Program for the Advancement January 16, 2020 Submitted by of Malaria Outcomes (PAMO) Dr. Caroline Phiri Chibawe Chief of Party, PAMO Year 5 Work Plan January 1–September 29, 2020 Contract number: AID-611-C-15-00002

Mailing address Mikwala House Stand 11059 Off Brentwood Road, Post Net Box 370 Pvt. Bag E10, Long acres, Lusaka, Zambia 10101

Tel : +260211378950 Fax : +260211378973 www.path.org

DISCLAIMER: The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID), United States President’s Malaria Initiative (PMI) or the United States Government.

Table of contents

List of acronyms ...... iii Table of figures ...... v List of Tables ...... v Introduction ...... 1 Overview ...... 1 Contents and funding source of this Year 5 work plan ...... 1 Situational analysis ...... 1 The PAMO consortium ...... 9 The PAMO strategic approach ...... 10 PAMO priority districts ...... 14 Overview of program objectives, tasks, and life-of-project outcomes...... 16 Objective 1: Support proven malaria interventions in alignment with the National Malaria Strategic Plan (NMSP) 2011–2016 and the follow-on plan of the MOH ...... 19 Task 1.0: Strengthen national technical working groups ...... 19 Task 1.1: Strengthen insecticide-treated net distribution ...... 20 Task 1.2: Improve access to and quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment ...... 22 Task 1.3: Increase delivery of IPTp-SP as part of an integral package of ANC services ...... 26 Task 1.4: Strengthen SBC implementation for malaria at health facilities and community levels through community mobilization and dialogue ...... 28 Task 1.5: Strengthen malaria policies and guidelines ...... 32 Task 1.6: Support civil society organizations (CSOs) and community-based organizations (CBOs) to implement malaria control activities ...... 33 Task 1.7: Conduct operations research ...... 35 Objective 2: Strengthen management capacity of provincial and district MOH personnel ...... 36 Task 2.1: Identify health system deficiencies at the provincial and district levels that constrain delivery of high impact malaria interventions in close collaboration with the MOH and other malaria actors ...... 36 Task 2.2: Develop and implement a plan to strengthen management capacity as measured by set targets within each targeted province and district ...... 36 Objective 3: Strengthen provincial and district HMIS to improve data reporting, analysis, and use for decision-making ...... 38 Task 3.1: Provide technical/material assistance to DHOs, health facilities, and communities to improve the timeliness and accuracy of HMIS reporting ...... 38 Task 3.2: Provide technical/material assistance to DHOs, health facilities, and communities to assist with training for the rollout of DHIS2 in the targeted provinces and districts ...... 41 Task 3.3: Provide technical and material assistance to DHOs, health facilities, and communities to strengthen malaria data analysis and use for planning and decision-making ...... 47 Project staffing ...... 49 Project monitoring, evaluation, and reporting ...... 51 Project closeout...... 53

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Annex 1: List of SBC target districts ...... 54

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List of acronyms ACT Artemisinin-based Combination Therapy AMP Alliance for Malaria Partnership ANC Antenatal Care BRITE BroadReach Institute for Training and Education CBO Community-based Organization CCC Community Change Champions CCI Champion Communities Initiative CCO Clinical Care Officer CCP Johns Hopkins Center for Communication Programs CDC U.S. Centers for Disease Control CHA Community Health Assistant CHAI Clinton Health Access Initiative CHAZ Churches Health Association of Zambia CHW Community Health Worker CoP Chief of Party CSO Civil Society Organization DCoP Deputy Chief of Party DHIO District Health Information Officer DHIS2 District Health Information System 2 DHO District Health Office DM Durability Monitoring DQA Data Quality Audits EDS Electronic Data System ETB Eradicate Tuberculosis EPI Expanded Program on Immunization GHSC-PSM Global Health Supply Chain-Procurement and Supply Management GRZ Government of the Republic of Zambia GUC Grants under Contract HF Health Facility HFCA Health Facility Catchment Area HMIS Health Management Information System iCCM Integrated Community Case Management ICEMR International Center for Excellence in Malaria Research ICT Information Communication and Technology IMCI Integrated Management of Childhood Illnesses IPTp Intermittent Preventive Treatment in Pregnancy IRS Indoor Residual Spraying ITN Insecticide-treated Net LLIN Long-lasting Insecticide-treated Net LOE Level of Effort M&E Monitoring and Evaluation MACEPA Malaria Control and Elimination Partnership in Africa MCSP Maternal and Child Survival Program MCH Maternal and Child Health MIP Malaria in Pregnancy MIS Malaria Indicator Survey MOH Ministry of Health MOP Malaria Operational Plan MRR Malaria Rapid Reporting NAC National Aids Council NHC Neighborhood Health Committee NMEC National Malaria Elimination Center NMEP National Malaria Elimination Program NMESP National Malaria Elimination Strategic Plan NMSP National Malaria Strategic Plan OPD Outpatient Department OR Operations Research OTSS Outreach Training and Supportive Supervision PA Performance Assessment

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PAMO Program for the Advancement of Malaria Outcomes PHO Provincial Health Office PMI President’s Malaria Initiative RAS Rectal Artesunate Suppository RDT Rapid Diagnostic Test RMNCAH/N Reproductive, maternal, newborn, child, and adolescent health/nutrition SARAI Sexual and Reproductive Health for All Initiative SBC Social and Behavior Change SBH Systems for Better Health SHIO Senior Health Information Officer SIDA Swedish International Development Cooperation Agency SMAG Safe Motherhood Action Group SMEO Surveillance, Monitoring, Evaluation and Operations Research SP Sulfadoxine-Pyrimethamine SPSMA Senior Policy, Strategy, and Management Advisor SUN TA Scaling up Nutrition Technical Assistance TSS Technical Supportive Supervision TWG Technical Working Group USAID United States Agency for International Development USG United States Government WHO World Health Organization ZMLA Zambia Management and Leadership Academy ZNS Zambia National Service

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Table of figures

No Description Pg. Fig 1 Malaria prevalence among children under age five by province, 2010–2018 7 Fig 2 Malaria Incidence by quarter (2016-2019) for PAMO supported provinces (HMIS data only) 9 Fig 3 Reduction in proportion of reported malaria cases which are unconfirmed by province, 2014- 9 2019 Fig 4 Trends in reported malaria deaths by province, 2015-2019 10 Fig 5 Trends in passive tests administered by CHWs by district, province and month from July 2018- 11 October 2019 Fig 6a-d Trends in malaria case reporting from HMIS malaria OPD and iCCM community malaria 11-13 passive positive by month and by province (all districts), 2019 Fig 7 Illustration of the PAMO strategic approach 16 Fig 8 The community partnership approach 18 Fig 9 Pie Chart illustrating PAMO’s Year 5 budget allocation in each thematic area 23 Fig 10 Malaria data flow diagram 44 Fig 11 PAMO Organogram for Year 5

List of Tables

No Description Pg. Table 1 Transmission intensity levels and proposed intervention packages and actions, National 14 Malaria elimination Strategic Plan 2017-2021 Table 2 Major USG-funded partners working on malaria at the national level 17 Table 3 USG-funded partners in Eastern province 17 Table 4 USG-funded partners in Luapula province 17 Table 5 USG-funded partners in Muchinga province 18 Table 6 USG-funded partners in Northern province 18 Table 7 Enhanced investments in PAMO focus districts, by province 20 Table 8 Activity and implementation timeline for task 1.0 25 Table 9 Activity and implementation timeline for Task 1.1 26 Table 10 Overview of OTSS targeting for 2020 28 Table 11 Activities and implementation timeline for case management at facility level 29 Table 12 Overview of PAMO supported ICCM and surveillance training 29 Table 13 Activities and implementation timeline for case management at community level 31 Table 14 Activities and implementation timeline for increasing coverage of IPTp 31 Table 15 Activities and implementation timeline for SBC 37 Table 16 Activities and implementation timeline for strengthening malaria policies and guidelines 38 Table 17 List of PAMO contracted CSOs and districts they operate in 39 Table 18 Activities and implementation timeline for CSO/CBO-implemented malaria control activities 40 Table 19 Number of health managers trained by PAMO in all four provinces 42 Table 20 Activities and implementation timeline capacity building 43 Table 21 Summary of the DQA findings based on facilities visited 45 Table 22 Activity and implementation timeline task 3.1 46 Table 23 Confirmed malaria deaths, Luapula province, by district, January-June 2018 48 Table 24 Distribution list for mobile phones requested by NMEP 50 Table 25 Activities and implementation timeline task 3.2 51 Table 26 Activities and implementation timelines for task 3.2 54

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Introduction

Overview The Program for the Advancement of Malaria Outcomes (PAMO) is a flagship malaria activity program for the United States President’s Malaria Initiative (PMI) in Zambia. The PMI Strategy for 2015–2020 states that “the U.S. Government's goal is to work with PMI-supported countries and partners to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.” In line with PMI’s strategy, PAMO was designed to assist the Government of the Republic of Zambia (GRZ) to accelerate progress toward its goal of eliminating local malaria infection and disease in Zambia. This will be achieved by increasing access to and uptake of quality malaria control interventions.

As specified in the project contract, PAMO’s three objectives are:

1. To support proven malaria interventions in alignment with the National Malaria Strategic Plan (NMSP) 2011– 2016 and the follow-on plan of the Ministry of Health (MOH). 2. To strengthen management capacity of provincial and district MOH personnel to provide supervision and mentoring to improve delivery of proven interventions. 3. To strengthen the provincial and district health management information system (HMIS) to improve data reporting, analysis, and use for decision-making.

PAMO’s programmatic focus is on long-lasting insecticide-treated nets (LLINs), malaria in pregnancy (MIP), case management, social and behavior change (SBC), surveillance, monitoring and evaluation (M&E)—but not indoor residual spraying (IRS), which in Zambia is handled by PMI’s VectorLink project.

PAMO’s geographic focus is on four high burden provinces in northeast Zambia, namely Eastern, Luapula, Muchinga, and Northern. This geographic area consists of 47 districts and 839 health facilities (HFs). PAMO maintains effective partnerships with the National Malaria Elimination Center (NMEC), provincial health offices (PHOs), district health offices (DHOs), HFs, communities, civil society organizations (CSOs), and others to implement and scale up evidence- based, World Health Organization (WHO)-recommended strategies to fight malaria.

Contents and funding source of this Year 5 work plan The activities outlined in this work plan align strategically with Zambia’s National Malaria Elimination Strategic Plan (NMESP) 2017–2021 and the PMI Zambia Malaria Operational Plans (MOPs). This PAMO Year 5 work plan covers the implementation period of January 1 through September 30, 2020. Of note, this work plan covers activities in the “main” PMI program, which continues to focus on the reduction of malaria burden in historically high-prevalence provinces of Luapula, Northern, and Muchinga, and the high burden districts of Eastern Province. As such, the work plan funding corresponds with the FY18 MOP reprogrammed funds which are $718,292 the FY19 MOP which are $1,485,000, project pipeline from not yet sub-obligated funds of $400,000 and the pipeline of $2,295,340 totaling $4,898,632.

For activities in the “pre-elimination” PMI program in three low-burden districts of Eastern Province, PAMO is operating under a separate but complementary “Year 2 Pre-Elimination Work Plan” that covers the pre-elimination activities during the period of September 2019 to September 2020.

Situational analysis

Trends in malaria prevalence rates

No new cross-sectional survey results are available to inform Year 5 of PAMO implementation. The results from the last national Malaria Indicator Survey 2018 (MIS 2018) showed that the four PAMO-supported provinces are still among the highest malaria burden provinces in Zambia (Figure 1). Luapula has shown very little change in prevalence rates since 2012, Muchinga has shown some progress and Northern has had clear improvement. Serial MIS findings suggest

1 improvement in Eastern as well. Notably, nationally, malaria prevalence among children under five years of age is declining.

Figure 1: Malaria prevalence among children under age five by province, 2010–2018 (2018 MIS).

Trends in malaria incidence

Early in 2019, the HMIS underwent significant changes to migrate the national HMIS DHIS2 instance to an instance hosted at the National Data Centre. This migration of the system has resulted in some inconsistencies in HMIS malaria data and not all issues are clearly understood. The data presented here is the PAMO’s team best understanding of the resulting dataset, building on the situation analysis from the PAMO Year 4 Work Plan. (This is further discussed in Task 3.2). Currently PATH MACEPA is supporting a consultant to help with the transition although the Ministry of Health (MoH)M&E section has indicated they are diligently working to load all the older data which is still not updated into the new server. MACEPA is continuing to support the old server until this transition is complete. MoH indicated this will conclude by the end of the first quarter of 2020.

Malaria incidence in Zambia is presented in Figure 2 which compares incidence in PAMO-supported and non PAMO supported provinces. To calculate incidence, in districts where community health care workers exist, the current practice is that at facility level, clinical and confirmed malaria cases are added to passive positive community health worker cases. In the districts where there are no community health workers, only clinical and confirmed malaria cases are added to calculate incidence. Due to changes in HMIS servers and the ongoing rollout of Community Health Workers (CHWs), the level of malaria incidence data should be interpreted with caution. Declines could be attributable to a mix of interventions, increasing care seeking among CHWs, and from missing data from the transition from one server to another.

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Figure 2: Malaria incidence by quarter (2016-2019) for PAMO-supported and non PAMO-supported provinces (HMIS data only)

250

200

150

100

50 Malaria cases Malariacases per 1000 population

0 Jan to Apr to Jul to Oct to Jan to Apr to Jul to Oct to Jan to Apr to Jul to Oct to Jan to Apr to Jul to Oct to Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec 2016 2016 2016 2016 2017 2017 2017 2017 2018 2018 2018 2018 2019 2019 2019 2019

PAMO-supported provinces Non-PAMO-supported provinces

Figure 3 shows the trend in clinical malaria case reporting by province for the six-month period January through June each year from 2014-2019. All provinces had shown a decline in the percentage of clinical reporting each year through outpatient department (OPD), however in 2019, Eastern and Muchinga provinces reported an increase in the percentage of clinical malaria cases reported compared to the previous year.

Figure 3: Reduction in proportion of reported malaria cases which are unconfirmed by province, 2014-2019

45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Jan to Jun Jan to Jun Jan to Jun Jan to Jun Jan to Jun Jan to Jun 2014 2015 2016 2017 2018 2019 Eastern 40.9% 14.3% 29.0% 12.4% 4.1% 11.4%

Proportion of cases reported clinical as Luapula 25.0% 13.2% 14.8% 12.6% 6.5% 2.1% Muchinga 33.1% 15.4% 24.0% 11.8% 3.1% 4.9% Northern 24.4% 22.8% 15.3% 8.0% 1.9% 1.4% 6-month period, 2014-2019

Eastern Luapula Muchinga Northern

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Trends in malaria deaths

Malaria deaths trends are presented in Figure 4 by province. There has been a decline in reported deaths since 2015, except in 2019. However, as discussed earlier, the quality of the data resulting from the HMIS DHIS2 server migration may be causing problems with availability of data in 2018.

Figure 4: Trends in reported malaria deaths by province, 2015-2019

450 400 350 300 250 200 150 100

50 Numberreported of deaths 0 2015 2016 2017 2018 2019 Eastern 237 164 110 94 122 Luapula 420 297 241 196 311 Muchinga 117 70 37 29 54 Northern 136 100 120 132 128 Year

Eastern Luapula Muchinga Northern

Community surveillance data

In 2019, all provinces in Zambia increased their malaria case reporting from community levels through the expanded roll outs of iCCM and community surveillance. Among the four PAMO-supported provinces, the trainings including the malaria surveillance component began either in the latter half of 2018 or in early 2019. This includes a mix of training and roll out support from PMI, Global Fund and MOH. Figure 4 shows the reporting of the number of passive tests administered at community level by province and district from July 2018 to October 2019. As successive districts have been trained, passive case detection activities have increased dramatically during this period.

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Figure 5: Trends in passive tests administered by CHWs by district, province and month from July 2018- October 2019 in PAMO-supported areas

Malaria case reporting from HMIS and community iCCM is presented in Figure 5a-d by province. Among cases reported at community level, Eastern province has the highest percentage of community cases out of the total passive case reports, compared to the other provinces. By June 2019, 20% of malaria cases were being reported at community level in Eastern province. This has continued to rise since June. All other provinces were hovering around 5% community malaria case reporting in 2019, although even Muchinga province percentage of community malaria case reports began to increase too by July during the dry season.

Figure 5a-d also reflects the percentage of clinical malaria cases out of the total malaria positive cases reported through the HMIS or iCCM community levels reported by month and province in 2019. Of note, in 2019 Northern province is reporting the lowest percentage of clinical cases, while Eastern province is reporting on average the highest percentage of clinical cases. In general, a higher percentage of cases are reported as clinical during the peak transmission months.

