Zimbabwe Assistance Program in Malaria Quarterly Report

ZIMBABWE ASSISTANCE PROGRAM IN MALARIA

QUARTERLY REPORT

OCTOBER 1–DECEMBER 31, 2020

Recommended Citation: Zimbabwe Assistance Program in Malaria (ZAPIM). January 2021. Year 6, Quarter 1, October 1– December 31, 2020 Report. Rockville, MD and Harare, Zimbabwe. ZAPIM, Abt Associates. Contract and Task Order Number: AID-613-A-15-00010 Submitted to: United States Agency for International Development/President’s Malaria Initiative Submitted on: January 31, 2021

CONTENTS

Acronyms ...... iii Executive Summary ...... v 1. Background ...... 1 2. Administrative Activities ...... 3 2.1 Staffing and Management ...... 3 3. Technical Activities ...... 5 3.1 Malaria Case Management and Malaria in Pregnancy ...... 5 3.1.1 Remote Mentorship to Support Continuity of Malaria Services During the COVID-19 Pandemic in Zimbabwe ...... 5 3.1.2 CM and MIP Training ...... 6 3.1.3 Malaria Death Audit Meeting in Mashonaland East, November 2020 ...... 7 3.1.4 CM and MIP Subcommittee Meeting ...... 8 3.1.5 Community Case Management ...... 9 3.2 Long-Lasting Insecticidal Nets...... 9 3.2.1 LLIN Delivery to District Holding Points and Distribution Facilities ...... 9 3.2.2 CD Training - Rushinga and Shamva Districts ...... 11 3.2.3 Continuous Distribution of LLINs to Beneficiaries ...... 12 3.2.4 Electronic Reporting System ...... 14 3.2.5 LLINs Data Quality Assessment ...... 14 3.2.6 Targeted District LLIN Support and Supervision ...... 15 3.3 Social and Behavioral Change ...... 16 3.3.1 Support for NMCP Rebranding ...... 16 3.3.2 Development of Malaria Elimination Leaflet ...... 18 3.3.3 Development of LLIN Promotional Video ...... 19 3.3.4 Support to Malaria Commemoration by NMCP Malaria Day ...... 19 3.3.5 Community SBC ...... 20 3.3.6 CAC Evaluate Together Trainings ...... 20 3.3.7 CAC Documentation Visits ...... 20 3.4 M&E and Operational Research ...... 21 3.4.1 Epidemic Preparedness and Response Guidelines ...... 21 3.4.2 Malaria SM&E Training Manual ...... 21 3.4.3 Weekly VHW Mobile Reporting Pilot in Mbire District ...... 21 3.4.4 Routine Evaluation of Audio Book in Chikunda Language ...... 21 3.4.5 Malaria Elimination Review and Planning Meeting ...... 23 4. Gender ...... 27 5. Environmental Compliance...... 29 5.1 Medical Waste ...... 29 5.2 Management of Public Health Medicines and Commodities ...... 29 6. Challenges Recommendations, And Lessons Learned ...... 31 Annex A: PMP Indicators/Year 5 Milestone Matrix ...... 33

LIST OF TABLES

Table 1: Health Workers Reached Through Virual Mentorship, By Designation ...... 5 Table 2: CM and MIP Training Paritipants in Mashonaland Centeral by Profession and Gender, October 2020...... 6 Table 3: Distribution of cadres trained in CM and MIP in Mashonaland East by district, November 2020 6 Table 4: Summary of pre- and post-test results for CM and MIP training held in Mashonaland Central, October 2020...... 7 Table 5: Summary of pre- and post-test results for CM and MIP training held in Mashonaland East, November 2020...... 7 Table 6: Malaria related deaths by district in Mashonaland East, November 2020 ...... 7 Table 7: Community CM training of VHWs in ZAPIM- supported districts in Mashonaland Central...... 9 Table 8: ZAPIM Supported LLINs delivered by district, November 2020 ...... 10 Table 9: Health workers trained in CD of LLINs in Rushinga and Shamva Districts, November/December 2020 ...... 11 Table 10: VHWs trained in CD of LLINs in Rushinga and Shamva Districts, November/December 2020 ...... 12 Table 11: Recommendations from the CD trainings in Rushinga and Shamva Districts November/December 2020 ...... 12 Table 12: Participants trained in LLINs electronic reporting October 14-15, 2020 ...... 14 Table 13: Issues, challenges, and recommendations from DQAs, November 2020 ...... 15 Table 14: Number of people targeted per ward for rebranding interviews and focus group discussions (FGDs) ...... 16 Table 15: List of key informant stakeholders for the NMCP rebranding ...... 17 Table 16: Functional status of Chikunda audio books in Chapoto, November 2020 ...... 22 Table 17: Key elements, challenges, and action plans from the elimination review and planning meeting, November 2020...... 24

