is currently completing the hiring process for the following positions:

 Two candidates accepted offers to start work in July 2016. These are the Clinical Care Specialist for Copperbelt Province and a driver for .

 Eight candidates, all drivers, accepted offers to start work in August 2016 when new vehicles will be received.

 Two candidates accepted offers to start work in July 2016, namely Clinical Care Specialist Copperbelt and Driver for Monze district.

 SBH conducted interviews for several positions and is completing the recruitment process for the following positions: Clinical Care Specialist and RMNCH for Eastern Province; Human Resources for Health (HRH), SMGL Coordinators for Chipata and Livingstone districts; and the Maternal Newborn and Child Health Specialist.

 SBH is still searching for candidates for four positions: Health Systems Specialist for Petauke, SMGL Coordinator for Luangwa, 2 Drivers for Petauke and Lusaka districts, respectively. These positions will be identified by reviewing the CVs on the Abt International Jobs website.

USAID Systems for Better Health ▌pg. 22 SBH Quarterly Progress Report April – June 2016

4. Challenges and Solutions

Challenges Solutions

Recruitment for a few selected positions in The project engaged a recruitment agency for one Eastern Province has been difficult position and is using professional networks for others

Requests from the central MOH for SBH negotiated with the Ministry based on planned support with several activities has aligned resources and activities to arrive at a funding relatively well with the SBH workplan, but compromise for several activities. the level of resources requested has been very high in comparison to the project’s planned budget. Often the cause of the differences in cost is Ministry requests for Daily Subsistence Allowance for all participants in a venue which requires all participants to travel.

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5. Progress on Links to Other USAID Programs and Government of Zambia Agencies

This quarter, SBH hosted a meeting with all USAID-funded health partners to discuss the MOH annual planning process. The project presented an overview of the planning process and encouraged all partners to participate in the national launch and in provincial planning meetings wherever the project is working. Subsequently, SBH observed several partners present in the National Health Strategic Plan initial brainstorming meeting and the national planning launch.

USAID Systems for Better Health ▌pg. 24 SBH Quarterly Progress Report April – June 2016

USAID Systems for Better Health ▌pg. 25