Figure 6a-d: Trends in malaria case reporting from HMIS malaria OPD and iCCM community malaria passive positive by month and by province (all districts), 2019

Figure 6a Eastern province 250000 50.0% 200000 40.0% 150000 30.0% 100000 20.0% 50000 10.0%

0 0.0% Numbercases of

HMIS malaria OPD ICCM malaria passive positive % community passive % clinical of HMIS and ICCM passive

5

Figure 6b

Luapula province 90000 10.0% 80000 70000 60000 50000 5.0% 40000 30000

20000 NumberCases of 10000 0 0.0%

HMIS malaria OPD ICCM malaria passive positive % community passive % clinical of HMIS and ICCM passive

Figure 6c

Muchinga province 90000 15.0% 80000 70000 60000 10.0% 50000 40000 30000 5.0%

20000 NumberCases of 10000 0 0.0%

HMIS malaria OPD ICCM malaria passive positive % community passive % clinical of HMIS and ICCM passive

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Figure 6d

Northern province 80000 10.0% 70000 60000 50000 40000 5.0% 30000

20000 NumberCases of 10000 0 0.0%

HMIS malaria OPD ICCM malaria passive positive % community passive % clinical of HMIS and ICCM passive

Stratified approach to targeting malaria interventions

Consistent with the 2017 WHO Framework for Elimination guidelines, Zambia’s current NMESP calls for prioritization of the various malaria interventions in different geographic areas depending on their malaria burden. The unit of assessment and operations is the Health Facility Catchment Area (HFCA), of which there are approximately 2,385 nationally, with an average of 37 per district, and an average of ten community health worker (CHW) zones per catchment area.1 The distribution of HFCAs by epidemiologic “level” is depicted in Table 1.

To best support the national plan, PMI/PAMO has largely adopted this stratification scheme as a tool to prioritize investments. Almost all HFCAs in Luapula, Muchinga, and Northern provinces fall in high-burden strata (level 3 and level 4). There does exist a cluster of HFCAs in the plateau area of Eastern Province which have tended to fall in the low burden strata (level 2 or level 1). PAMO activities in those districts are supported through the PMI “pre-elimination” program, which, as previously mentioned, are covered in a separate work plan.

1 Source: MOH Preliminary Report of the 2017 List of Health Facilities in Zambia. It is important to note that because there are great variations in the number of health facilities in each district this is an estimate.

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Table 1: Transmission intensity levels and proposed intervention packages and actions, National Malaria Elimination Strategic Plan 2017–2021.

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The PAMO consortium

PAMO activities are implemented through a consortium of partners (initially four, now two partners) structured to draw on each partner’s complementary strengths. PATH is the prime contractor and Jhpiego as a subcontractor.

PATH

As the prime contractor, PATH is accountable for overall project management, administration, and monitoring to ensure effective implementation, compliance with the United States Agency for International Development (USAID) rules and regulations, and achievement of project deliverables and objectives. Technically, PATH is responsible for improving access to and quality of malaria case management services at facility and community levels, ensuring support to civil society and community-based organizations to implement malaria control activities, overseeing management capacity strengthening of provincial and district MOH personnel, and strengthening the HMIS to improve decision-making. PATH is leveraging the previous experience of the Malaria Control and Elimination Partnership in Africa (MACEPA) to support the PAMO M&E system, as well as the technical expertise of PATH’s Global Malaria Control Program to provide short- term technical assistance. PATH is leading the implementation of the PAMO M&E plan.

Jhpiego

Jhpiego provides technical and programmatic leadership for MIP and case management, as well as strategic direction and the identification of key activities at national, district, and facility levels. Jhpiego advises on incorporating promotion of MIP services, effective LLIN distribution through MIP services, and integration of case management into PAMO’s community engagement efforts. Jhpiego is responsible for organizing, implementing, and monitoring PAMO’s implementation plan in Luapula Province under the leadership of PAMO’s senior technical and program staff based in Lusaka. Jhpiego seconds an MIP/case management specialist to PAMO in Lusaka to provide strategic direction and to monitor the quality of PAMO activities in these areas. Jhpiego has two additional staff based in Luapula seconded to PATH and seated within the PHO. Jhpiego has a cadre of headquarters-based and international technical staff available to provide short-term technical assistance and implementation and management support for the life of the project.

BroadReach Institute for Training & Education (BRITE)

This partner will not be active in Year 5. BRITE’s focus as a member of the PAMO consortium during Years 1 to 4 was to provide support in the identification of malaria program management capacity development needs in targeted provinces and districts. Additionally, BRITE supported the development of malaria program management capacity plans across malaria control interventions with a focus on improving linkages between facility and community levels.

Johns Hopkins Center for Communication Programs (CCP)

This partner will not be active in Year 5. In PAMO Years 1 to 3, Johns Hopkins CCP provided technical and programmatic leadership to support campaign-based and continuous distribution of LLINs and SBC activities in target provinces. However, the leadership and management of CCP decided to withdraw from the PAMO consortium. PATH subsequently absorbed the two specialist positions and took on all the associated activities which fall under Tasks 1.1 and 1.4.

Other partners

The core local partners are the PHOs, DHOs, HFs and communities in the four target provinces. PAMO supports these entities by funding activities in their respective districts.

At an operational level, the Churches Heath Association of Zambia (CHAZ) has a network of affiliates in the four target provinces that PAMO leverages to support its community engagement and partnership work and to strengthen the linkages of these partnerships to the health system.

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The PAMO strategic approach

The PAMO consortium brings together extensive expertise and experience in four core technical and programmatic areas: (1) sustained universal coverage and use of LLINs, (2) SBC for malaria control interventions, particularly at the community level, (3) improved prevention and management of MIP, and (4) improved malaria case management (including iCCM). These efforts are complemented by improved management capacity; improved implementation of national-, provincial-, district-, facility-, and community-level malaria control programs; and improved health information to direct interventions and monitor progress.

Figure 7: Illustration of the PAMO strategic approach

PAMO makes every effort to ensure that PHOs and DHOs feel ownership of and are empowered to manage the assistance that is provided to their respective networks of districts, facilities, and communities. As a matter of strategic management, in Year 5 PAMO will continue to integrate capacity-building interventions for provincial and district managers, leverage government structures and personnel, and support planning and supervision cycles.

At the national level, PAMO has and will continue to take a lead role in the improved functioning of technical working groups (TWGs) and other stakeholder platforms that bring together malaria stakeholders to share best practices and drive harmonized programming and policy. PAMO has and will continue to leverage investments made by the Global Fund and MACEPA to promote sustainable, system-focused results and efficient resource use. For example, in Eastern province, planning and review of provincial OTSS is jointly done by MOH, PAMO and Global Fund.

At the provincial level, PAMO supports USAID and the MOH by coordinating with malaria stakeholders in PAMO- supported provinces to ensure complementarity, efficient resource use, and synergistic impact. Leveraging and

10 integrating a portfolio of United States Government (USG)-funded projects and other partners, PAMO will work in Year 5 with VectorLink, Global Health Supply Chain-Procurement and Supply Management (GHSC-PSM), IMPACT Malaria, and the Breakthrough Action Project. Health partner coordination will continue to be facilitated by the USAID/Zambia provincial offices in Mansa (Luapula) and Kasama (Northern). The USAID provincial offices are sited at the PHOs.

To ensure that PAMO activities are complementary and not duplicative, a mapping exercise (Tables 2–6) was conducted at the national level and in the four provinces. At provincial level there is minimal overlap among USG- funded projects in the four PAMO-supported provinces, however at the national level there is some overlap with Impact Malaria (OTSS) and VectorLink (ITNs). At operational level, PAMO and Impact malaria roles are differentiated through geography (operate in different provinces). PAMO’s role in ITNs at the national level will be handed over to VectorLink as PAMO will be winding down before the 2020/2021 mass campaign is concluded.

Table 2: Major USG-funded partners working on malaria at the national level.

Project name Major GRZ partners Focus areas Breakthrough Action NMEC, National AIDS Council (NAC), SBC National Food and Nutrition Commission, MOH Health Promotion Unit GHSC-PSM NMEC, Medical Stores Limited (MSL) ITN procurement, antimalarial medication and diagnostic supplies, supply chain and logistics management IMPACT Malaria NMEC Outreach training and supportive supervision (OTSS) VectorLink NMEC, Zambia Environmental IRS and entomologic monitoring. ITN Management Agency campaign planning and implementation.

Table 3: USG-funded partners in Eastern Province.

Project name Districts of operation Focus areas Catholic Relief Services Chipata and Petauke HIV/AIDS prevention, nutrition GHSC-PSM All districts ITN procurement, antimalarial medication and diagnostic supplies, supply chain and logistics management Reproductive, maternal, All districts Maternal and child health newborn, child, and adolescent health/nutrition (RMNCAH/N) Continuum of Care Program USAID-DISCOVER HEALTH All districts HIV/AIDS prevention

VectorLink Chadiza, Katete, Sinda IRS and entomologic monitoring. ITN campaign planning and implementation.

Table 4: USG-funded partners in Luapula Province.

Project name Districts of operation Focus areas Breakthrough Action Samfya, Lunga and Chembe SBC DISCOVER-Health All districts HIV prevention Eradicate Tuberculosis (ETB) Mansa, Chembe, Kawambwa, Tuberculosis Chiengi Equip All districts HIV/AIDS prevention GHSC-PSM All districts ITN procurement, antimalarial medication and diagnostic supplies, supply chain and logistics management

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Marie Stopes International All Districts Reproductive health, family planning RMNCAH/N Continuum of Care All Districts Direct funding through Swedish Program International Development Cooperation Agency (SIDA) and USAID to all districts Safe Motherhood 360 Lunga, Mansa, Chembe, Samfya Maternal health Sexual and Reproductive Health Chiengi, Nchelenge, Kawambwa, Integrated reproductive health for All Initiative (SARAI) Mansa, Samfya United Nations Population Fund All districts Reproductive health VectorLink All districts IRS and entomologic monitoring. ITN campaign planning and implementation.

Table 5: USG-funded partners in Muchinga Province.

Project name Districts of operation Focus areas Breakthrough Action Chinsali, Mpika and Nakonde SBC ETB Chinsali, Mpika, Nakonde, and Isoka Tuberculosis Equip All districts HIV testing and treatment GHSC-PSM All districts ITN procurement, antimalarial medication and diagnostic supplies, supply chain and logistics management RMNCAH/N Continuum of Care All Districts Direct funding through SIDA (and USAID) Program to all districts SARAI Isoka, Kanchibiya, Lavushimanda, Reproductive health and Mafinga USAID DISCOVER-Health Mpika, Nakonde, and Chinsali HIV testing and treatment VectorLink All districts IRS and entomologic monitoring. ITN campaign planning and implementation.

Table 6: USAID-funded partners in Northern Province.

Project name Districts of operation Focus areas Clinton Health Access Initiative All districts Maternal Health (CHAI) DISCOVER-Health Kasama Logistics, Antiretroviral Therapy

Equip All districts Antiretroviral therapy and logistics ETB All Districts Tuberculosis

GHSC-PSM All districts ITN procurement, antimalarial medication and diagnostic supplies, supply chain and logistics management Institute for Health Measurement All Districts Information, Communication and Southern Africa (CDC Funded) Technology (ICT)

JSI AIDSFree All districts Information technology (IT) Society for Family Health Kasama (Zambia National Service HIV prevention among military men, (Department of Defense project) ZNS Chishimba) and Mbala (Zambia voluntary medical male circumcision Airforce and ZNS Mbala)

SUN TA Currently in Kaputa, Mbala and Nutrition, 1000 Most Critical Days, Kasama. Luwingu to come on board education, agriculture, social cash soon. transfer, village banking.

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Strengthening of supervision and mentorship are key elements of the PAMO approach. PAMO has and will continue to support PHOs to closely supervise and support DHOs, with a focus on the district malaria focal point officers. Between DHOs and facility and community levels, PAMO has and will continue to employ a rigorous mentorship strategy designed to strengthen specific technical skills in line with national standards and guidelines, link closely to management and data monitoring processes, and encourage ownership of results at all levels. As described in Task 1.2, the PAMO mentorship approach draws from the Jhpiego mentoring approach as well as from the former MalariaCare project’s outreach training and supportive supervision (OTSS) approach, while aligning closely with the GRZ’s program of formal performance assessments (PAs).

At the facility and community level, the PAMO team works to strengthen facility-based service delivery and works with existing structures to foster community ownership of malaria control. PAMO utilizes the integrated Community Partnership Approach developed by PATH for facility capacity strengthening (Figure 8), which aims to provide high- quality care while supporting communities to more effectively demand (seeking access and use) the services and care they need. Strengthening the relationship between the two levels leads to better collaboration, coordination, and synergy; improved health systems; and, ultimately, reduced vulnerability to malaria.

Figure 8: The Community Partnership Approach

Building on the experience of MACEPA in Southern Province, a cross-cutting element of PAMO’s approach is strengthening data systems for routine management and decision-making. PAMO is working to strengthen implementation and use of the existing district health information system 2 (DHIS2) platform for the HMIS, specifically the routine analysis of all malaria data, while working to improve timeliness and quality of data entry and of reporting from facilities to districts. This is done through several activities which include training, data quality audits, and malaria data review meetings. A strengthened data system serves as the foundation for monitoring outcomes at provincial, district, and facility levels, and for informing annual planning.

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PAMO priority districts From the project’s inception, PAMO has worked in all districts (originally 36, now 47) of its four focus provinces to bring to scale coverage of effective preventive and curative malaria interventions and strengthened information systems. This is to ensure that the entire at-risk population is protected by effective evidence-based interventions, in line with GRZ health policy, the current NMESP, and the PAMO contract.

Practically, it can be challenging to show year-to-year local impact when limited resources are spread across a vast geographic area in a high-burden zone. The lack of real-time feedback on impact limits the project’s ability to refine its operations and strategy over time and to contribute maximally to NMEP learning.

Focus districts

In Year 3, PAMO introduced the concept of “focus districts,” where, paired with enhanced monitoring, resources would be concentrated to scale up interventions in a limited area. Enhanced support for routine data gathering would ensure that HMIS indicators of malaria burden are accurately tracked, including, at a minimum, case incidence, total OPD and in-patient department (IPD) cases, and deaths—each disaggregated by age and pregnancy status. Ideally, other malaria burden indicators are tracked as well. The focus district approach is not a formal research trial, but it does allow PAMO to maximize program learning. Nchelenge was selected in Year 3, with additional focus districts (Chama, Mambwe, Mbala, Senga and Nakonde) added in Year 4. No new focus districts will be included in Year 5. However, iCCM training will be done in Lundazi, Chembe and Kawambwa.

Nchelenge District, Luapula Province (International Center for Excellence in Malaria Research)

Nchelenge in Luapula Province was selected as a focus district in Year 3 and will continue to be a focus district in Year 5. Selection was based largely on the availability of unusually rich and high-quality data available in Nchelenge, courtesy of the National Institutes of Health-funded International Center for Excellence in Malaria Research (ICEMR). Each month, researchers sample a range of MIS and entomologic indices from a cross-section of households in Nchelenge. This provides a set of malaria indicators that allow for longitudinal tracking of the impact of malaria control programs, dating to at least 2014 and extending through 2022 and beyond.

The objective in Nchelenge District is to implement the “full package” of interventions for high burden areas called for in the NMESP by applying PAMO resources in tandem with IRS and in close collaboration with GRZ and local partners. PAMO will ensure that the district is prioritized for interventions by conducting management training, continuous ITN distributions such as ANC/EPI, school or community, and OTSS (each of which are detailed later in the work plan). PAMO will also support active neighborhood health committees (NHCs) in all catchment areas, backstopped by grants to a CSO that will engage in community mobilization across the district.

Crucially, PAMO will support the district to establish a vigorous program of community-level case management and surveillance—an intervention whose coverage rates remain limited outside of Southern Province, with its extraordinary “army of community health workers” engaged in malaria elimination.

As appropriate for high burden areas (level 4 in the NMESP stratification), the community-level efforts in Nchelenge will focus on passive case management. The proposed package of enhanced support for CHWs in focus districts will include training and enabler kits adequate to attain a coverage ratio of 1 to 750, as recommended by MACEPA, with 50% deployed in 2018 and 50% in 2019. Reactive case detection (“Step D”) would be prepared for and would be introduced as appropriate when and if incidence levels fall into the 0–2 level range. Further details of the package are given under Task 1.2 (in the section on community-level case management).

Other focus districts in Northern, Muchinga, and Eastern

On a more limited scale, PAMO introduced the focus district approach in five additional districts in Year 4, with four districts representing high burden—Chama (Muchinga), Mambwe (Eastern), Mbala, and Senga (Northern)—while Nakonde (Muchinga) represents low burden (level 2).