LIST OF FIGURES

Figure 1: VHWs being trained on CD of LLINs in Rushinga, November 2020 ...... 11 Figure 2: CD of LLINs in ZAPIM supported districts by year and by quarter, 2016-2020 ...... 13 Figure 3: LLIN distribution by channel, October to December 2020 ...... 14 Figure 4: Observing COVID-19 precautions during interviews and FGDs at community level ...... 18 Figure 5: Illustrative draft of elimination leaflet ...... 18 Figure 6: Illustrative graphic of LLIN promotional video ...... 19 Figure 7: Decline in malaria cases in children under 5 years of age in Chapoto Ward, 2017-2020 ...... 23 Figure 8: Chikunda audio book coverage by gender and by village, November 2020 ...... 23

ACRONYMS

ACT Artemisinin-based Combination Therapy ANC Antenatal Care CD Continuous Distribution CM Case Management DHIS District Health Information System DMO District Medical Officer DNO District Nursing Officer EHT Environmental Health Technician EPI Expanded Programme on Immunization IPTp Intermittent Preventive Treatment in Pregnancy IRS Indoor Residual Spraying LLIN Long-Lasting Insecticidal Net MIP Malaria in Pregnancy MOHCC Ministry of Health and Child Care NMCP National Malaria Control Program ODK Open Data Kit PEDCO Provincial Epidemiological Disease Control Officer PMI President’s Malaria Initiative SBC Social and Behavioral Change SM&E Surveillance Monitoring and Evaluation SP Sulfadoxine Pyramethamine UMP Uzumba Maramba Pfungwe VHW Village Health Worker ZAPIM Zimbabwe Assistance Program in Malaria

iii

EXECUTIVE SUMMARY

The President’s Malaria Initiative (PMI) requested the Zimbabwe Assistance Program in Malaria (ZAPIM) to extend its original end date from September 30, 2020 to March 31, 2021. This report presents ZAPIM performance during the Year 6, Quarter 1 (October 1 to December 31, 2020) no-cost extension period. The number of project activities implemented and goals accomplished during this quarter were influenced by the COVID-19 related lockdown. All activities were carried out while strictly observing COVID-19 mitigation measures, prioritizing the safety of project staff, Ministry of Health and Child Care (MOHCC) staff, and all stakeholders. COVID-19 containment measures were effective in the country from March 27, 2020 onwards. ZAPIM postponed several field activities, staff worked from home, and activities were limited mainly to virtual meetings and technical support to the National Malaria Control Program (NMCP), the provinces, and the districts. This quarter saw slight relaxation of the strict lockdown measures in the country with the government allowing essential services to operate and group meetings to occur under strict COVID-19 measures. In line with the project’s close-out plan and financial considerations, the contract for the Chief of Party (COP), Dr. Noe Rakotondrajaona, ended on September 30, 2020 and the Technical Director, Dr. Anthony Chisada, took over as the COP. Most other staff – Provincial Coordinators, Drivers, and the Data Quality and Reporting Officer – completed their work with the project on December 31, 2020. Beyond December 31, the Long-Lasting Insecticidal Net (LLIN) Specialist and the Social and Behavioral Change (SBC) Specialist will continue to work at 50% time through to the end of February 2021. The Finance and Administration Director, the COP, the Accountant and one Driver will continue with the project until its end on the March 31, 2021. ZAPIM completed the following planned activities during this quarter:  Conducted malaria mentorship calls with facility based health care workers and village health workers (VHWs); the virtual mentorship led to improved availability of commodities and malaria testing and treatment services in supported health facilities and communities.  Trained 32 health workers in Mashonaland Central and 40 health workers in Mashonaland East provinces on malaria case management (CM) and malaria in pregnancy (MIP).  Trained 78 VHWs in Centenary District, Mashonaland Central, and 40 VHWs in Uzumba Maramba Pfungwe (UMP) District, Mashonaland East, on community CM.  Supported one CM and MIP subcommittee meeting.  Provided support for the NMCP rebranding exercise.  Developed draft SBC materials for malaria elimination.  Developed a draft LLIN promotional video.  Supported NMCP to integrate COVID-19 considerations in SBC programs at all levels.

 Continued working on malaria epidemic preparedness and response training materials.  Finalized malaria surveillance, monitoring, and evaluation (SM&E) training materials for use in training health care workers.  Provided support to health center committees under the “evaluate together” phase of the Community Action Cycle (CAC) as they self-evaluated the performance of implementing their plans.  Supported VHW mobile reporting in Mbire District.  Conducted a performance evaluation of the Dipa LaMalaria audio book in Chapoto Ward in Mbire.  Supported the delivery of 85,000 LLINs to 116 health facilities in 12 districts as part of continuous distribution (CD).  Supported the distribution of 31,433 LLINs to beneficiaries through the CD system  Trained 43 health facility staff on electronic reporting of LLINs and on use of the DHIS2 platform.  Conducted LLIN data quality assessments in 10 districts.  Participated in the national malaria elimination review and planning meeting.