Building on the successful investments in iCCM from Year 3 in these districts, PAMO will ensure continued scale-up deployment of CHWs in Year 5, while also investing in enhanced data generation and analysis. These districts were selected in 2018 by the PHOs as focus districts for iCCM in order to satisfy the need of CHWs in high burden districts. Nakonde was of interest to the Muchinga PHO as it was at level 2 of transmission (due largely to its high elevation) and can be prepared for pre-elimination. Other factors contributing to the selection were strength of district health management teams and accessibility.

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Due to resource limitations in Year4, CHWs in these PAMO-supported districts were less concentrated, therefore in Year 5, PAMO will saturate interventions in Chama, Mambwe, Mbala, Senga and Nakonde. (Details of this are outlined in Task 1.2). PAMO will work with partners to align as much as possible with the national program’s efforts to scale up CHWs.

Pre-elimination districts

As mentioned, PMI Zambia has selected Eastern Province for a pre-elimination program. Three districts in the higher, cooler plateau areas of the province provide an opportunity to support pre-elimination activities, as they have lower malaria transmission potential and are more amenable to the next tier of pre-elimination planning and interventions. These districts are functioning as full-package PAMO focus districts as well. Although activities are covered in a separate work plan, they are mentioned here because the concept and approach are similar. In these districts, PAMO , began by conducting a baseline assessment in 2018 the three pre-elimination districts and neighboring districts of Petauke and Chipata, PAMO works with the MOH to ensure universal coverage of insecticide-treated nets (ITNs), enhance malaria case management, strengthen SBC implementation by engaging CSO/community-based organizations (CBOs) to promote malaria control interventions, increase intermittent preventive treatment in pregnancy (IPTp) coverage, build management and leadership capacity, and enhance surveillance and reporting.

Details of PAMO pre-elimination activities are provided in the PAMO Year 2 Pre-Elimination Work Plan, September 1, 2019–September 30, 2019.

Table 7: Enhanced investments in PAMO focus districts, by province.

Province District Enhanced iCCM Rectal Enhanced School- SBC/ Increased IRS Scale-Up Artesunate HMIS data based CSO coverage (RAS) ITNs supp (VectorLink) ort Yr. 3 Yr. 4 Yr. Yr. Yr. Yr. Yr. Yr. Yr. Yr. 3–5 Yr. 3- Yr. 3 Yr. 4–5 5 3 4 5 3 4 5 5 Luapula Chembe X

Kawambw x a Nchelenge x x x x x x x x x x

Eastern Pre- x x x x x x x x x x elimination districts * Lundazi x X

Mambwe x x x x x x X

Northern Mbala x x x x x x** x X

Senga x x x x x X

Muchinga Chama x x x x x x x x** x

Nakonde x x x x x

*The three pre-elimination districts in Eastern Province are shown here for comparison purposes, but activities are covered in a separate work plan.

** These districts don’t have CSOs but will still be supported with extra SBC activities under Task 1.4.

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Overview of program objectives, tasks, and life- of-project outcomes

The ordering of objectives and tasks in this work plan follows the structure of PAMO’s contract and does not imply a rank order in terms of priority or level of effort. Some tasks, by their nature, require a higher level of effort and resource investment than others. Moreover, their relative importance changes across the life of the project. For a sense of prioritization among the tasks and objectives in Year 5, see the pie chart in Figure 8, which illustrates the relative level of effort by technical area.

The tasks associated with Objective 1 focus on strengthening national strategies, policies, and guidelines through TWGs and strengthening LLIN distribution, case management and SBC. These are all key interventions that are outlined in the NMESP. In Year 5 the bulk of PAMO investments will fall under Objective 1.

Objective 2 focuses on strengthening management capacity of provincial and district managers to effectively coordinate and implement malaria control activities. In Year 5, PAMO will invest only modestly in management capacity strengthening.

Objective 3 has three inter-related focus areas, which relate to HMIS data quality improvement, HMIS capacity- building for health facility staff, and support to MOH for the rollout of DHIS2 training for selected provincial and district health staff in PAMO-supported provinces and districts. PAMO also focuses on assisting DHOs, HFs, and communities to strengthen malaria data analysis and use for decision-making.

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The expected life-of-project outcomes are specified in the contract. Seven of these are linked to the findings within the national MIS in the four target provinces. The most recent MIS was conducted in 2018. These outcomes will be obtained not through PAMO’s contributions alone, but in concert with all public and private sector actors working to reduce malaria in the four focus provinces.

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Figure 9: Pie chart illustrating PAMO’s Year 5 Budget allocation in each thematic area

Other Health Systems Strengthening MIP 3% 6%

LLINs 12% Case Management 37%

SBCC 20%

Survelliance, Monitoring & Evaluation 22%

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Objective 1: Support proven malaria interventions in alignment with the National Malaria Strategic Plan (NMSP) 2011–2016 and the follow-on plan of the MOH

PAMO has aligned its tasks and activities within the NMESP, which places an emphasis on maximizing coverage of key interventions such as sustained universal coverage of LLINs), case management (diagnosis and treatment), malaria in pregnancy (IPTp), health promotion (community engagement and SBC), surveillance, and research. This section details the activities that the project will undertake in 2020 to contribute to the MOH’s goals and objectives.

Depending on the task, PAMO will continue to direct its support to either the national or the sub-national level. Under Task 1.0 (TWGs) and Task 1.5 (policy and guidelines), PAMO will support the NMEC at the central/national level by supporting coordination, planning, and development of policies, strategies, and technical guidelines. Under other tasks (Tasks 1.1, 1.2, 1.3, 1.4, 1.6, and 1.7) PAMO will continue to direct the bulk of its efforts sub-nationally, supporting key NMESP interventions at the provincial, district, health facility, and community levels.

Task 1.0: Strengthen national technical working groups Since Year 3, PAMO has provided technical assistance to the three national TWGs: vector control; case management; and surveillance, monitoring, evaluation, and operations research (SMEO). PAMO also supported SBC adhoc TWGs at the NMEP. PAMO provided technical assistance to each of these TWGs to develop and/or update their respective terms of reference. Quarterly TWG meetings have been institutionalized.

In Year 5, PAMO will continue to provide technical and material support at the national level for the TWGs. The work will encompass:

• Agenda development. • Improvement of the implementation process (e.g., guiding decisions and investments). • The continual review of progress. • Development of cases for resource mobilization. • Support for the continuity of TWG mechanics. • “In-between meetings” work.

In addition to focusing its efforts on the three TWGs, PAMO will participate in the MOH Child Health Unit’s integrated community case management (iCCM)/integrated management of childhood illnesses (IMCI) TWG, and the MOH Health Promotion directorate’s SBC TWG. PAMO will also work closely with Breakthrough Action to strengthen the SBC TWG through which standardization of messages will be done.

PAMO’s support to the TWGs in Year 5 will include but will not be limited to:

• Vector control: providing technical support to the TWG to prepare for the 2020/2021 national LLIN mass distribution campaign and expansion of continuous distribution channels of LLINs. • Case management: updating the Guidelines for the diagnosis and treatment of malaria in Zambia and facilitate policy modifications and adaptations as appropriate. • SMEO: Review malaria data elements in HMIS • SBC: disseminating findings of the formative research conducted by PAMO in 2019. It is important to note that the SBC TWG at the NMEC will be supported by Breakthrough Action.

Closely complementing the work with the TWGs, PAMO will continue to participate in the NMEC’s monthly directorate meetings.

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In Year 5, the PAMO senior policy, strategy, and management advisor (SPSMA) will, in line with the project’s objective of enhancing the NMEP capacity to effectively manage the malaria program, support the NMEP with technical support on various malaria management aspects. The SPSMA will provide support to the NMEP to leverage investments from key players in the sub-sector such as the Global Fund and the private sector to create an enabling environment in which the NMEC will function professionally. In year 4, PAMO supported the mid-term review (MTR) of the NMESP and therefore in year 5 the SPSMA will support the NMEP to revise the national strategy and develop new guidelines and policies based on the findings of the MTR. The SPSMA will also support the NMEC to ensure sustained use of the only harmonized workplan and malaria scorecard platforms (see task 1.5).

Outputs

• Case management: updated Guidelines for the diagnosis and treatment of malaria in Zambia. • Vector control: technical support provided for the preparations of the 2020/2021 national LLIN mass distribution campaign. • SMEO: review malaria data elements in HMIS • SBC: formative research findings disseminated.

Table 8: Activity and implementation timeline for Task 1.0.

Hold quarterly TWG meetings Timeline in quarters Activities Outputs Q1 Q2 Q3 Q4 Provide technical and material assistance to Technical support provided for the x x x the NMEC to conduct quarterly case updating of the 2017 Diagnosis and management TWG meetings treatment guidelines Provide technical assistance to the NMEC to Technical support provided for the x x x conduct quarterly vector control TWG preparations of the 2020/2021 meetings National LLIN mass distribution campaign Provide technical and material assistance to Review malaria data elements in x x x the NMEC to conduct quarterly SMEO TWG HMIS meetings Provide technical and material assistance to Formative research findings x x x the NMEC to conduct SBC TWG meetings as disseminated applicable

Task 1.1: Strengthen insecticide-treated net distribution In Year 5, PAMO will utilize the findings from a health facility assessment and other data from ongoing supervisory visits and the malaria scorecard to identify the lowest performing districts in the PAMO provinces and provide supportive supervision to the health facilities in those districts to improve data reporting and collation of LLINs distributed through ANC and EPI.

The health facility assessment was conducted in Year 3 and showed that while the institutional framework for delivering ANC and EPI was in place, there was a lack of standardized registers and tally sheets at facility level to document the issuing of LLINs to pregnant women and young children. PAMO provided technical support to the NMEC in Year 4 to focus on addressing the identified gaps. In Year 5, PAMO will provide technical assistance to a cohort of health facilities in the first quarter and track the same facilities in the second quarter to ensure that the health facilities are complying with the guidance on data management of LLINs through ANC and EPI. PAMO will utilize the HMIS data to measure progress on reporting on a quarterly basis. To further improve reporting in ANC and EPI, PAMO will provide PHO, DHO, and health facility staff with copies of the 2017 Zambia LLIN Distribution Guidelines. PAMO will orient health workers per facility (total target 832) on these guidelines during the supervisory visits.

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PAMO also plans to provide technical and material assistance to the NMEC to conduct the third round of data collection for LLIN durability monitoring (DM) 2 (i.e., 24 months post distribution) in Katete and Lundazi districts in Eastern Province. The DM activity began after the 2017/2018 mass campaign and monitors the physical and chemical integrity of two different types of nets (PermaNet® and Olyset®) over time to better understand the performance of these LLINs in the Zambian environment and the main factors affecting their durability. This effort has involved PAMO-organized workshops to build capacity of the NMEC to conduct DM studies independently and to build local capacity in LLIN DM data processing, analysis, interpretation, and reporting in Zambia. Following the workshops, PAMO assisted the NMEC to produce the baseline report on DM, which provided preliminary data showing PermaNet is performing better than Olyset. The third data collection and analysis will be done in April 2020 (12 months after the second round of data collection). PAMO will disseminate the DM findings through the Vector Control TWG. PAMO will assist the NMEC to process, analyze, interpret and report on the data collected at the second (12 months post distribution) and third (24 months post distribution) rounds of data collection. After the third round of DM, the NMEC will be in a position to contribute to the Africa-wide evidence base on ITN durability to inform decisions on frequency of ITN distributions.

Lastly, PAMO will provide technical assistance to the NMEC as they prepare for the 2020/2021 LLIN mass distribution campaign. Since PAMO ends in September 2020, the bulk of the LLIN technical support to the NMEC will be provided by Vector Links. In Year 5, to avoid duplication of efforts, PAMO’s technical support to the NMEC will be at national level through the Vector Control TWG and the ITN Planning Task Force. While some technical support needs will emerge as the mass distribution campaign starts, PAMO’s technical support efforts will focus on assisting the NMEC to develop and refine estimates of ITN procurement costs; distribution and warehousing costs; technical and operational costs; and expected partner contributions. Through the ITN Planning Task force, PAMO will collaborate with the SBC TWG to ensure SBC activities are considered during registration and post campaign activities. PAMO will also facilitate travel of one NMEC Officer to attend the Alliance for Malaria Partnership (AMP) meeting in Geneva.

Outputs

• Two rounds of supportive supervision visits conducted to selected health facilities in each province. • 1800 copies of the 2017 Zambia LLIN Distribution Guidelines printed and distributed to all provinces and districts. • 832 selected health facility staff oriented on the 2017 Zambia LLIN Distribution Guidelines. • LLIN durability monitoring data collected at 24 months from distribution and reports shared. • Technical assistance provided to NMEC for planning of the 2020/2021 LLIN mass campaign. • One MOH Officer to attend the AMP meeting in Geneva

Table 9: Activity and implementation timeline for Task 1.1.

Strengthen ITN distribution in the target provinces Timeline in quarters

Activities Outputs Q1 Q2 Q3 Q4

Conduct two supportive supervision visits to Two rounds of supportive supervision health facilities to strengthen the ANC/EPI data visits conducted to selected health X X collection and stock control inclusive of SBC facilities in each province activities

Distribute 2017 Zambia LLIN Distribution 1800 copies of the 2017 Zambia LLIN Guidelines to all provinces and districts Distribution Guidelines printed and X X distributed to all provinces and districts

Orient selected health facility staff on the 2017 832 selected health facility staff oriented Zambia LLIN Distribution Guidelines during on the 2017 Zambia LLIN Distribution X X supervisory visits Guidelines during OTSS

2 LLIN durability monitoring aims to provide information to optimize procurement, delivery, and effectiveness of LLINs. It allows national programs to identify products that perform below expectation and provides useful feedback to manufacturers as they strive to improve their products.

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Support NMEC to collect, analyze and report on LLIN durability monitoring data collected LLIN Durability Monitoring at 24 months from distribution and X X reports shared

Provide technical assistance to the NMEC to Technical assistance provided to NMEC plan for the 2020/2021 LLIN mass campaign at for planning of the 2020/2021 LLIN X X X national level through VCTWG meetings mass campaign

Facilitate travel of one MOH Officer to attend the One MOH Officer to attend the AMP X AMP meeting in Geneva. meeting in Geneva

Task 1.2: Improve access to and quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment

Universal coverage with early diagnosis and effective treatment is a key strategy for reducing morbidity and mortality due to malaria (NMESP 2017–2021). PAMO will continue to support the improvement of access to and quality of malaria case management at public health facilities and at the community level to ensure prompt, accurate diagnosis and appropriate treatment of malaria.

In order to operationalize Task 1.2 in line with NMESP 2017–2021 and the PMI FY2019 MOP, PAMO will use the approaches below in the four targeted provinces. • Improve the quality of parasitological diagnosis in the public sector through training and supportive supervision of health care providers at the health facility and community levels. PAMO is committed to working at the provincial, district, facility, and community level to improve the appropriate use of diagnostics (microscopy and rapid diagnostic tests [RDTs]), including interpreting test results and managing patients based on results. To support quality malaria diagnosis in health facilities where there is no microscopy or well-trained laboratory staff, PAMO will strengthen the use of malaria RDTs. In addition to the above, PAMO will support the NMEC in the printing and distribution of job aids for quality malaria microscopy and RDT use as part of the package of training materials, and advocate to other procurement and supply management implementing partners to ensure the availability of microscopy and RDT-related commodities. • Strengthen malaria case management at the facility level through training and support for the supervision of healthcare providers in the treatment of uncomplicated and severe malaria. PAMO will support the NMEC to adhere to 2017 Guidelines for the Diagnosis and Treatment of Malaria in Zambia. PAMO will also support the printing and distribution of job aids for malaria case management such as algorithms/flow charts as part of the training material package, the supervision and mentorship of health providers in managing patients based on results (i.e., adhering to test results), and treatment in line with the classification of malaria (uncomplicated malaria in normal and special risk groups, severe malaria, and pre-referral treatment). PAMO will support training of health workers at health facilities with inpatient services on use of injectable artesunate for severe malaria during the OTSS and mentorship visits. • Strengthen malaria case management at the community level by continuing to support the training of CHWs and CHW supervisors in iCCM using the iCCM harmonized curriculum. In selected districts, PAMO will also work with the MOH to provide supportive supervision of the CHWs as they implement iCCM. Acceptability of the CHWs by the community will be enhanced through the use of community malaria agents and CSOs as outlined in Task 1.4

Case management at facility level

PAMO’s support aims to improve both access and quality of services. The biggest contributor to malaria inpatients and malaria deaths is access to care. On the access side, PAMO is aiming to reduce malaria inpatients and deaths by rolling out iCCM and surveillance to improve access to care. Access to care and treatment closer to infected febrile children is the best way to reduce inpatient attendance and malaria deaths. On the quality side, OTSS will be the major

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investment in health system strengthening activity targeting outpatient quality of care. OTSS will not reduce OPD attendance or any other measurable indicator of disease burden but it may improve quality of care for uncomplicated malaria patients attending these facilities with the view that the uncomplicated cases will not progress into severe malaria.

Improving the quality of parasitological diagnosis in the public sector In Year 5, PAMO will not conduct refresher training of microscopists (which has been conducted in the past) nor support biomedical scientists to attend the WHO Accredited Malaria Microscopy Competence Assessment and Training (which was facilitated in Year 4) but will focus on supporting the laboratory staff to participate in the provincial OTSS in order to support microscopy quality assurance. The laboratory supervisors will provide on-site training, corrective action, and immediate feedback to facility staff during OTSS. A recent assessment done by the NMEC revealed that only 2.8% of malaria diagnosis in 2018 was done by microscopy with the rest done by RDT. PAMO will support the increase in the use of quality microscopy in malaria diagnosis through OTSS in health facilities which provide malaria microscopy services, particularly referral facilities with well-functioning laboratories. Microscopy remains the gold standard method for malaria diagnosis. It has advantages for patient follow up for severe malaria cases (inpatient care), determination of parasite density (assessment of severe malaria), gametocyte detection and speciation.

Strengthening malaria case management at facility level In Years 2–4, PAMO supported provincial and district teams to conduct two rounds of OTSS. In Year 5, PAMO will be winding down its activities by the end of the second quarter of 2020, therefore PAMO will only conduct one round of OTSS for both facilities with malaria microscopy services (provincial OTSS) and those without malaria microscopy services (district OTSS). PAMO has planned to conduct OTSS in 93% (n=78 out of 93) health facilities providing malaria microscopy services and in 63% (n=323 out of 515) health facilities without malaria microscopy services (Table 10). These facilities are essentially the same facilities which have been “followed” over the course of the project because principally OTSS is a quality assurance program for malaria case management. The trends generated may inform relevant programmatic decisions; for example, the need for targeted trainings and other relevant inputs. PAMO will continue to encourage the districts to take ownership in the implementation of these activities.

Table 10: Overview of OTSS targeting for 2020.

Province Total Number Total Number % of Total Number % of Number of number of of targeted number of of targeted of facilities facilities facilities health facilities facilities health districts in the offering targeted facilities which do targeted facilities province malaria for for not offer for for microscopy provincial provincial malaria district District services OTSS OTSS microscopy OTSS OTSS services

Eastern 5 112 12 100% 92 62 67% 12 (main)

Luapula 12 163 23 23 100% 140 77 55%

Muchinga 9 122 19 19 100% 103 66 64%

Northern 12 210 30 27 90%* 180 118 65%

Total 47 607 84 78 93% 515 323 63%

*In Northern province 3 out of the 30 microscopy facilities do not provide microscopy services. These are Army Clinic in Kasama, Nsama Clinic in Nsama and Mambwe Clinic in Senga. They do not have trained laboratory staff, so they are not yet functional.

PAMO will also support the provincial and district teams to conduct one round of intermediate technical supportive supervision (TSS). TSS is an intervention that will take place in between the rounds of OTSS to address specific gaps identified in the previous round of either provincial or district OTSS. intermediate technical supportive supervision to address any specific weaknesses identified during the rounds. This intermediate round will include a peer to peer mentorship approach where well-performing health facilities go to support those that are not performing well. This will take the form of mentorship with fewer technical persons to fewer facilities. This is similar to the TSS conducted in the MOH typically following provincial or district biannual Performance Assessments. TSS will occur only in twenty low performing facilities (five per province) identified immediately after a round of either provincial or district OTSS. HMIS data will also be used to identify areas that require technical support. The technical teams formed will comprise

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clinicians, laboratory staff, pharmacists, and/or maternal and child health coordinators but will focus on gaps identified in those selected facilities. The transferring of knowledge and skills will either be done one-on-one or using a group mentorship approach.

Outputs

• One provincial OTSS and mentorship round in 78 health facilities with microscopy services conducted to maintain the quality of microscopy services. • One district OTSS and mentorship round conducted in 324 health facilities without microscopy services in order to improve the quality of malaria diagnosis and treatment. • One technical supportive supervisory visit to 20 low performing facilities to improve performance of health facility staff following the provincial and district OTSS rounds.

Table 11: Activities and implementation timeline for task case management at facility level.

Case management at facility level Timeline in quarters Activities Outputs Q1 Q2 Q3 Q4 Conduct provincial OTSS and mentorship One provincial OTSS and mentorship X round in health facilities with microscopy round in 78 health facilities with services to maintain the quality of microscopy microscopy services conducted. services. Conduct district OTSS and mentorship round One district OTSS and mentorship X in health facilities without microscopy services round in 323 health facilities without to improve the quality and malaria diagnosis microscopy services conducted. and treatment. Conduct technical support supervision visits to One TSS visit to 20 low performing X low performing health facilities to improve health facilities conducted. performance of health facility staff

Case management at the community level

Strengthen malaria case management at the community level through integrated community case management

The expansion of community-level case management of malaria is an essential part of the current strategy to progress toward malaria elimination in order to engage the needed work force, improve access to care, and expand malaria surveillance and reporting (Box 1). Zambia’s national strategy has long emphasized the scale-up of community case management using artemisinin-based combination therapy (ACT) and RDTs.

Over the life of the project PAMO has not only supported the training of CHWs and their supervisors but also built capacity within the PAMO supported districts to handle iCCM and surveillance training. Provincial and district CHW trainers were trained for this purpose. In Year 2 PAMO trained 1,239 CHWs in iCCM only and trained 135 supervisors. In Year 3 and Year 4, PAMO trained a total of 1,808 CHWs, 208 iCCM supervisors and 89 trainers using the NMEC revised iCCM and surveillance module. In Year 5, PAMO will continue to support training and deployment of more CHWs in iCCM and surveillance focusing on selected districts in each province with a ratio of one CHW to 500 population in order to saturate the HFCA as per the recommendation of the MOH and expand access to case management. PAMO will train 840 CHWs broken down as follows: (Eastern 120, Luapula 175, Muchinga 305, and Northern 240) and 99 CHWs supervisors (Eastern 25, Luapula 24, Muchinga 25, and Northern 25).

Table 12: Overview of PAMO supported iCCM and surveillance training

Number of CHW Need 2019 estimated CHWs to be based on (1 Number of CHWs trained by District target trained by Supervisors CHW/500 PAMO by end of 2019 population PAMO in People) 2020 EASTERN PROVINCE Mambwe 87,348 175 165 20 5 Lundazi 139,229 278 0 100 10 Total EP 226,577 453 165 120 15

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LUAPULA PROVINCE Chembe 37,052 75 0 75 9 Kawambwa 111,375 223 0 100 10 Total LP 148,427 298 276 175 19 MUCHINGA PROVINCE Nakonde 174,478 349 165 199 15 Chama 151,428 303 60 106 10 Total MP 325,906 652 225 305 25 NORTHERN PROVINCE Mbala 179,554 359 145 140 15 Senga 125,783 252 80 100 10 Total NP 305,337 611 225 240 25

TOTAL 1,006,247 2,014 891 840 99

Box 1: Implementing passive versus reactive case detection at community level—when and where? In high burden, resource-limited areas, most malaria diagnosis and treatment will occur through “passive case detection,” where symptomatic patients present to a health facility or to a CHW. The deployment of increased numbers of CHWs who can provide prompt, convenient, free care is recommended for all areas of Zambia and serves at least three major purposes: it reduces morbidity and mortality of individual malaria victims, it can reduce malaria transmission at the population level by decreasing the infectivity of malaria patients, and it improves surveillance.

As malaria burden falls and the ratios of health workers to population increases, community case management can be expanded by incorporating “reactive” case detection (screening household members and neighbors of index cases found in passive case detection— a.k.a. “Step D” activities in Zambia). In certain pre-elimination and/or operational research settings, consideration has been given by MOH and partners (although not by PMI to date) to other forms of active case detection as well, such as screening populations for cases during mass drug administration. The experience in Southern Province has demonstrated the feasibility of these approaches in Zambia and their potential to greatly reduce local malaria incidence when part of a high quality, high-coverage package of interventions including vector control, SBC, and facility-level case management.

Each of these approaches calls for high coverage of CHWs. The MOH recommends in the Community Health Worker Strategy to have one CHW per 500 population. However, the PATH Malaria Control and Elimination Partnership in Africa (MACEPA) has demonstrated the effectiveness of one CHW per 850 population in lower transmission areas of Southern Province and the ratio of approximately one CHW per 750 population in higher transmission areas within Southern and Western provinces

Surveillance using DHIS2 helps to track the number of CHWs engaged in the process. The NMEC has set up a database on DHIS2 that helps keep track of who has been trained, where they are located, what facility they are assigned to work with, how many commodities are being used through testing and treatment services, the levels of malaria recorded in CHW-specific catchment areas, and management of top-up incentives for data reporting. This level of information and workload management requires extra support to the MOH.

In short, not all areas of Zambia or levels of transmission will be ready for nor benefit from reactive case detection. But as the full package of malaria interventions are deployed, reactive case detection may be an important step in sustaining gains made in areas as a result of intensive vector control or other treatment strategies that the MOH hopes to use with the strategy. Changes in burden can occur very quickly in focal areas, and CHWs should be equipped with the tools to sustain these gains as much as possible. Public health officials will determine when a catchment area may begin reactive case detection, based on the NMEC’s criteria related to: (1) low case incidence, (2) strong surveillance, and (3) adequate human resources.

Rollout of Rectal Artesunate Suppository (RAS)

PAMO will also roll out Rectal Artesunate Suppository (RAS) implementation in Chama District in Muchinga Province. The main objective of this activity will be to prevent deaths caused by severe malaria by using early diagnosis and treatment (including administration of RAS in children less than six years of age) and early referral. The activity has been described in detail in the PAMO Year 4 work plan addendum, with phase 1 (October 1, 2019–December 31, 2019) focusing on rapid startup of the project, and phase 2 focusing on strengthening the implementation of RAS in Chama

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District. In Phase 2, which will be implemented starting January 2020, PAMO will train 106 CHWs in this district. PAMO will extend the SOW for one of the CSOs supporting Chama to establish the food banks for RAS.

PAMO will also work with the MOH to provide supportive supervision and mentorship of the CHWs who have been implementing iCCM since 2018. PAMO will support monthly mentorship of 276 CHWs in Nchelenge District, 165 CHWs in Mambwe District, and 145 CHWs in Mbala and 80 in Senga in Northern Province. These trained CHWs have been implementing iCCM and surveillance (where appropriate) without regular supportive supervision and mentorship by the health facility staff due to inadequate resources.

PAMO has planned to procure enablers including t-shirts, aprons, caps, and where necessary starter kits for the CHWs in order for them to become fully functional.

Outputs

• 840 CHWs trained in iCCM with surveillance and deployed to provide iCCM (120 in Eastern, 175 in Luapula, 305 in Muchinga and 240 in Northern). • 99 CHW supervisors trained (25 in Eastern, 24 in Luapula, 25 in Muchinga and 25 in Northern). • Enablers procured for 840 CHWs • Two supportive supervision and mentorship visits to trained CHWs in Nchelenge, Mambwe, Mbala and Senga districts conducted

Table 13: Activities and implementation timeline for case management at community level.

Case management community level. Timeline in quarters Activities Outputs Q1 Q2 Q3 Q4 Train and deploy 840 CHWs in iCCM and 840 CHWs trained in iCCM with X X surveillance surveillance and deployed Train 99 CHW supervisors 99 CHW supervisors trained X X

Procure enablers for 840 trained CHWs Enablers procured for 840 CHWs X Provide logistical support to MOH to conduct Two supportive supervision and X X supportive supervision and mentorship visits mentorship visits to trained CHWs in to trained CHWs Nchelenge, Mambwe, Mbala and Senga districts conducted

Task 1.3: Increase delivery of IPTp-SP as part of an integral package of ANC services

Due to its link to various complications during and after pregnancy, the prevention of malaria among pregnant women is regarded as an important strategy for reducing mortality and adverse maternal and neonatal health outcomes, such as maternal anemia, low birth weight, and perinatal deaths. The NMEP has developed and is implementing a well- defined MIP strategy, which includes the provision of free IPTp for pregnant women with at least four doses of SP during pregnancy, free LLINs, and free prompt diagnosis and treatment of malaria. This malaria control package is implemented as part of routine ANC.

The MIP interventions aim to increase ANC attendance and the consistent delivery of IPTp. PAMO supports three main strategies to address malaria in pregnancy: LLINs distribution to pregnant women through ANCs (Task 1.1), appropriate case management of MIP through training of healthcare workers on malaria diagnosis and treatment guidelines (Task 1.2), and intermittent preventive treatment in pregnancy using sulfadoxine pyrimethamine (IPTp-SP). The MIP activities align strategically with the NMESP 2017-2021.

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Throughout pregnancy, all women should have contact with a health care provider at a health facility or during community outreach services eight times. The NMEC recommends starting IPTp with SP as early as possible in the second trimester (starting at 13 weeks) of pregnancy and at each ANC contact until delivery, provided that the doses are given at least one month apart. SP is not recommended during the first trimester of pregnancy; however, the last dose can be administered up to the time of delivery making up to six doses of IPTp possible in any pregnancy. Most CHWs are also in the SMAGs. PAMO supports orientation of SMAGs to encourage and promote early ANC attendance and Task 1.4 provides SBC as well to SMAGS.

Strengthening the provision and use of IPTp

The adequate provision and use of IPTp is closely linked to ANC services. Thus, in Year 5, to increase uptake of IPTp- SP, PAMO will support the participation of ANC staff in one round of provincial OTSS in each of the PAMO-supported provinces. One TSS follow-up to fill the ANC (MIP) gaps observed during the second 2019 provincial OTSS round. Similarly, PAMO will also support the participation of ANC staff in one round of district OTSS in each province and one TSS follow-up round to fill ANC (MIP) gaps observed during the district OTSS. This approach concentrates on specific skills gaps identified and facilitates understanding and practice. The number of visits are conducted regularly, until the required practice is acquired so as to ensure improved and sustainable technical skills for IPTp-SP using the ANC platform.

PAMO will provide support to Nchelenge to orient 16 new ANC providers in IPTp WHO 2016 guidelines because it is the focus district and it was noted that many ANC providers trained in 2017 have since left the district. PAMO aims to sustain the gains in IPTp uptake, therefore all the facilities in Nchelenge will have at least one provider oriented in IPTp- SP. Communication-related activities to promote healthy and effective malaria prevention behaviors during pregnancy (Task 1.4), and support for routine distribution of LLINs through ANC (Task 1.1) will be supported in Eastern, Luapula Muchinga and Northern provinces.

As it is evident that uptake reduces with subsequent doses of IPTp (MIS 2018), PAMO will promote “diagonal” integration which means, getting close to the pregnant women by systematically combining services, leveraging existing platforms to increase uptake of SP. This is in efforts to ensure continuity of the program within available resources, in line with the PAMO sustainability plan. It is critical to use existing platforms and link with current and planned investments such as, Safe Motherhood Action Groups (SMAGs) which encourage pregnant women to attend ANC as scheduled preferably first booking to be done in the first trimester of pregnancy, promote the uptake of SP at community level in rural settings, early treatment-seeking behavior of malaria cases in pregnancy, and LLIN utilization throughout the women’s pregnancy. Orientation of SMAGS to WHO ANC guidelines will also be supported by PAMO (30 SMAGs in Eastern, 30 in Luapula, and 100 in Muchinga) and will take advantage of safe motherhood week (six days) to provide directly observed therapy of IPTp-SP with the aim of contributing to increased uptake of IPTp-SP among eligible ANC pregnant women.

Due to SP stock out during 2018 and 2019, “no commodity no program”, thus, in year 5, PAMO shall continue engaging the MOH to advocate for the availability of SP and 0.4 mgs of folic acid in the health facilities.

Outputs

• One round of five follow-up TSS rounds with a focus on IPTp (one in Eastern, Luapula, and Northern, and two in Muchinga) conducted. • One round of provincial OTSS with a focus on IPTp conducted in 78 health facilities. • One round of district OTSS/mentorship with a focus on IPTp conducted in Eastern, Luapula, and Northern provinces in 323 health facilities • 16 ANC health facility providers updated on IPTp based on the revised 2016 ANC guidelines in Nchelenge. • 160 SMAGS (30 in Eastern, 30 in Luapula, and 100 in Muchinga) oriented in WHO ANC guidelines. • Support safe motherhood week commemoration in Northern province.

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Table 14: Activities and implementation timeline for increasing coverage of IPTp.