1. BACKGROUND

PMI was established in 2005 to reduce malaria-related mortality by 50% across 15 high-burden countries in sub-Saharan Africa. PMI’s commitment to combating malaria was bolstered with the 2008 passage of the Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act (www.pmi.gov/about). In 2011, Zimbabwe was chosen to be a PMI country; before then, USAID had provided some limited support for indoor residual spraying (IRS) and commodity procurement through the USAID/Zimbabwe Office of Health, Population, and Nutrition. PMI supports an array of malaria prevention and treatment activities in Zimbabwe including: the procurement and distribution of LLINs, rapid diagnostic tests, artemisinin-based combination therapy (ACT), and sulfadoxine-pyrimethamine (SP); the provision of IRS in high-burden areas; and the training of health care workers in the diagnosis and treatment of malaria. On September 25, 2015, USAID awarded the five-year ZAPIM to Abt Associates and its partners Save the Children, Jhpiego, and the Liverpool School of Tropical Medicine. This project’s purpose is to support the NMCP in providing comprehensive malaria prevention and treatment services to Zimbabweans, with the goal of reducing malaria morbidity and mortality. The project has five main areas of concentration: 1) CM and MIP, 2) LLINs, 3) SBC, 4) Operational Research, and 5) Surveillance-Monitoring and Evaluation (SM&E). In addition, in Year 4, ZAPIM started implementing malaria elimination activities in Lupane District of Matabeleland North Province. The project was originally scheduled to end on September 30, 2020, but received approval in Quarter 2 for a six-month no-cost extension to March 31, 2021. The project operates in 16 districts in three provinces:  Mashonaland Central: Bindura, Centenary/Muzarabani, Guruve, Mazowe, Mbire, Mt. Darwin, Rushinga, and Shamva  Mashonaland East: Goromonzi, Mutoko, Mudzi, Murehwa, and UMP.  Matabeleland North: Binga, Hwange, and Lupane

2. ADMINISTRATIVE ACTIVITIES

2.1 STAFFING AND MANAGEMENT With support from Abt’s home office management team and under the leadership of the Acting COP/Technical Director, the project has moved into close-out mode. All staff continued to work full- time through to December 31, 2020. With the exception of a small close-out team and the SBC Specialist and the LLIN Specialist, all staff contracts ended on December 31, 2020. The close-out team is comprised of the COP/Technical Director, the Finance and Administration Director, the Accountant, and one Driver. This team will continue to work until March 31, 2021. The SBC Specialist and LLIN Specialist have been retained to complete some technical activities, and will work until February 28, 2021.

3. TECHNICAL ACTIVITIES

3.1 MALARIA CASE MANAGEMENT AND MALARIA IN PREGNANCY Key achievements:

 Supported malaria mentorship calls to health care workers and VHWs;  Supported Mashonaland Central and Mashonaland East to carry out CM and MIP trainings for 72 facility-based health care workers;  Supported training of 118 VHWs in community CM;  Supported a malaria death audit meeting in Mashonaland East; and  Supported one CM and MIP subcommittee meeting.

3.1.1 REMOTE MENTORSHIP TO SUPPORT CONTINUITY OF MALARIA SERVICES DURING THE COVID-19 PANDEMIC IN ZIMBABWE ZAPIM supported the use of WhatsApp groups and phone calls for virtual mentorship in 10 facilities in Matabeleland North Province. The Provincial Coordinator organized the activity with the help of district mentors. The health facilities have new Registered General Nurses and Environmental Health Technicians (EHTs) who had not previously been trained on malaria CM. The WhatsApp groups were used to follow up on commodity status. It was through these groups that mentors noted that some facilities (e.g., Lukosi, Mwemba, and Chunga) had no functional sphygmomanometer. The district pharmacy managers were engaged and they helped source batteries or replacement machines. Table 1 summarizes the reach of virtual mentorship: Table 1: Health Workers Reached Through Virual Mentorship, By Designation Oct –Dec 2020

Designation Male Female Total EHTs 9 2 11 Registered General Nurses 10 14 24 Primary Care Nurses 8 19 27 Field Orderlies 5 1 6 Nurse Aides 0 14 14 Total 32 50 82

In Matabeleland North, ZAPIM conducted virtual support for 60 VHWs during the quarter. Only Simatelele had stock outs for VHW commodities, which resulted in a higher number of cases reporting to the health facility than usual. The Provincial Epidemiology and Disease Control Officer (PEDCO) helped the facility to replenish stocks for the VHWs.