Support malaria in pregnancy Timeline in quarters Activities Outputs Q1 Q2 Q3 Q4 Conduct TSS visit in selected health One TSS visit in selected health facilities facilities to improve performance of conducted. Targets will derive from finding X health facility staff from first round of OTSS Conduct one round of provincial One round of provincial OTSS with focus X OTSS on IPTp conducted in 78 health facilities One round of district OTSS with focus on Conduct one round of district OTSS X X IPTp conducted in 323 health facilities Provide support for orientation of 16 ANC health facility providers oriented in ANC health facility providers in WHO guidelines in Nchelenge District X WHO ANC guidelines (focus district) 160 SMAGS (30 in Eastern, 30 in Luapula, Provide support for orientation of and 100 in Muchinga) oriented in WHO X X SMAGS in WHO ANC guidelines ANC guidelines Provide support for provision of IPTp Support safe motherhood week and first booking LLINs missed commemoration in Northern province. X opportunities during safe motherhood week

Task 1.4: Strengthen SBC implementation for malaria at health facilities and community levels through community mobilization and dialogue

The 2018 MIS reports declines in knowledge on malaria. Nationally, the percentage of women aged 15–49 who have heard of malaria and those who know that mosquito nets prevent malaria dropped from 94.5% in 2015 to 90.2% in 2018 and from 91.3% to 85.7% in the same period, respectively. MIS results also showed a decline in the percentage of people who heard of malaria—from 99.3% in 2015 to 90.2% in 2018 and the percentage of people who recognize fever as a symptom of malaria also reduced from 75.3% in 2015 to 71.5% in 2018.

In the first and second quarter of 2019, PAMO carried out a formative study aimed at informing SBC interventions and the revision of the current malaria communication strategy which has highlighted key challenges with regard to knowledge and attitudes on malaria. The findings show that community level misconceptions on malaria persists. Some members of the community still think that a pregnant woman can commence IPTp-SP before 13 weeks of pregnancy and that a person can get malaria if they are soaked by rain, eating sugar cane, and drinking dirty water. The study found that there is poor health care seeking behaviors which delays necessary timely treatment of malaria particularly for under-five children; and that the use of vector control interventions, particularly IRS and ITNs, remains suboptimal. With regard to the use of media, the study found that the most preferred channel of communication was interpersonal engagement through health talks and community meetings while radio was the second preferred.

These findings call for strengthened SBC strategies and sharpening channels of delivering messages for SBC activities targeting communities and individuals in order to increase awareness and knowledge of malaria prevention and treatment interventions and to enable community members to translate knowledge into practice and adopt proven malaria interventions (such as early care seeking behaviors and ITN use) as social norms.

In PAMO’s year 5 work plan, SBC activities are informed by PAMO’s past experience implementing activities at community level and by the key findings of the formative research whose recommendations has put emphasis on the use of community and health facility based meetings as an efficient avenue to enhance malaria education in communities; engagement of influential people such as civic, religious, and community leaders as essential to

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enhancing acceptance of vector control methods particularly IRS and ITN use; and addressing myths and misconceptions associated with malaria. To be responsive to these findings and to build on previous SBC interventions, PAMO’s SBC activities will focus on three interlinked approaches: creating demand for uptake and utilization of malaria services; promote utilization of proven malaria interventions particularly vector control and promote ownership and sustainability at community level. These approaches will simultaneously be implemented in 26 out of 42 districts in which the PAMO main program operates (this number excludes pre-elimination district covered under a separate work plan). See annex 1 for the names of the districts in which PAMO will implement SBC activities. In 22 of these districts PAMO will implement activities through civil society organizations (CSOs) – see Task 1.6 – while in 4 districts (Milenge, Mbala, Chama, and Mambwe), where there are no CSOs, PAMO will closely work with DHOs and communities to implement SBC interventions. To maximize impact in all the districts, PAMO will use two broad strategies – community wide interventions targeted at whole communities and interpersonal approaches to influence adoption of positive behaviors. The earlier will be about creating demand through mass media activities while the later on promoting utilization of malaria services, ownership and sustainability at community level. In all the SBC interventions messages will focus on improving health care seeking behaviors particularly for under-five children with fever, uptake and use of vector control services, and acceptance of community health workers providing malaria case management at community level. Create demand for malaria services

To create demand for malaria interventions and services at individual, community, and institutional levels, PAMO will utilize mass media approaches including the use of community radio stations and supporting participation in World Malaria Day activities aimed at reaching whole communities. These approaches are strategic in reaching wider audiences and the general populations that cannot be reached through targeted community approaches with accurate and appropriate messages. The aim is to increase general population’s awareness of and ability to access malaria services.

Mass media: The use of mass media will focus on radio programs and airing of the PAMO documentary. In Year 4 PAMO held media awareness and sensitization workshops among 16 radio stations in the four target provinces to build capacity in disseminating information on malaria and also engaged a video production company to produce a documentary highlighting PAMO’s activities over the last four years. In Year 5, PAMO will engage 9 of the 16 radio stations to broadcast radio discussion programs and jingles and three local TV stations to broadcast the PAMO documentary. The 9 selected community radio stations include the Zambia national broadcasting cooperation (ZNBC)’s radio 2 that has national wide coverage and 8 community radio stations with district wide coverage in the selected districts where PAMO operates. Hence PAMO will cover all the 46 targeted districts in all four provinces with radio messages. In Luapula (Samfya and Chembe districts) and Muchinga (Nakonde and Chinsali) provinces, however, there are two other PMI supported partners broadcasting malaria messages on radio. These are Breakthrough Action and Population Media Services. PAMO will coordinate with these partners to align messages, radio discussion programs, and broadcasting schedules to avoid duplication. In each province, PAMO will use separate radio stations from those being used by the two partners in order to expand reach and increase opportunities for people to listen to various malaria messages on different radio stations.

PMI has already approved PAMO’s radio discussion guides and the radio jingles that were produced in English and local languages to encourage people access malaria services, however, at the time of producing this work plan the production of the documentary was still underway. In Year 5 PAMO plans to broadcast 17 radio discussion programs, 600 radio spots focusing on key messages on proven malaria interventions, and to air the documentary on three TV stations – ZNBC the public broadcaster and two private stations with a wide coverage. The messages will be broadcast repeatedly to increase the opportunity for communities to tune in and listen to the programs. Both radio and TV stations will be encouraged to advertise the programs in advance to alert the general population to tune in at the time of broadcast.

Dissemination of malaria messages during World Malaria Day commemoration events: Every year in April Zambia joins the world to commemorate the World Malaria Day (WMD) whose value is in increasing awareness on malaria in the general population and enhancing political commitment to malaria elimination. In Year 5, during the week leading up to WMD, PAMO will support the NMEC to participate in WMD by supporting community level activities to disseminate malaria messages in 26 districts. In Mambwe, Mbala, Chama, and Milenge districts where there are no CSOs community activities will be carried out by 760 community change champions that PAMO will directly support through DHO and will conduct health talks at community and health facility level. In the 22 remaining districts, CSOs

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will support DHO and health facilities to implement SBC activities during WMD commemorations. PAMO’s messaging focus for 2020 WMD, will be on: enhancing IPTp among pregnant women, encouraging mothers with children under the age of five to take their children with fever for early malaria diagnosis, and educating the general public on the importance of utilizing available malaria services in order to prevent malaria in their communities. Additionally, PAMO will support each of the focus districts to hold a commemoration event at which MOH officials, other line ministries, and key stakeholders will be invited. To increase the opportunity of the public to have access to more information on malaria, PAMO will procure and distribute 1,650 branded communication materials to be distributed to all the 26 districts. These will include banners and stickers, photo frames, and malaria briefs which will also be used by CSOs to educate the community beyond WMD. On the actual WMD, PAMO will award certificates to hardworking malaria agents and CHWs that provide iCCM to recognize their service to their communities.

Promote utilization of malaria interventions and services through community dialogues: In Year 5, PAMO will continue supporting interventions that assist community members in adopting behaviors and norms that lead to increased use of malaria prevention services. To influence the uptake and use of proven malaria interventions, PAMO will work with CSOs and health care workers to implement community dialogues in select communities in all the districts. To ensure high impact for community dialogues, PAMO will provide discussion guides to encourage early care seeking behaviors including testing for malaria as soon as one experiences signs and symptoms and accessing treatment upon confirmation of malaria.

In Year 4, PAMO supported DHOs and CSOs in 26 districts to conduct 500 community dialogues—community meetings led by community leaders (headmen, chiefs) and Community Change Champions (CCCs) with the support of health facility staff and PAMO staff—surrounding 250 health facilities. In Year 5, in the same districts, PAMO will continue to support DHOs and CSOs to conduct 600 community dialogues. The number of dialogues will increase in year five because PAMO plans to increase the number of community champions that will conduct the dialogues (see community champions approach below). The dialogues will help address the knowledge gaps on malaria as identified in the MIS, the formative research report, and previous dialogues that identify key challenges such as inadequate ITN use, lack of adherence to treatment, delayed ANC bookings, and poor acceptance of vector control measures particularly IRS and ITNs by some community members. Community dialogues will also be used to sensitize communities on the 2020-21 ITN mass distribution campaign and the acceptance of rectal artesunate suppository (RAS), a pre-referral drug aimed at reducing severe malaria in children, for Chama district where PAMO has received funding to implement a RAS program.

Promote ownership and sustainability: To promote ownership and sustainability, in Year 4 PAMO provided sub- grants to 15CSOs to implement SBC activities at community level. Through the CCI approach, PAMO trained and deployed 2,475 Community Change Champions (CCCs) who were supported to conduct health talks, door to door visits, village meetings and health talks at health facilities and religious gatherings.

As the project winds down in 2020, PAMO’s approach on ensuring sustained ownership of malaria interventions at community level will be to continue supporting the CCI and to support district health officials to own the monitoring and supportive supervision of CCCs beyond PAMO. PAMO will also disseminate the formative research findings in order to empower PHOs and DHOs to develop SBC interventions informed by evidence.

Support to faith-based organizations (FBOs): Faith communities play a significant role in influencing and shaping behavior of individuals and communities. They can engage people at individual and community level to adopt malaria preventive behaviors and ensuring that those with fever and other malaria symptoms promptly access malaria testing and treatment services. In Year 5, PAMO will provide SBC support to a select number of activities through FBOs. A scope of work will be submitted to PMI with further details on the mechanisms of supporting FBOs when additional information is available.

Implementation of Champion Communities Initiative: In Year 5, to sustain the gains made in reaching community members with key malaria messages, PAMO will continue to provide sub grants to local civil society organizations (CSOs) to implement the CCI approach and other community level SBC activities (health talks, community dialogues, religious leaders’ meetings, village meetings, community video shows, and quiz competitions in schools). Refer to Task 1.6 for details of CSOs engaged.

To further rollout the CCI approach, and expand sustainability, PAMO will directly support DHOs in four focus districts of Chama, Mambwe, Mbala, and Milenge to increase the number of Community Change Champions. PAMO will train an additional 760 CCCs bringing the total CCCs to 3,235 in all the 26 districts that PAMO targets for SBC activities. To increase the number of CCCs, PAMO will first train 60 DHO and health facility staff in how to sustain the CCI approach who will in turn rollout the CCI approach to 76 selected health facilities where the CCI approach will be implemented.

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From each of the 76 health facilities PAMO will train 10 CCCs bringing the total to be newly trained and deployed in the first quarter of 2020 to 760 additional CCCs.

The CCCs will target households in each of their communities. Using a malaria flip chart developed by PAMO, CCCs will facilitate discussions at household level encouraging individuals and families to adopt early health seeking behaviors and vector control interventions. The CCCs will also be conducting health talks during ANC and under-five clinics to encourage mothers access malaria services and they will conduct community dialogues on key malaria interventions. For effective documentation of their activities, CCCs will be equipped with knowledge on how to collect SBC data related to malaria services within their communities and will be provided with tools to carry out their activities that include flip charts, t-shirts, books, pens, and data collection tools.

Support health facility staff to monitor and supervise SBC activities implemented by CCCs: As PAMO withdraws from communities in PAMO targeted provinces, it is important that MOH staff continue implementing the activities that have jointly been implemented over the last four years of the project. In Year 5, therefore, PAMO will support health facility staff to conduct monthly monitoring and supervision visits in all PAMO supported districts to ensure quality SBC activities and messaging are delivered. Health facility staff will have built their sustained capacity to continue with SBC activities beyond PAMO. To leverage resources, PAMO will ensure that health facility staff integrate SBC activity monitoring with other supervisory visits such as OTSS, data quality audits or maternal and child health outreach programs.

Dissemination of formative research results: As mentioned earlier on, PAMO supported the NMEC to conduct formative research exploring social behavioral and normative factors underlying malaria prevention in order to help revise the current national communications strategy. To make the research results available and relevant to key stakeholders’ plans, PAMO has planned to disseminate the report. PAMO will use various avenues including disseminating it through the SBC TWG meeting during which results of the formative research as well as key recommendations will be shared. It is hoped the findings will lead to the development of evidence-based communication strategies that address the behavioral factors for the country’s changing malaria epidemiology.

Outputs

• 60 DHO and health facility staff oriented on the CCI approach and SBC messaging. • 760 community change champions oriented on the CCI approach • 3,235 CCCs supported to conduct SBC activities in 26 districts • 26 districts supported to hold world malaria day commemorations • 600 community dialogues held in communities around health facilities in 22 districts. • Health facility staff supported to conduct five monthly monitoring and supervisory visits • 600 radio spots broadcast • 17 radio discussion programs aired on 9 radio stations covering all PAMO supported districts. • Formative research results disseminated through the SBC TWG. • 1,650 branded communications materials procured for 22 districts.

Table 15: Activities and implementation timeline for SBC.

Strengthen SBC for malaria at health facility and community level through Timeline in community mobilization and dialogue quarters Outputs Activities Q1 Q2 Q3 Q4 60 DHO and health facility staff oriented Hold two-day orientation meeting for DHO and X on the CCI approach and SBC health facility staff on the CCI approach in messaging Chama, Mbala and Mambwe 760 community change champions Hold one-day orientation meetings for X oriented and equipped with enablers community change champions on the CCI in four districts 3,235 CCCs supported to conduct SBC CCCs conduct health talks, door to door X X activities in 26 districts activities and community dialogues

26 districts supported to hold world Commemorate World Malaria Day in 26 districts X malaria day commemorations

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600 community dialogues held in Conduct community dialogues to discuss key X X communities around health facilities in malaria interventions 22 districts. Support health facility staff to monitor and super X X Health facility staff supported to conduct 5 monthly monitoring and supervisory CCCs visits Air radio spots and radio discussion programs X X • 600 radio spots aired on 9 radio stations on key malaria interventions • 17 radio discussion programs aired Support the SBC TWG meeting and X Formative research results disseminated through the SBC TWG disseminate formative research findings 1,650 branded communications materials Procure branded communication materials X X procured for 22 districts.

Task 1.5: Strengthen malaria policies and guidelines

In Year 5, PAMO will continue to support the NMEC to strengthen the policy environment in Zambia. This includes supporting the revision of the national malaria policy based on an updated NMESP 2017–2021 and the development of a new operational plan. The updates will be informed by the findings of a midterm review of the NMESP conducted in 2019 with support from PAMO. As the revised malaria policy will need to be responsive to these findings and based on available programmatic and research evidence, PAMO will provide technical support to the NMEC to convene a consultative process that will review the current policy, develop a new malaria policy document, and generate and produce any guidelines that will emerge because of the revised policy. PAMO will also provide critical technical assistance to address some challenges in the following important areas:

- Community case management data capture for accurate stratification

- Rational use of commodities in iCCM, especially in high burden areas

- Procurement and distribution of SP

- Appropriate targeting of mass drug administration (MDA)

- Operationalizing the strategy of deploying ITN and IRS in a mosaic approach

At the national level, PAMO has a critical role to play in strengthening national -level planning and delivery of proven malaria interventions through supporting the government to coordinate the community of malaria stakeholders in Zambia to ensure complementary, efficient use of resources and synergistic impact. This role is commensurate with Tasks 1.1 (TWGs) and Task 1.5 (policy and guidelines). Since Year 3, PAMO and MACEPA jointly contributed to position of Senior Policy, Strategy and Management Advisor (SPSMA) to the NMEC leadership. The SPSMA has played an important role in translating policies and operational planning for improved implementation at every level through the institutionalization of the harmonized work planning tools, the malaria scorecard, the monthly NMEC Directorate management meetings. The SPSMA will continue to aid PAMO to leverage and integrate with other investments in the subsector such as the Global Fund to provide an enabling environment in which the NMEC will function professionally. Through partnership with the MACEPA mechanism, PAMO will be a part of the core team providing high-level mentorship to the NMEC senior leadership.

To ensure that the national policy documents are available at national, provincial, district, and health facility level, PAMO will support the printing and distribution of the revised national strategy, the revised operational plan, the policy document, and emerging guidelines. PAMO will hire a consultant to finalize the malaria operational plan for NMEC.

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Outputs

• Consultative process for policy review held. • Malaria policy document developed. • Revised national strategy, operational plan, national policy, and guidelines printed and distributed.

Table 16: Activities and implementation timeline for strengthening malaria policies and guidelines.

Strengthen malaria policies and guidelines Timeline in quarters Activities Outputs Q1 Q2 Q3 Hold a consultative policy review process to Consultative meeting held and policy x inform the new malaria policy document draft produced Provide technical assistance to the NMEC to Malaria policy document developed x x develop a malaria policy document and implemented Revised malaria strategy, operational x x Print and distribute national documents plan, national malaria policy, and guidelines printed and distributed

Task 1.6: Support civil society organizations (CSOs) and community- based organizations (CBOs) to implement malaria control activities

Malaria affects individuals in communities such that elimination of malaria requires active participation of the community as the primary stakeholders. To harness this community involvement in the promotion and uptake of malaria interventions at the community level, PAMO envisaged contracting CBOs and CSOs through the Grants under Contract (GUC) mechanism in the PAMO-supported provinces. PAMO will also support faith-based organizations to leverage their positive influence on communities. A detailed scope of work for supporting FBOs will be submitted to PMI later when details on the support mechanism is available.

To facilitate the promotion of community participation, PAMO works with DHOs to ensure that resources provided to selected CSOs through GUCs are effectively managed for key activities. Through Task 1.6, CSOs implement district community engagement plans developed by DHOs as described in Task 1.4.

Table 17: List of PAMO contracted CSOs and the districts they operate in

Names of CSOs and Districts they will work in

Name of CSO Province District(s) Time Frame for 2020 1 Action Africa help Luapula Mwansabombwe January– June Chiengi, Chembe 2 Caritas Mpika Muchinga Mpika, Chinsali and January– June Chama 3 Community Based Care Foundation Northern Mungwi January– June

4 Eastern Province Women’s Eastern Chipata January– June Development Association 5 Group Focused Consultations Luapula Mansa, Samfya January– June

6 Kasama Christian community Care Northern Senga Hill, January– June

7 Mphatso Development Foundation Eastern Nyimba January– June

8 Network of Zambian People living with Luapula Nchelenge January – June HIV & AIDS (NZP+) Nchelenge Chapter

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9 Network of Zambian People living with Eastern Petauke, January– June HIV & AIDS (NZP+) Petauke Chapter 10 Reformed Open Community Schools Muchinga Mafinga, January– June (ROCS) 11 Society for Women and Aids in Zambia Muchinga Isoka, January– June (SWAAZ) 12 Thandizani Integrated Health and Eastern Lundazi January– June Community Development Programs 13 Vision Africa Regional Network Luapula Chipili, Mwense January– June (VAREN) - Zambia 14 Young Women’s Christian Association Northern Kasama January– June (YWCA) 15 Youth Development Association (YDA) Luapula Kawambwa, Lunga January– June

In its first two years, PAMO developed its GUC manual, mapped and identified CBO/CSOs, and conducted risk assessments for potential subgrantees. PAMO then proceeded to select and subcontract 19 subgrantees that had met the criteria stipulated in the GUC manual. In Year 3, the 19 subgrantees implemented SBC activities that facilitated the promotion of community uptake of malaria interventions through MOH structures in the community. In Year 4, only 16 CSOs continued the work with a changed methodology of CCI to respond to the shift of focus in the NMESP from control to elimination. In Year 4 CODEP was assigned to work exclusively under pre-elimination leaving PAMO main with 15 CSOs.

In Year 5 PAMO main will work with 15 CSOs. From the 15 CSOs PAMO worked with in Year 4, one called DOPE will be dropped for failing to meet the minimum standards of implementing Grants Under Contract. Its district (Chinsali) will be taken over by CARITAS to ensure the work is concluded well even in Chinsali. EPDWA currently working in the pre- elimination will get money from main PAMO to work in Chipata which restores the number of CSOs under PAMO main to 15. The difference in level of support is dependent in the number of facilities being supported. This is shown in Table 17.

PAMO has been conducting monitoring visits to the CSOs quarterly in an effort to ensure compliance of resources and also implementation of activities. These monitoring visits consist of PAMO staff (both from the head office in Lusaka and from the field), MOH staff, and CSO staff. Through these visits, PAMO has been able to:

• Discover misapplication and misappropriation of funds and take timely, corrective actions. • Authenticate, validate, and triangulate data on activities being reported by CSOs. • Provide onsite capacity-building and attend to challenges CSOs are facing as they implement activities in their respective scope of works. • Assess the results verses the plan on the ground and change the CSO implementation approach to the more impactful CCI.

In addition to these joint quarterly meetings, community engagement and mobilization officers from PAMO provincial offices have been monitoring the work of CSOs on a monthly basis and even attend select activities to provide technical assistance. These visits helped PAMO decide to drop two of the 19 CSOs for failing to meet the minimum standards of implementing grants under contract in 2019.

PAMO comes to a close in September 2020. One more CSO has failed to meet the standard of continuing to implement SBC activities under PAMO’s GUC component and so will be dropped at the close of 2019. The remaining 16 CSOs will continue implementation for five months up to May 2019, mainly concentrating on consolidating the achievements made in the last two years and preparing communities to continue working beyond PAMO. Each CSO will write a scope of work and budgets complete with implementation schedules which will be submitted separately to PMI for approval. PAMO prepared proposed activities for the CSOs to buy into using the community engagement plans that were prepared in Year 2.

Outputs

• CSOs implement community-based malaria interventions. • Bimonthly monitoring and technical support visit done and reported. • Closeout activity reports written.

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Table 18: Activities and implementation timeline for CSO/CBO-implemented malaria control activities.

Support CSOs/CBOs to implement malaria control activities Timeline in quarters Activities Outputs Q1 Q2 Q3 Q4

CSOs conducts and reports on community- Month and quarterly financial and X X based malaria intervention activities narrative reports PAMO and DHO staff monitor and report on Monitoring reports X X CSO work PAMO in conjunction with DHO staff and Closeout activity reports X CSOs carry out closeout activities

Task 1.7: Conduct operations research

In Year 5, no funding was allocated for operations research. Therefore, PAMO support to the NMEC will be restricted to technical support to the NMEC through the Surveillance, Monitoring, Evaluation, and Operations Research (SMEO) TWG.

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Objective 2: Strengthen management capacity of provincial and district MOH personnel

Task 2.1: Identify health system deficiencies at the provincial and district levels that constrain delivery of high impact malaria interventions in close collaboration with the MOH and other malaria actors

In Year 5, PAMO will not implement any new activities in this task but will continue to support the NMEC to strengthen malaria health systems. Since 2016, PAMO has been supporting the MOH through the NMEC at various levels (national, provincial, district, health facility, and community) to address the identified gaps in key areas such as project management, data management, leadership skills, coordination and problem analysis and to strengthen further capacities at provincial and district health offices to manage malaria programs more effectively. A core strategy that PAMO has employed throughout the project is to imbed staff within MOH. At the national level, PAMO has embedded malaria specialists in case management, ITNs, SBC, and M&E within NMEC offices who not only participate in policy and planning meetings, but also provide mentorship to their MOH colleagues. At the provincial level, PAMO embedded all staff (provincial coordinator, capacity building officers, surveillance officers, and community engagement officers) in each of the four provincial health offices to work alongside provincial teams to mentor and provide technical support to district health offices, health facilities and community members. This strategy ensured sustainable strengthening of MOH capacity and enabled PAMO to contribute to strengthening the malaria health systems, particularly malaria case management at both health facility and community levels (see Task 1.2), data quality improvements (Task 3.1), and community engagement (Task 1.4 and 1.6).

Task 2.2: Develop and implement a plan to strengthen management capacity as measured by set targets within each targeted province and district

In PAMO’s first and second year, to enhance management capacity of malaria programs in target provinces, BRITE, a PAMO consortium partner, assessed the capacity of district and provincial health managers to identify skills and management gaps at the time. A provincial and district profile outlining malaria response priorities and capacity gaps was developed. BRITE then developed a Malaria Management Capacity Building Plan using the Zambia Management and Leadership Academy (ZMLA) curriculum as a framework to build the capacity of district and provincial health managers. In its third and fourth year, PAMO completed the training. Through BRITE, PAMO trained 84 health managers and 12 mentors in all PAMO-supported provinces (Table 19). The model of training was a five-day, face-to- face training, followed by a two-month online e-learning program, and ongoing management mentorship by trained mentors for sustained use of the acquired skills. The training-built health manager’s skills in project management; administrative management; management, leadership and mentorship; planning and problem solving; strategic information management; and community health management.

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Table 19: Number of health managers trained by PAMO in all four provinces

Location Cadre Target Total Number Trained All PAMO provinces MOH, Local Authority and Line Ministries in 48 60 (main program) Luapula, Northern, Muchinga & Eastern Provinces Pre-elimination MOH staff based in the pre-elimination districts 14 12 districts Lusaka NMEC Officers* 10 0 All PAMO provinces Management Mentors 12 12 Total 84 84 *Although PAMO had planned to train 10 NMEC staff, the training did not take place, as the NMEC staff were not available for the training.

With the project coming to an end in September 2020, PAMO’s major activities in support of provincial and district health offices will wind down by June 2020. Therefore, PAMO’s capacity-building activities will focus on sustaining provincial and district health office capacity to continue building local level capacity for effective malaria management beyond the PAMO project. To do so, PAMO will support the four PHOs and 23 selected low performing DHOs to update their capacity development plans and to develop strategies of how to implement those plans. The output of this support will be an updated provincial and district capacity-building plan. The plan will articulate the capacity that PAMO has built so far, current gaps to be addressed, and a clear and cost-effective roadmap that provincial and district teams will use to address the identified gaps. Provincial and district health offices will also use the updated capacity-building plan to lobby for continued technical support and financial resources to strengthen their malaria interventions as they move toward malaria elimination beyond the PAMO project.

PAMO will support frontline field epidemiology training program (FETP) to hold a workshop to train MOH staff in epidemiology preparedness. Support for the Frontline program is cited in the FY19 malaria operational plan and will complement other PMI and CDC investments in the FETP program in Zambia. More details will be provided in a scope of work which will be submitted to PMI for approval.

Lastly PAMO will engage a consulting firm to produce an inventory of private sector organizations involved in supporting malaria control programs, including the identification of the most promising areas for enhanced public-private partnership in the future. While much anecdotal information on private sector activities is known – for example the contributions of mines to Vector Control on the Copperbelt – the need for a comprehensive and up-to-date inventory was identified during the MOP exercise in September 2019. The objective will be to enhance the capacity of the MOH to effectively leverage private sector resources, including through the recently constituted End Malaria Council and End Malaria Fund. A SOW for this consultancy will be developed in consultation with PMI during Q1, for implementation in Q2 and Q3.

Outputs

• Four provincial capacity development plans updated. • 23 district capacity development plans updated. • One FETP workshop held • Inventory of private sector involved in malaria programs developed

Table 20: Activities and implementation timeline.

Management capacity strengthening Timeline in Quarters Activities Outputs Q1 Q2 Q3 Conduct a provincial meeting to update Four provincial capacity x x capacity development plans development plans updated Conduct a district meeting to update 23 district capacity development x x capacity development plans. plans updated Support one FETP workshop One FETP workshop held x Develop an inventory of private sector Inventory of private sector involved x involved in a malaria programs in Zambia in malaria programs developed

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Objective 3: Strengthen provincial and district HMIS to improve data reporting, analysis, and use for decision-making

In order to achieve the objective of strengthening the HMIS to improve data reporting, analysis, and use for decision- making, PAMO set out to implement activities under three strategically inter-related project tasks. Task 3.1 focuses on HMIS data quality improvement, and Task 3.2 focuses on HMIS capacity-building for health facility staff and DHIS2 for selected provincial and district health staff. Task 3.3 focuses on assisting PHOs, DHOs, health facilities, and communities to strengthen malaria data analysis and use for decision-making.

Task 3.1: Provide technical/material assistance to DHOs, health facilities, and communities to improve the timeliness and accuracy of HMIS reporting

Task 3.1 is focused on supporting data quality based on three dimensions, namely timeliness, completeness, and accuracy. In the life of the project, PAMO set targets on these three elements based on three performance indicators.

The first performance indicator is for timeliness which is percentage of health facilities in all districts in target provinces reporting timely HMIS data. The 2015 baseline was 42% and the 2020 life of project target was set at 90%. So far, the 2019 overall average performance on the indicator is 81.8%, a 195% progression from the baseline and 91% of the life of project target.

The performance indicator for data completeness is percentage of health facilities in all districts in target provinces reporting complete HMIS data. The baseline in 2015 was 80% and the life of project target was set at 98%. The result up to August 2019 was 89%, a 111% progression from the baseline and 91% of the life of project target.

The data accuracy indicator is a percentage of health facilities in all districts in target provinces reporting accurate HMIS data, which compares HMIS/DHIS2 reported data with health facility registers. The baseline used was the 2016 data quality audit (DQA) result, which was 22% with the life of project target set at 97%. The latest DQA result was 63.3%, a 288% progression from the baseline and 65.3% of the life of project target. Although there has been significant improvement in the data accuracy indicator, at 63.3% it remains low. The low performance is attributable to challenges in transferring data from service registers to the electronic system. To measure accuracy, data quality auditors compare data that is in the health facility registers with the data that is submitted into the HMIS/DHIS system. If the data is the same, then it is accurate. Before data is entered into the HMIS/DHIS2 system, health facility staff use tally sheets to aggregate data from various service registers into the Health Information Aggregation (HIA) form. Data from the HIA form is then entered into the HMIS/DHIS2 system. PAMO has noticed that some facility staff tend to make mistakes when tallying or compiling data on the HIA forms which results in data inaccuracies. This is so, especially when health facilities have new staff who may not have undergone HMIS orientation. Although DQAs have always been helpful in identifying these challenges and making corrective measures, while at the same time giving immediate technical guidance, a need has arisen to strengthen the DQA approach with an onsite mentoring approach in order to improve data accuracy. Under Task 3.2, PAMO has planned to provide regular technical support and mentorship to staff in health facilities that, in the Year 4 DQA rounds, were found to be weak with regard to data accuracy. That should be helpful in improving their accuracy scores in Year 5.

It should be noted that these performance indicators are for the life of the project from baseline and the figures are for all the health facilities in the four PAMO provinces and obtained from the HMIS/DHIS2 database, while the DQA results are for selected health facilities visited for DQAs and the data source is the DQA report based on the field level findings. It is envisaged that the activities planned for the last year of the project will help to sustain the gains on data quality performance as well as raise the overall scores toward the ultimate targets for the life of the project.

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Since the strategic aim for Objective 3 in the Year 5 work plan is not only to push for achieving the life of project targets but to also sustain the positive baseline performance results, priority areas under Task 3.1 will include HMIS DQAs and malaria surveillance DQAs. The HMIS DQA will target health facilities with data reported into the main MOH HMIS/DHIS2 database while the surveillance DQA will target health facilities with data reported into the NMEC DHIS2 database, which will include both malaria rapid reporting (MRR) and Component D data.

Current policy and practice is that health facility based MRR data is reported weekly into HMIS. However, in high burden malaria areas, this may not be necessary. Based on PAMO’s experience so far with the performance and low reporting rates for MRR, the project will provide technical assistance to the NMEP and the TWG to reconsider the weekly reporting requirement in high malaria burden areas. PAMO will advocate that the weekly MRR requirement be changed to for instance a monthly interval.

Figure 10: Malaria data flow diagram

HMIS/DHIS2 data forms 1. HIA1 (diseases) 2. HIA2 (Health center services) 3. HIA3 (Hospital services) 4. HIA4 (Community data) a. HIA4A (CHAs) Health b. *HIA4 B (All CHW cadres) 5. All submitted monthly HMIS

facility DHIS2 NMEC/DHIS2 data level 1. Malaria Rapid Reporting (MRR) 2. Submitted weekly by EHTs via mobile phones Note: Low reporting rates in some high burden areas so far, where there is no phone network, where EHTs have no malaria phones and airtime credit

*All CHW cadres’ data 1. Sourced from CHW registers 2. Submitted to health facility 3. Consolidated on HIA4B 4. Submitted to DHO/DHIO 5. Entered into HMIS/DHIS2 Community 6. Submitted monthly

*Note: Low coverage and low reporting rates NMEC level DHIS2

Malaria CHW data 1. Malaria cases from passive register

2. Malaria cases from active register

Tableau Tableau dashboards 3. Data submitted by CHWs monthly via mobile phones

To improve data quality on the key stated dimensions, various activities have been implemented during the first four years of the project. In Year 1, PAMO oriented the MOH in the four PAMO provinces on the malaria data quality tool developed by MACEPA, which is now the standard tool for the country. PAMO also conducted a malaria health systems gap analysis, which, among other things, was aimed at assessing HMIS data management skills and practices. PAMO also worked with the respective PHOs and DHOs to gather GIS coordinates for unmapped health facilities across all four PAMO-supported provinces.