During the period under review, ZAPIM conducted two mentorship phone calls to follow up on five health facilities in Mbire District. The mentorship calls checked on the availability of commodities and compliance with COVID-19 regulations. The availability of commodities had improved in all the health facilities and at community level due to reduced cases of malaria during the review period. The calls emphasized the provision of safe malaria testing and treatment in the context of COVID-19, the provision of commodities and medicines to VHWs through the use of mobile EHTs supported with fuel from ZAPIM, and promotion of early treatment seeking and early referral of severe cases to prevent malaria related deaths.

3.1.2 CM AND MIP TRAINING During the no-cost extension period, ZAPIM trained health workers from the high burdened districts of Centenary, Mbire, Mt Darwin, Rushinga, and Shamva. ZAPIM provided logistical and technical support for MOHCC facilitators to conduct the trainings. The trainings helped to close training gaps among the newly recruited staff in Mashonaland Central and Mashonaland East Provinces. Thirty-two facility-based health care workers were trained in Mashonaland Central out of a target of 40, and 40 were trained in Mashonaland East with 10 from each district - Goromonzi, Murewa, Mutoko, and UMP. Tables 2 and 3 contain more details about the training participants.

Table 2: CM and MIP Training Paritipants in Mashonaland Centeral by Profession and Gender, October 2020

Profession Male Female Total Registered General Nurses 5 18 23 Doctors 5 1 6 Laboratory Scientists 0 3 3 Total 10 22 32

Table 3: Distribution of cadres trained in CM and MIP in Mashonaland East by district, November 2020

Participants District Male Female EHTs Lab Pharmacy Total Mutoko 9 1 0 0 0 10 Murehwa 4 2 2 1 1 10 UMP 5 1 2 1 1 10 Goromonzi 6 1 2 1 0 10 Total 24 5 6 3 2 40 Trainers emphasized the importance of early diagnosis and correct management of malaria cases in the context of COVID-19. Participants were instructed to follow the standard operating procedures provided for correct management of severe malaria, including adoption and use of the new malaria treatment guidelines for children under 5kgs using ACTs. Copies of this guidance were distributed for further dissemination to health facilities. The PEDCO assisted in clarifying and emphasizing policy issues, including administration of intermittent preventive treatment in pregnancy (IPTp) as a directly observed treatment at four-week intervals.

To evaluate the trainings, participants’ knowledge was assessed before and after training using multiple- choice questions. Knowledge increased as evidenced by the increase in participants’ marks. Tables 4 and 5 show the results. Table 4: Summary of pre- and post-test results for CM and MIP training held in Mashonaland Central, October 2020

Pre-test Post-test Total participants 32 32 Highest mark 94% 96% Lowest mark 44% 56% Total attained above 50% 31 32

Table 5: Summary of pre- and post-test results for CM and MIP training held in Mashonaland East, November 2020

Pre-test Post-test Total participants 40 40 Highest mark 85% 95% Lowest mark 47% 44% Total attained above 50% 37 39 Total attained below 50% 3 1 No change 0 1 Delearning 0 5

3.1.3 MALARIA DEATH AUDIT MEETING IN MASHONALAND EAST, NOVEMBER 2020 ZAPIM supported the Mashonaland East Province to conduct a malaria death audit meeting. At the time of the meeting in November 2020, the province had experienced 64 malaria related deaths in the past year. Table 6 shows the distribution of malaria deaths in the province.

Table 6: Malaria related deaths by district in Mashonaland East, November 2020

District Number of Deaths Mutoko 23 Mudzi 11 Murewa 9 UMP 8 Wedza 6 Chikomba 3 Marondera 2 Seke 1 Goromonzi 1 TOTAL 64

Key recommendations from the malaria death audit meeting in Mashonaland East: 1. Strengthen SBC communication to encourage early treatment seeking behavior so that the community avoids the first delay as delayed presentation contributed to some of the deaths.. 2. Improve treatment and care of malaria complications in facilities. Detection and correct management of malaria complications, such as hypogyceamia, anaemia, acute kidney injury and pulmonary oedema, are important in preventing malaria related deaths. 3. Treat pregnant women with malaria with ACTs regardless of gestational age to avoid unnecessary delays that result in maternal death related to non-availability of Quinine. ACTs are the first line treatment for MIP throughout pregnancy. 4. Ensure health facilities provide correct management of hypovolemic shock using Normal Saline 0.9% and Ringer’s Lactate in severe malaria. 5. Ensure meticulous care of comorbidities in all cases of severe malaria with comorbid conditions to improve survival. 6. Strengthen and institutionalize malaria death audits for health care workers at hospitals to improve care and reduce avoidable malaria deaths. Regular ongoing facility based malaria death audits reach more health care workers than provincial level death audits. 7. Educate community members about the importance of adherence to malaria treatment, including completing treatment courses even if they feel better before the course is complete, and to return to the facility or VHW if they experience recurrent vomiting or worsening of symptoms while on treatment. During the no-cost extension, five malaria related deaths were recorded in Mashonaland Central; three deaths in Centenary, and one each in Mbire and Mt Darwin Districts. These were all investigated. Delays in seeking medical care and non-availability of public transport due to COVID-19 restrictions were some of the contributing factors in the deaths.