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Since Year 2, all four provinces, with technical and material support from PAMO, managed to conduct DQAs in randomly selected health facilities in all districts (188 in Year 2, 126 in Year 3, 180 in Year 4). The health facilities were identified through a data review process done before the DQA rounds. The DQAs were coordinated by the PHOs through their respective senior health information officers (SHIOs). This was based on the understanding that the improvement of data quality and related practices cannot be attained without adequate supervisory follow-ups on findings and action plans decided. Technical oversight of the DQAs was provided by the NMEC. On-site interaction during DQAs involved guiding health facility staff on how to complete health facility registers and health information aggregation forms. The audit teams, comprised of the PAMO surveillance officers, district health information officers (DHIOs), clinical care officers (CCOs), and the malaria focal persons, facilitated comprehensive support on the negative audit findings.

Table 21 below shows the findings of the DQA conducted in Years 2, 3 and 4, these findings will be used by each province to track progress in the improvement of data quality and planning for Year 5.

Table 21: Summary of the DQA findings based on facilities visited.

Indicator Result Notes Year 2 Year 3 Year 4 Reporting rates 100% 100% 100% • For Year 2 the data audited were for a selected period of 6 months, and the 188 audited facilities were found to have submitted all (100%) of the expected reports. • This good performance of 100% reporting has been sustained up to Year 4. Accuracy 48% 61% 63% • For Year 2 the result was 48%, Year 3 recorded improvements at 61% and 63.3% in Year 4. Completeness of 100% 100% 100% • For Year 2, the data elements selected for the reports audited period were all available for all (100%) of the submitted reports. • The good performance of 100% data completeness has been sustained up to Year 4. Timeliness 86% 74% 88% • For Year 2, the result (86%) shows the proportion of reports submitted on time. • For Year 3, there was a slight drop to 74%. • Year 4 recorded an improvement to 88%.

The findings in this table show that there is an improvement on two of the four DQA indicators, with reporting rates and completeness of reports remaining at 100%. Accuracy has improved from 48% in Year 2 to 63% in Year 4 and timeliness dropped from 86% in Year 2 to 74% in Year 3 but improved to 88% in Year 4. The Year 4 timeliness result can be sustained or improved upon if DHIOs ensure that DHIS2 data entries are done by the 23rd of every month.

Outside of the HMIS, PAMO supported a data review meeting for malaria surveillance system data in Nchelenge in Year 4. The data review was done by bringing select health facility staff and data CHWs together to share their experiences with regard to data collection and reporting.

Based on this progression of activity implementation since inception, in Year 5, PAMO will provide technical and material support to conduct just one HMIS DQA round in 180 health facilities (45 per province) with data quality challenges. The health facilities will be the same ones identified in Year 4 through data reviews and DQA rounds. This support will be through respective PHOs with technical oversight by the NMEC and PAMO staff. The project will support activities aimed at enhancing HMIS data quality in order to improve timeliness, accuracy, and completeness of malaria data. Practically, the malaria DQAs will involve assessing data quality and providing immediate technical support for improvement on the inadequacies found. On-site technical support during DQAs will involve guiding staff on how to complete health facility registers and health information aggregation forms. With technical guidance from respective PHO staff and PAMO surveillance officers, the audit teams will comprise of DHIOs, CCOs, and malaria focal persons. The HMIS DQA will only happen once in Year 5, in the second quarter of 2020, because by then six months will have elapsed from the previous DQA for HIMS and enough data will have been uploaded into the MOH HMIS system from the selected health facilities.

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Aside the HMIS-focused DQA, PAMO will also conduct one DQA in Year 5 for the enhanced malaria surveillance system in the PAMO focus districts of Nchelenge, Mbala, Mpika, Nakonde, Chama, Mambwe, and Senga. Just like the HMIS DQA, the implementation of these malaria surveillance DQAs will involve health facility staff and CHWs and will require six months of reported data. The focus of the surveillance DQA (MRR and Component D data) is to work with all trained health facility staff and CHWs at each health facility to review and compare the reported data from the NMEC DHIS2 and the actual data from the passive and active registers, including the data registers. Technical support will be provided to them on how to record data and how to compile reports in the data registers, including how to upload data to DHIS2 using phones. Other technical support to be provided will include how to monitor the supply and consumption of commodities, which include RDTs and ACTs at both the health facility and community level.

Outputs

• One malaria DQAs conducted in 180 health facilities (45 per province) in the four PAMO provinces. • One malaria surveillance DQA on MRR done in seven districts (Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe) involving all health facilities. • One malaria surveillance DQA done on Component D reporting in seven districts (Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe) involving all CHWs. • Technical assistance provided to the TWG and NMEC to review the weekly MRR reporting requirement

Table 22: Activity and implementation timeline for Task 3.1.

Data Quality Audits Timeline in quarters Activity Output Q1 Q2 Q3 Q4

Work with NMEC staff and PHOs to One malaria DQA conducted in 180 health x conduct DQAs in all PAMO- facilities (45 per province) in the four supported provinces PAMO provinces Conduct Malaria Surveillance DQA One malaria surveillance DQA on MRR x x on MRR in seven districts done seven districts involving all health facilities One Malaria Surveillance DQA on One malaria surveillance DQA done on x x Component D Reporting in seven Component D reporting in seven districts districts involving all CHWs

Task 3.2: Provide technical/material assistance to DHOs, health facilities, and communities to assist with training for the rollout of DHIS2 in the targeted provinces and districts

The focus of Task 3.2 is capacity building for staff involved in data reporting, analysis, and use at all levels. In order to achieve the expected outcome under this particular task, the following priority areas have been identified: • Technical supportive supervision to health facilities to strengthen HMIS data capturing and reporting. • Mentorship for PHO, DHO, and hospital staff trained in DHIS2 to enhance data analysis and use for decision- making. • Mobile phones for malaria surveillance reporting under MRR and Component D. • Charger adapters for mobile phones used for MRR and Component D reporting. • Batteries for mobile phones used for MRR and Component D reporting. • OTSS/electronic data system (EDS) data sharing meeting. • EDS capacity building and trouble-shooting support to other OTSS implementing partners • EDS server license.

PAMO support is aimed at strengthening routine data management systems at provincial, district, health facility and community levels in the PAMO provinces. Activities include support for CHWs and health facility staff in HMIS data collection and reporting, as well as use of DHIS2 for PHO and DHO staff.

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PAMO acknowledges that inadequate understanding of data sources and the meaning of specific data elements at data source levels compromises the functionality of the overall HMIS. This adversely affects data quality as discussed under Task 3.1 (DQA findings). PAMO has been supporting HMIS trainings for health facility staff with the aim of ensuring that, by the end of the project all (100%) health facilities in PAMO provinces have at least one staff trained in HMIS. The performance tracking indicator for this is percentage of health facilities in all districts in target provinces with at least one individual trained in HMIS reporting. The 2015 baseline was at 68%. There has been steady progress with PAMO supported HMIS trainings helping the provinces to record 78% in 2016, 85% in 2017, and 100% in 2018 and 2019. It is also worth noting that the denominator used here is the number of health facilities, which change due to the opening of new ones.

In terms of activity implementation under Task 3.2, PAMO has progressed on schedule with all planned activities. In Year 5, since the project is approaching its closeout, there will be no trainings in HMIS, DHIS2, and EDS. The critical activities during this period will be focused on mentorship, technical supervisory visits, and material support. Therefore, PAMO will work closely with PHO and DHO staff to provide two technical supportive supervision visits in quarter one and two to strengthen HMIS data capturing and reporting to health facility staff trained in HMIS with a focus on improving data accuracy. During the technical supportive supervision, health facility staff will be mentored on how to ensure accuracy when transferring data from registers and HIA forms into the HMIS/DHIS2. In addition, PAMO will support one mentorship visit to enhance data analysis and use for decision-making for 80 PHO and DHO staff trained in DHIS2. To strengthen data capturing and reporting, PAMO will procure 60 mobile phones and 240 batteries to replace the damaged and/or faulty ones. In addition, PAMO will procure 240 adapters for charging mobile phones used for malaria surveillance reporting by health facility staff and CHWs. PAMO will conduct an OTSS/EDS data sharing meeting with OTSS supervisors to prepare them to take over the running of EDS enhanced OTSS rounds on their own under the overall coordination of the NMEC. NMEC central level staff have always been part of OTSS/EDS PAMO support and will also be expected to be part of this data sharing meeting. In Year 4, other OTSS implementing partners apart from PAMO experienced EDS technical challenges regarding their data pushing onto the DHIS2 platform. PAMO provided some emergency support to them. PAMO also provided support to build their capacity.

As earlier mentioned, as a result of Zambia’s efforts to comply with the forthcoming changes expected under the Smart Zambia initiative, the HMIS during early 2019 underwent significant changes to migrate the national HMIS/DHIS2 instance to an instance hosted at the National Data Centre. This migration of the system has resulted in some inconsistencies in HMIS malaria data and not all issues are clearly understood. Two servers currently exist, one with HMIS data prior to 2019 (the old HMIS server) and one with data since early 2019 (the new HMIS server). However, some facilities are still reporting into the old HMIS server and the new HMIS server has a lot of data from prior years, although tabulations to find the consistencies in the old data between the servers show differing numbers. Table 1, for example presents the new server data on malaria deaths for 1-4-year-old children by district from Luapula province for the 6-month period January to June 2018 and 2019. There appear to be missing data from 2018 which is not yet available on the new server from 2018. Therefore, the data presented here is the PAMO’s team best understanding of the resulting dataset, building on the situation analysis from the PAMO Year 4 Work Plan.

Table 23: Confirmed malaria deaths, Luapula province by district, January-June 2018 and 2019

Confirmed Malaria Deaths (1-4 yrs.)

Province District Jan to Jun 2018 (new HMIS Jan to Jun 2019 (old server) HMIS server)

Luapula Chembe District 16

Luapula Chiengi District 14

Luapula Chifunabuli District 4

Luapula Chipili District 1

Luapula Kawambwa District 5

Luapula Lunga District 5

Luapula Mansa District 3 5

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Luapula Milenge District 2 2

Luapula Mwansabombwe District 1

Luapula Mwense District 18

Luapula Nchelenge District 12 17

As far as supporting the functionality of the main MOH HMIS/DHIS2 platform is concerned PAMO and MACEPA, will work together to support the HMIS team to resolve the data migration challenges in order to ensure that the transition of older HMIS datasets into the new HMIS/DHIS2 instance is successfully completed. MACEPA plans to support backend system trainings and maintenance for the MOH ICT team to better support HMIS team data management needs and to continue to strengthen the skills within the MOH to identify and solve problems that inevitably arise with system migrations and upgrades. This support by MACEPA includes training attendance for DHIS2 Academy within the region. As for PAMO the plan is to support a workshop for NMEC and MOH M&E staff to review all malaria data elements captured in the HMIS/DHIS2. Through the SMEO technical working group and other fora, suggestions have been made by malaria data stakeholders that certain malaria data technicalities should not always be left to MOH M&E staff alone because their mandate is too broad. Besides malaria, they look at numerous other health data components including HIV/AIDS, TB and Maternal health with hundreds of data elements. The proposed workshop is therefore expected to provide a strategic platform for malaria stakeholders to review malaria data elements in order to improve the information system. After the workshop MOH M&E and NMEC staff are expected to work together with other relevant malaria data stakeholders on ways to take the recommendations from the workshop to improve HMIS malaria data capturing, analysis and reporting.

PAMO will also support the NMEC to develop a more standardized approach to reporting malaria incidence based on both health facility and community level passive case detection activities. As community health workers and their surveillance capabilities are expanded nationally, malaria incidence is likely to change significantly because of the greater influence and number of these agents for capturing the symptomatic burden of treatment seeking malaria patients. It will be important to account for the community-level burden in the overall malaria incidence-based stratification and classifications to correctly assign the appropriate package of malaria interventions. This will also involve ensuring a strong linkage between the reporting unit registries (at least at the health facility level) from the HMIS DHIS2 instance and the NMEC DHIS2 instance.

At provincial, district and health facility level, PAMO does not intend to support any more HMIS trainings in Year 5 but will concentrate on providing regular technical supervisory visits to health facilities to provide support based on identified gaps and needed technical updates. This will be done by PAMO M&E staff working with DHIOs so that sustainability measures are put in place by allowing DHO staff to own the supporting effort.

Providing mentorship for PHO, DHO and hospital staff trained in DHIS2 to enhance data analysis and use for decision- making will help PAMO to ensure that the capacity that has been built over the years remains relevant and sustainable. PAMO has supported capacity building in DHIS2 for selected PHO, DHO, and hospital staff with the aim of enabling access for key staff to analyze and utilize malaria data for decision-making. The performance tracking indicator for this is percentage of districts with staff trained in the use of DHIS2 for HMIS reporting, analysis, and using data for decision- making. At baseline in 2015, only 18% had this training. PAMO has been supporting these DHIS2 trainings since 2016, recording 100% achievement with all key staff at PHOs, DHOs, and hospital levels trained in DHIS2.

In Year 5, PAMO will only provide mentorship to the trained staff. This mentorship will also include other data platforms that use the DHIS2 software and not only the main MOH HMIS platform. It will therefore include the NMEC and OTSS/EDS DHIS2 databases, so that the participants are able to use malaria data much more broadly and effectively. Basically, there are three DHIS2 online reporting systems supported and used by PAMO and they all have to be understood properly by those trained in DHIS2 so that they have a comprehensive view of the data. For instance, someone who only uses the main MOH HMIS/DHIS2 to track malaria incidence may give a wrong perspective, so it becomes imperative to account for passive malaria cases reported by CHWs under the NMEC DHIS2 instance. Moreover, for PAMO supported provinces, the tracking of malaria confirmation rates would be done more effectively by not only using the main MOH DHIS2 data but by also comparing it with OTSS/EDS composite adherence scores on cases tested prior to treatment.

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Regarding technical and material support to malaria surveillance reporting under the NMEC DHIS2 database, PAMO will ensure effective support by providing replacement mobile phones, battery chargers, and airtime credit for submission of data. The NMEC has requested, PAMO to procure 900 mobile phones for the CHWs and Health facility staff already trained in iCCM who currently don’t report their data to the NMEC DHIS2 instance. Table 23 is a list of districts and the number of phones required by NMEC for each of the districts. In addition, PAMO will procure 240 mobile phones for PAMO trained CHWs. This gives a total of 1140 mobile phones. The primary aim is to strengthen data management and use at the national level; the contribution will build on PMI investments in CHW training in the PAMO provinces and will leverage Global Fund investments in the non-PAMO provinces.

Table 24: Distribution list for Mobile phone requested by NMEP

Province Province/District Number of phones allocated Copperbelt Lufwanyama District 38 Copperbelt Mpongwe District 35 Copperbelt Masaiti District 35 Central Serenje District 23 Central Ngabwe District 6 Central Mkushi District 34 Central Chitambo District 24 Central Luano District 26 Lusaka Chongwe District 32 Lusaka Rufunsa District 24 Luapula Chienge District 11 Luapula Mwense District 19 Luapula Chifunabuli District 12 Luapula Milenge District 8 Luapula Mansa District 40 Luapula Samfya District 19 Luapula Lunga District 2 Luapula Mwansabombwe District 5 Luapula Chipili District 13 Muchinga Isoka District 10 Muchinga Kanchibiya District 8 Muchinga Shiwang'andu District 14 Muchinga Lavushi Manda District 6 Muchinga Chinsali District 10 Muchinga Mafinga District 9 Northern Luwingu District 12 Northern Kasama District 22 Northern Nsama District 6 Northern Lunte District 9 Northern Chilubi District 14 Northern Mpulungu District 14 Northern Mporokoso District 8 Northern Mungwi District 12

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Northern Kaputa District 9 Northern Lupososhi District 9 Northwestern Mufumbwe District 32 Northwestern Kasempa District 38 Northwestern Mushindano District 28 Northwestern Kalumbila District 45 Northwestern Ikelenge District 24 Northwestern Kabompo District 28 Northwestern Zambezi District 44 Northwestern Chavuma District 18 Northwestern Mwinilunga District 23 Northwestern Solwezi District 22 Northwestern Manyinga District 20 Total 900

As for the OTSS/EDS, which also uses the DHIS2 software, PAMO will support one data sharing meeting, at which OTSS supervisors will be given final technical support and planning for carrying on with EDS-enhanced OTSS without PAMO support. PAMO will also pay for the EDS server for the year 2020. But regarding EDS specific support to other OTSS implementing partners, PAMO plans to support them and this is to ensure sustained and effective EDS use after PAMO close-out. A training workshop will be organized where all problems experienced with EDS will be addressed with the help of experts for both the front end and the backend components of the EDS/DHIS2 system.