3.1.4 CM AND MIP SUBCOMMITTEE MEETING ZAPIM supported the NMCP to hold the CM and MIP subcommittee meeting in Harare. Some of the key deliberations during the meeting included a review of the results of a pilot of community administration of single dose primaquine by VHWs in Beitbridge East. While the study results showed the feasibility of community administration by VHWs if properly trained, monitored, supported, and supervised, the committee felt that the nation was not ready given the challenges still occurring with single dose primaquine at the facility level. The committee recommended that VHWs in high burden areas of Beitbridge should be allowed to test and treat malaria cases – as is the case in all other high burden districts in the country – but there is no need for single dose primaquine as it has no role in high burden settings.

There was limited data about the community pilot of first dose SP for IPTp as only Manicaland presented their results. Masvingo was not represented at the meeting, and there was no data from Mashonaland Central. Data from Manicaland raised questions about the utility of single dose SP at community level at 13 weeks gestation when the next scheduled antenatal care (ANC) visit is at 20 weeks and SP doses are

recommended at least four weeks apart during pregnancy. The committee felt that there was need to continue gathering more data about the uptake of first dose SP at community level, and there was need to engage with the Department of Reproductive Health to ensure seamless harmonization with the NMCP to ensure smooth administration of IPTp. The province shared data from malaria death audits which showed proportionally high malaria deaths among those aged above 60 years compared to other age groups. This was thought to be related to the presence of comorbidities in the upper age group. The committee highlighted the need for meticulous nursing and supportive care for the elderly with severe malaria. There were also disproportionately higher malaria deaths among young males aged 19-45 compared to their female counterparts, underlining the need to address behaviors and socioeconomic activities (e.g., artisanal mining) which put men at higher risk of malaria and death.

3.1.5 COMMUNITY CASE MANAGEMENT ZAPIM supported the training of 78 VHWs in Centenary District of Mashonaland Central. Table 7 shows the total number of VHWs trained in ZAPIM supported districts in Mashonaland Central and the remaining training gaps.

Table 7: Community CM training of VHWs in ZAPIM- supported districts in Mashonaland Central 2016-2020

Total number Total number Total VHW trained trained training Total number Gaps in District through through other coverage per of VHWs training ZAPIM partner district Support support (# and %) Centenary 333 243 71 314 (94%) 19 Mt. Darwin 339 80 75 155 (45%) 184 Bindura 223 80 40 120 (54%) 103 Shamva 228 40 98 138 (61%) 90 Mbire 200 40 120 160 (80%) 40 Total 1,323 483 404 887(67%) 436(33%)

ZAPIM supported the training of 40 VHWs in community CM from UMP District of Mashonaland East. The training was conducted in two groups of 20 trainees each to allow for social distancing and with strict observation of wearing of masks at all times, frequent handwashing and use of hand sanitizer. All participants had daily temperature checks during the training.

3.2 LONG-LASTING INSECTICIDAL NETS 3.2.1 LLIN DELIVERY TO DISTRICT HOLDING POINTS AND DISTRIBUTION FACILITIES ZAPIM calculated the six-month LLIN requirements for the 12 districts it supports. CD data for the period October to March (2018, 2019, and 2020) was used to quantify LLIN requirements for each district. After the quantification, ZAPIM coordinated with the Global Health Supply Chain project and delivered 85,000 LLINs to 12 district holding points in November 2020. The LLINs are expected to be sufficient until May

2021. This initiative was undertaken to ensure adequate uninterrupted supply of LLINs during the ZAPIM close-out period. See Table 8 for more details. Table 8: ZAPIM Supported LLINs delivered by district, November 2020

LLINs Delivered LLINs Available (in stock) by Department from LLINs # of Health National delivered to District Facilities Warehouse Health HF Total supported ANC EHT Grand to District Facilities EPI Unit Store- LLINs Unit Office Total Holding room available Points 1 Bindura 2,500 2,500 7 341 196 206 1,103 1,846 4,346 2 Centenary 7,500 5,250 7 0 56 203 7,100 7,359 12,609 3 Guruve 10,000 10,000 12 140 108 104 10,635 10,987 20,987 4 Mazowe 10,000 7,889 23 0 54 40 4,059 4,153 12,042 5 Moire 5,000 1,500 5 5 5 9 556 575 2,075 6 Mt. Darwin 10,000 10,000 9 n/a n/a n/a n/a 7,631 17,631 7 Rushinga 5,000 2,500 8 14 22 385 753 1,174 3,674 8 Shamva 10,000 4,500 8 0 0 1,195 808 2,003 6,503 Subtotal 60,000 44,139 79 500 441 2,142 25,014 28,097 72,236 9 Goromonzi 10,000 8,000 16 25 0 0 3,023 3,048 11,048 10 Hwedza 2,500 2,250 6 62 32 648 287 1,029 3,279 11 Murewa 10,000 10,000 13 2 1 5,165 855 6,023 16,023 Subtotal 22,500 20,250 35 89 33 5,813 4,165 10,100 30,350 12 Binga 2,500 2 0 0 0 0 0 0 Grand 85,000 64,389 116 589 474 7,955 29,179 38,197 102,586

Total As shown in Table 8, ZAPIM helped the districts to deliver LLINs to 116 health facilities in 12 districts. A data collection tool was designed and distributed to district delivery teams. The tool was used to collect LLIN data at each health facility at the time of delivering a new consignment. The 116 health facilities had 64,389 LLINs at the time delivery. A major concern was the availability of LLINs within ANC and Expanded Programme on Immunization (EPI) units. These held only 3% of the total LLINs available, whereas the EHTs’ offices held 21% of the LLINs, and storerooms 76%. Recommendations were made to the health facilities that the maternal and child health units should store adequate LLINs for distribution to ANC and EPI clients as per the national policy on LLIN distribution.

3.2.2 CD TRAINING - RUSHINGA AND SHAMVA DISTRICTS Figure 1: VHWs being trained on CD of LLINs in Rushinga, November 2020

ZAPIM supported Rushinga District to distribute LLINs to special populations living along the border with Mozambique. These communities leave their homes in Zimbabwe during November and December each year to farm in Mozambique where the soils are considered fertile. Their movement coincides with IRS. However, due to their migratory way of living, a lot of rooms are left unsprayed. Furthermore, if they contract malaria whilst in Mozambique, they return to Zimbabwe to receive treatment. It is against this background that ZAPIM supported the district to distribute LLINs, covering eight wards bordering with Mozambique. A mass campaign was conducted followed by CD of LLINs. In addition, Shamva District has two wards that transitioned from IRS to LLINs due to their low malaria burden. ZAPIM supported the district in deploying LLINs. Tables 9 and 10 provide more details about the trainings conducted to support LLIN distribution. Table 9: Health workers trained in CD of LLINs in Rushinga and Shamva Districts, November/December 2020

Health Dates Health workers trained facilities covered Male Female Total Rushinga 8 8 8 16 Shamva 2 0 3 3 Total 10 8 11 19

Table 10: VHWs trained in CD of LLINs in Rushinga and Shamva Districts, November/December 2020

VHWs Trained District Wards covered Target VHWs Male Female Total Shamva 2 21 0 24 24 Rushinga 10 79 32 33 65 Total 12 100 32 57 89 (89%)

Rushinga District trained 16 health workers and 65 VHWs, and Shamva District trained three health workers and 24 VHWs on CD of LLINs. At the end of the training, recommendations were made to strengthen program performance and effectiveness. These are summarized in Table 11. Table 11: Recommendations from the CD trainings in Rushinga and Shamva Districts November/December 2020

Challenges/Issues Possible solution Time frame Responsible Persons Missed opportunities for Supply ANC and EPI Immediate District Nursing Officer (DNO)/ CD of LLINs through departments with LLINs for District Environmental Health Officer ANC and EPI when easy access (DEHO) LLINs are not readly accessible in these departments at the facilities High movement of Provide continuous Ongoing EHT/DEHO people into Mozambique education to special for farming purposes populations; distribute LLINs to special populations Poor communication Improve communication Immediate DEHO/DNO between EHTs and between EHTs and nurses on nurses on CD LLINs LLIN distribution High incidence of malaria Involve all stakeholders to Ongoing DHE in Rushinga District. tease out the causes and figure out ways to control the high incidence of malaria No training in CD of District to arrange training By December EHO/Nurse in Charge LLINs of Mafigu and for the two health facilities 31, 2020 Chimandau VHWs before end of December 2020 Poor recording of Train all health workers on Ongoing DEHO/DNO people who are LLIN distribution and receiving LLINs through recording ANC and EPI

3.2.3 CONTINUOUS DISTRIBUTION OF LLINS TO BENEFICIARIES ZAPIM supported the distribution of 31,433 LLINs to beneficiaries in 11 districts. The number of LLINs distributed this quarter was 81% more than during the same quarter last year. See Figure 2.