Outputs

• Technical supportive supervision conducted quarterly to health facilities to strengthen HMIS data capturing and reporting. • Mentorship conducted for 80 PHO, DHO, and hospital staff who have been trained in DHIS2 to enable them to analyze and use data for decision-making. • 240 mobile phones procured for malaria surveillance reporting under MRR and Component D. • 900 mobile phones procured for the NMEC to use for malaria surveillance reporting under MRR and Component D • 1140 charger adapters procured for mobile phones used under MRR and Component D reporting. • 1140 batteries procured for mobile phones used under MRR and Component D reporting. • Technical supportive supervision and troubleshooting of mobile phone problems conducted to data CHWs to strengthen data capturing and reporting roles. • NMEC and MOH M&E staff to hold a workshop to review malaria data elements captured in the HMIS/DHIS2 database • One OTSS/EDS data sharing meeting conducted with OTSS supervisors to compile experiences and recommendations. • EDS capacity building support provided to NMEC and other OTSS implementing partners • EDS server license paid

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Table 25: Activities and implementation timeline Task 3.2.

Technical assistance to strengthen HMIS Timeline in quarters Activities Outputs Q1 Q2 Q3 Q4 Conduct quarterly technical supportive Technical supportive supervision X X supervision to health facilities to strengthen conducted quarterly to health facilities to HMIS data capturing and reporting strengthen HMIS data capturing and reporting Conduct mentorship for PHO, DHO and Mentorship conducted for PHO, DHO and X hospitals staff trained in DHIS2 to enhance hospital staff who have been trained in data analysis and use for decision making DHIS2 to enable them to analyze and use data for decision making

Procurement of mobile phones for malaria 900 Mobile phones procured for malaria X surveillance reporting under MRR and surveillance reporting under MRR and Component D to replace damaged phones Component D Procurement of charger adapters for mobile 240 Charger adapters procured for mobile X phones used for MRR and Component D phones used under MRR and Component reporting D reporting Procure batteries for mobile phones used for 1140 Batteries procured for mobile phones X MRR and Component D reporting used under MRR and Component D reporting Conduct monthly technical supportive Technical supportive supervision and X X supervision and troubleshooting of mobile troubleshoot mobile phone problems phones for Data-CHWs to strengthen data conducted to Data-CHWs to strengthen capturing and reporting roles data capturing and reporting roles Support NMEC and MOH M&E staff to hold a NMEC and MOH M&E staff supported to X workshop to review malaria data elements hold a workshop to review malaria data captured in the HMIS/DHIS2 database elements captured in the HMIS/DHIS2 database Conduct and support OTSS/EDS data One OTSS/EDS data sharing meeting X sharing meeting with OTSS supervisors conducted with OTSS supervisors to compile experiences and recommendations Provide EDS capacity building support to EDS capacity building support provided to X NMEC and other OTSS implementing NMEC and other OTSS implementing partners partners EDS server license EDS server license paid for X

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Task 3.3: Provide technical and material assistance to DHOs, health facilities, and communities to strengthen malaria data analysis and use for planning and decision-making

Task 3.3 is focused on fostering data analysis and utilization and priority areas are listed below:

• Support scheduled submission of malaria surveillance data by health facility staff and CHWs through the provision of airtime for Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe districts. • HMIS malaria data review meetings in 20 districts (five per province). • Malaria surveillance data review meetings in seven districts (Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe). • Supportive supervision to CSOs and community champions to strengthen data collection and reporting functions. • Compilation and analysis of data reported by CSOs and community champions.

Support for the scheduled submission of malaria surveillance data by health facility staff and CHWs through the provision of airtime is aimed at enhancing malaria surveillance in the selected focus districts. PAMO supports malaria reporting surveillance activities in order to improve routine data flow from health facilities and communities. Nchelenge District was selected for high coverage of the full range of PAMO-supported interventions. This included implementation of malaria surveillance activities in the context of MRR and Component D reporting. In Year 5, PAMO will support the submission of malaria surveillance data by health facility staff and CHWs through the provision of airtime for seven focus districts (Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe districts).

PAMO will also support PHOs to conduct HMIS malaria data review meetings—important platforms in using data for decision-making—in 20 districts (5 districts per province) and these will be selected based on performance. PAMO will also support the PMOs and their respective DHOs to conduct malaria surveillance data review meetings in seven districts (Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe)

Regarding the work of CSOs and community champions to strengthen data collection and reporting functions, PAMO has implemented a number of activities. As described under Task 1.4, the CCI is a participatory behavior change communication methodology used as part of the Stop Malaria Campaign that has been implemented in Zambia since 2011. The cornerstone of the initiative is facilitating communities to set their own goals, while tracking progress toward achieving these goals. This component of malaria surveillance is focused on tracking SBC activities, which are implemented by CSOs under the GUC arrangement (see Tasks 1.4 and 1.6). The objectives of the champion communities are: (1) every member of the community, especially children under five and pregnant women, sleeps under an LLIN every night, (2) all pregnant women in the community attend ANC early and receive at least three recommended doses of IPTp, and (3) caregivers appropriately feed children suffering from malaria. Through their community-level structures, the CSOs collect data on malaria outcome indicators under LLIN utilization and care- seeking as follows:

LLIN utilization • Population who slept under an LLIN. • Children under five years of age who slept under an LLIN. • Pregnant women who slept under an LLIN.

Care-seeking • Reported fever prevalence for children under five years of age. • Under-five care-seeking with fever. • Under-five fever cases tested for malaria.

CSOs compile these data for all their community champions, share reports with PAMO and DHOs, and provide feedback to their community champions during their regular meetings and supervisory visits.

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This being the final year of implementation, in Year 5 PAMO will work on compiling and analyzing of all the CSO and community champion reports to come up with a comprehensive report for each province’s CSO activities. PAMO will also conduct supportive supervision to CSOs and community champions to strengthen their data collection and reporting functions.

Outputs

• Malaria surveillance data submitted by health facility staff and CHWs provided with airtime for seven districts (Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe). • HMIS malaria data review meetings conducted once in 25% selected districts. • Malaria surveillance data review meetings conducted once in seven districts (Nchelenge, Mbala, Senga, Mpika, Nakonde, Chama, and Mambwe). • Supportive supervision to CSOs and community champions conducted monthly to strengthen data collection and reporting functions. • Data reported by CSOs and community champions compiled, analyzed, and reported.

Table 26: Activities and implementation timeline for Task 3.3.

Technical assistance to enhance standardization and reporting of national-, Timeline in quarters facility-, and community-level data

Activities Outputs Q1 Q2 Q3 Q4

Support submission of malaria Malaria surveillance data submitted by x surveillance data by health facility staff health facility staff and CHWs provided and CHWs through provision of airtime with airtime for 7 districts (Nchelenge, for Nchelenge, Mbala, Senga, Mpika, Mbala, Senga, Mpika, Nakonde, Nakonde, Chama, and Mambwe districts Chama, and Mambwe)

Conduct HMIS malaria data review HMIS malaria data review meetings X meetings in 20 districts (five districts per conducted once in 20 selected districts province) (five districts per province)

Conduct malaria surveillance data review Malaria surveillance data review X X meetings in seven districts (Nchelenge, meetings conducted once in seven Mbala, Senga, Mpika, Nakonde, Chama, districts (Nchelenge, Mbala, Senga, and Mambwe) Mpika, Nakonde, Chama, and Mambwe)

Conduct supportive supervision to CSOs Supportive supervision to CSOs and X X and community champions to strengthen community champions conducted their data collection and reporting monthly to strengthen data collection functions and reporting functions

Compile and analyze data reported by Data reported by CSOs and community X X CSOs and community champions champions compiled, analyzed, and reported

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Project staffing

In Year 5 PAMO will continue providing technical and material assistance to the NMEP at national, provincial and district level. In order to achieve this PAMO will continue working with the structures as shown in Figure 10 that were approved in the Year 4 work plan. The period of implementation of the Year 5 work plan is only six months and therefore the activities will need to be frontloaded in the first five months. In order to achieve this, PAMO will bring in technical assistance from the larger PATH family through MACEPA

PAMO will pay for LOE for nine staff from MACEPA who will support the iCCM and surveillance training in the four provinces. These technical skills that will be needed are in surveillance, data management, IT and clinical training skills. These staff are John Miller, Marie-Reine Rutagwera, Christopher Lungu, Mathews Monde, Kafula Silumbe, Sande Litia, Prudence Malama, Enock Nsokolo and Julianna Ngalande.

PAMO also proposes to increase the staffing in operations by recruiting a procurement assistant who will report to the Finance and Operations Director. This person will be responsible for procurement in the project and will support the administrative assistant.

PATH headquarters will continue to provide support to the project, and this will include support for graphic design, documentation and knowledge management during the last three months of the project.

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Figure 11: PAMO organogram for Year 5

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Project monitoring, evaluation, and reporting

Internal project M&E, as opposed to technical assistance provided to the GRZ for HMIS strengthening, is a process that helps the project improve performance and achieve results. The practice helps systematically track activities (processes), outputs (short-term results), outcomes (intermediate results), and impact (long-term results). Just like what has been done since project inception, even in Year 5 M&E will be used to assess the performance of the project through the established indicators in the context of the performance framework. Therefore, tracking the performance framework will continue to be done through specific reports and PMI contractual platforms. These include monthly and quarterly activity reports generated by technical staff in accordance with work plans, bi-annual PMI portfolio reviews, annual PMI reports, annual reviews and planning sessions, a project end-term review and specific contractual deliverables.

In Year 1, PAMO focused on the development of the performance framework through the development of an M&E plan, data collection tools, and a performance tracking system. These tools allowed PAMO to submit timely reports to PMI. In Year 2, PAMO continued tracking the performance of the project through the use of regular project data and the HMIS. Even in Years 3 and 4 PAMO continued tracking the performance of the project through the use of regular project data and the HMIS. This will continue in Year 5. Data from these sources were used to give updates to stakeholders, including provinces, the NMEC, and PMI.

Table 25: Status of PAMO documents/platforms.

Document/platform Purpose 2019 status/updates

Y1 Y2 Y3 Y4 Y5 (2016) (2017) (2018) (2019) (2020) 1. M&E plan To describe the entire M&E system Done N/A N/A N/A N/A for PAMO and guide the implementation of all M&E activities. 2. M&E As a component of the M&E plan Done N/A N/A N/A N/A framework/project detailing all the indicators, their performance definitions, types, baselines, targets, framework data sources, frequency of data collection and indicator directions. 3. Updating M&E Address the changes in the Done Done Done Done Not framework/project improvements, number and nature of yet performance indicators. due framework annually 4. Monthly reports For status monthly updates to PMI Up to Up to Up to Up to Not (Ref: PAMO on planned activities. date date date date yet contractual due deliverables) 5. Quarterly reports For status quarterly updates to PMI Up to Up to Up to On- Not (Ref: PAMO on planned activities and include date date date course yet contractual accomplishments, challenges, due deliverables) success stories, Mapping Coordinates, Environmental Mitigation and Monitoring Plan (EMMP) updates. 6. Bi-annual PMI Done two times each year by way of Up to Up to Up to On- Not portfolio reviews a PowerPoint presentation date date date course yet (Ref: PAMO presenting all semi-annual and due contractual cumulative results against previously deliverables) agreed program targets, selected accomplishments for the previous six months, challenges and proposed solutions, and projected procurement actions for the next six months.

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7. Annual PMI In lieu of the 4th quarter report Up to Up to Up to On- Not reports date date date course yet (Ref: PAMO due contractual deliverables) 8. Staff field trip Trip reports of on supervisory spot Up to Up to Up to On- Not reports checks and technical support date date date course yet (Ref: Staff due TERs/WERs and trip reports) 9. Project mid-term Using the 2018 Malaria Indicator N/A N/A Up to N/A N/A review using MIS Survey to update the PAMO date 2018 results performance framework on all indicators including the outcome and impact indicators 10. Project end term Review overall performance of the N/A N/A N/A N/A Not review project in terms of implementation of yet planned activities due

All monitoring aspects of the project are contained in the PAMO M&E plan, which includes an M&E performance framework, as approved by PMI in Year 1 and updated in Year 2 to Year 5. In Year 3, the project captured additional indicators in the performance framework. These indicators covered aspects of SBC which were not included in the original approved performance framework. This action did not require extra budgetary input other than technical staff time and level of effort to update the M&E framework.

Indicators added to the PAMO performance framework and submitted to USAID for approval as a part of the Year 3 work plan were: proportion of people with a favorable attitude toward the product, practice, or service; proportion of people that believe the majority of their friends and community members currently practice the behavior; proportion of people who perceive they are at risk of malaria; proportion of people who name mosquitoes as the cause of malaria; and proportion of people who recall hearing or seeing any malaria message within the previous six months.

The PAMO performance framework was updated with these indicators and shared with PMI as appropriate.

In Year 4, PAMO reviewed some indicators in terms of redundancy, relevance, and level of detail. For instance, the IPTp 2 indicator will be supplemented with IPTp3 coverage, meaning the percentage of pregnant women who received three or more doses of IPTp while attending antenatal care.

Indicators on tracking meetings at the health facility level or lower will either be dropped or linked with district level activities like data reviews. For instance, the number of districts that review MIP data at monthly DMO meetings and the percentage of planned health facility level meetings held to discuss HMIS data will be addressed under “percentage of health facilities that review malaria case management data monthly.” Tracking health facilities here will help count the number of facilities represented at these district malaria data review meetings.

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Project closeout

The PAMO contract ends in September 2020. PAMO will carry out project closeout activities to ensure that the project is brought to a close in a professional and orderly manner. By December 2019, PAMO will have developed a demobilization plan that will inform a closeout plan to be completed in the second quarter of 2020. The closeout plan, which will be submitted to PMI, will contain in more detail the step by step process of closing out the project. Some of the key closeout activities will include the following:

• Through provincial integrated meetings (PIM), PAMO will hand over programmatic approaches that it has jointly been implementing with provincial and district health offices for their continued implementation without PAMO support. During PIM meetings, PAMO will share its demobilization and transition plans for the entire project and will seek commitment from provincial and district health officials to sustain the interventions. • PAMO will develop success stories and program briefs to share with stakeholders its approaches, successes, and lessons learned over the life of the project. PAMO will also produce a full project report that will highlight various aspects of the project including progress toward targets; lessons learned in rolling out, at large scale, proven malaria interventions; and recommendations for the successor project. • PAMO will also carry out various project closeout events that will include a final staff retreat, a partner’s closeout meeting to share key achievements and lessons learned, and production of the final documents, including financial and program reports that will be submitted to PMI.

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Annex 1: List of SBC target districts No Luapula Northern Muchinga Eastern

District # HF Partner District # HF CSO/PAMO District # HF Partner District # HF Partner target/t target/t target/tot target/t otal HF otal HF al HF otal HF

1 Mansa* 11/59 GFC Kasama* 25/31 YWCA Mpika* 7/26 CARITAS Lundazi* 18/53 THANDIZANE 2 Chipili* 13/21 VAREN Chilubi N/A N/A Chinsali* 9/11 CARITAS Mambwe* 5/21 PAMO 3 Mwense* 7/12 VAREN Luwingu N/A N/A Chama* 6/28 PAMO Nyimba* 15/27 MPATSO 4 Kawambwa* 9/29 YDA Lupososhi N/A N/A Lavushi N/A N/A Vubwi* 11/13 PAMO Manda 5 Mwansabombwe* 7/10 AAH Mpororkoso N/A N/A Shiwangandu N/A N/A Chipangali N/A N/A 6 Nchelenge* 18/18 NZP Mungwi* 15/18 CBCF Kanchibiya N/A N/A Chasefu N/A N/A 7 Chembe* 7/7 AAH Senga hill* 10/22 KCCC Nakonde N/A N/A Kasenengwa N/A N/A 8 Samfya* 6/40 GFC Mbala* 22/33 PAMO Isoka* 11/12 SWAAZ Lumezi N/A N/A 9 Chifunabuli* 11/11 GFC Mpulungu N/A N/A Mafinga* 9/11 ROCS Lusangazi N/A N/A 10 Lunga* 11/11 YDA Kaputa N/A N/A Chipata* N/A N/A 11 Milenge* 8/17 PAMO Lunte N/A N/A 12 Chiengi* 12/13 AAH Nsama N/A N/A *districts in which PAMO will implement SBC activities.

PAMO targets a total of 46 districts all of which will be reached with SBC messages through radio programs and jingles. However PAMO has targeted 26 districts out of the 46 (61%) to implement more interpersonal focused SBC activities broken down as follows: Luapula province 12 out of 12 districts (100%); Northern - 4 out of 12 districts (33%); Muchinga - 5 out of 9 districts (55%); Eastern 4 out of 9 districts (44%).

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