Figure 2: CD of LLINs in ZAPIM supported districts by year and by quarter, 2016-2020

120,000

100,000

80,000

60,000

40,000 LLINSDISTRIBUTED

20,000

0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Quarter 4 998 8,465 20,958 9,371 19,522 Quarter 3 25,411 6,127 29,809 16,514 21,500 Quarter 2 0 8,013 54,329 39,015 19,713 Quarter 1 0 2,964 10,226 29,042 17,310 31,433 YEAR OF DISTRIBUTION

Quarter 1 Quarter 2 Quarter 3 Quarter 4

The high uptake of LLINs was due to the COVID-19 backlog, as people redeemed their coupons after the relaxation of COVID-19 restrictions, as well as increased awareness created through continuous community communication and engagement. Of the three CD channels used in Zimbabwe, the community continues to be the main distribution channel. As indicated in Figure 3, from a total of 31,433 LLINs, 17,829 (56.7%) were distributed through the community channel, followed by 7,780 (24.8%) through ANC and 5,824 (18.5%) through EPI.

Figure 3: LLIN distribution by channel, October to December 2020

EPI 18%

Community Community ANC 57% 25% ANC EPI

3.2.4 ELECTRONIC REPORTING SYSTEM ZAPIM supported the roll out of the LLIN electronic reporting system using the DHIS 2 tracker by conducting training. Forty-three participants were trained from Bindura, Centenary, Goromonzi, Guruve, Hwedza, Mazowe, Mbire, Mt Darwin, Murehwa, Mutoko, Rushinga and Shamva Districts and the two provinces of Mash East and Mash Central. The training included participants from each district, representing the Community Nursing, Environmental Health, and Health Information Units. See Table 12. Table 12: Participants trained in LLINs electronic reporting October 14-15, 2020

Participants By gender Total Males Females Nursing 4 7 11 Environmental health 9 6 15 Health information 9 5 14 Doctors 1 0 1 M&E 2 0 2 Total 25 18 43

3.2.5 LLINS DATA QUALITY ASSESSMENT ZAPIM supported 10 districts to conduct data quality assessments (DQAs) for LLINs. The objectives of the DQAs were to:

 Check on the quality, accuracy, and completeness of reporting at the facility level;  Assess how CD of LLINs was being documented at the health facility level;

 Identify gaps and challenges in LLIN distribution;  Identify best practices for sharing with other health facilities and districts;  Provide on the job coaching to health workers; and  Recommend areas in need of strengthening. A total of 64 health facilities were assessed. The assessments revealed that:

 Knowledge about LLIN distribution among both old and new health workers was low;  At some health facilities, LLINs were stored in the EHTs’ offices and were not easily accessible to clients; and  There were inconsistences in data between clients seen and those issued with an LLIN. The DQA teams addressed the anomalies observed by educating health workers on the correct procedures for implementing LLIN activities. Table 13 presents a summary of the issues and challenges observed, as well as the recommendations.

Table 13: Issues, challenges, and recommendations from DQAs, November 2020

Challenges/Issues Possible solution Time frame Responsible Persons Poor recording of LLIN Use ANC and EPI registers Immediate DEHO/DNO beneficiaries for recording LLINs issued High numbers of missed Ensure availability of LLINs at January 1, 2021 DEHO/DNO opportunities for both each point of service delivery ANC and EPI channels and not the EHT’s office only Inadequate support and Include LLIN indicators in By March 31, PEDCO/DMO supervision on LLINs by the checklist on Result Based 2021 district staff Funding support and supervision No team work at health Improve communication Ongoing DNO/DEHO facilities on LLIN between nurses and EHTs to distribution avoid missed opportunities for beneficiaries of LLINs Lack of knowledge about Conduct district orientation Ongoing DEHO/ZAPIM CD by newly recruited trainings on CD LLIN and old staff distribution

3.2.6 TARGETED DISTRICT LLIN SUPPORT AND SUPERVISION Challenges identified during the DQAs were forwarded to the District Health Executives (DHEs) to address. The DHEs, with support from ZAPIM, then provided targeted support and supervision to address the problems onsite. A total of seven districts conducted targeted support and supervision covering 53 health facilities.

3.3 SOCIAL AND BEHAVIORAL CHANGE During the quarter, ZAPIM focused on supporting the following broad areas in relation to SBC:  The NMCP rebranding exercise;  Development of a malaria elimination leaflet;  Development of an LLIN animated promotional video;  Support to NMCP malaria commemorative events; and  Support for CAC activities.

3.3.1 SUPPORT FOR NMCP REBRANDING The NMCP rebranding effort entered the data collection and analysis phase during the period under review. Final preparations for data collection were conducted and included: training for field work, which was conducted virtually; procurement of field work provisions and supplies; allocation of field teams to cover data collection in the field; and allocation of team members to conduct stakeholder interviews, which were done virtually. Community mobilization was facilitated through health facility personnel at the ward level with six local EHTs carrying out the exercises. Field work was conducted in three provinces (six districts): Mashonaland Central (Centenary and Mazowe Districts); Masvingo (Chiredzi and Chivi Districts), and Matabeleland North (Binga and Umguza Districts). Table 14 summarizes the data collection targets for each district. Table 14: Number of people targeted per ward for rebranding interviews and focus group discussions (FGDs) held from 15-26 September 2020

Number of targeted persons Designation of targeted person per selected ward 1 Healthcare worker 1 Policy maker (councilor ) 1 Community Leaders (village head) 8 Focus group – men 8 Focus group – women

Key informant interviews were conducted virtually with selected stakeholders. Collected data was uploaded onto an online workspace (Huddle) from where transcription and translation work was conducted to repackage the data into English to facilitate analysis. Data quality checks were also conducted. An analysis plan was developed and a timeline for report writing developed. Table 15 summarizes the consulted stakeholders and communities.

Table 15: List of key informant stakeholders for the NMCP rebranding

Ministry or Organization Department Interviewee Job Title MOHCC HQ Chief Director, Preventive Services Chief Director, Policy and Planning National Institute of Health National Institute of Health Research Research representatives Zimbabwe Association of Church Executive Director or malaria focal person Hospitals United Methodist Church Malaria focal person PMI Malaria Resident Advisor, USAID WHO Malaria Focal Person Tongaatt Hullet Sugar Estates Health Partnership relations representative Nets for Africa - Bednet suppliers Partnership relations representative Health Environment and Partnership relations representative Development Consulting (HEDEC) University of Zimbabwe, Dept. of Community Medicine Head od Department Community Medicine Africa University Health Sciences/malaria Head of Department Matabeleland North Province Government MOHCC at Provincial Health Executive (PEDCO) province level Masvingo Province Government MOHCC at Provincial Health Executive (PEDCO) province level Mashonaland Central Province Government MOHCC at Provincial Health Executive (PEDCO)/DMO province level Matabeleland North Province Government MOHCC at DEHO district level Masvingo Province Government MOHCC at DEHO district level Mashonaland Central Province Government MOHCC at DEHO district level

The PMI VectorLink project continued to support budgetary oversight, procurement of outsourced services, and payment of service providers for the data collection and analysis. COVID-19 conditions in the country were a major consideration, and all preventive measures and guidelines were adhered to during data collection. See Figure 4.

Figure 4: Observing COVID-19 precautions during interviews and FGDs at community level, Mashonaland Central, Mazowe and Centenary based Health Facilities 22 & 26 September 2020

3.3.2 DEVELOPMENT OF MALARIA ELIMINATION LEAFLET In order to continue to support NMCP’s elimination agenda and help to sensitize communities on elimination, ZAPIM continued with development of a leaflet targeting communities in pre-elimination areas. The leaflet aims to educate and inform communities about what elimination entails, and to explain the key roles they are expected to play towards achievement of malaria elimination. The leaflet provides easy to understand information and illustrations for families, household members, and community members on how the malaria elimination program will impact them and how they can effectively contribute to malaria elimination in their area. The leaflet was drafted to an advanced stage during the quarter, and will be shared with NMCP and its partners in soft-copy to support planned SBC work in elimination districts.

Figure 5: Illustrative draft of elimination leaflet

3.3.3 DEVELOPMENT OF LLIN PROMOTIONAL VIDEO The continued promotion and engagement of communities on use of LLINs was prioritized during this quarter. An LLIN promotion and net hanging animated video was conceptualized and creative development commenced. The video will promote net ownership and demonstrate the proper consistent use and care of LLINs, including different ways of hanging nets to suit different environments, including outdoors. It will emphasize that LLINs are free of charge for community members, and highlight where to access them to enable use at all times and for all sleeping spaces. The video will be short, easy to understand, and accessible to communities via social media platforms, such as WhatsApp. The content is being designed to motivate communities to embrace LLINs by using community members to model good behavior and show case the benefits of using LLINs. The video also uses catchy phrases in local common “lingo” to help depict net use as a modern and trending habit for informed citizens. See Figure 6.

Figure 6: Illustrative graphic of LLIN promotional video

3.3.4 SUPPORT TO MALARIA COMMEMORATION BY NMCP MALARIA DAY ZAPIM provided technical, preparatory, and non-financial support to the NMCP for Southern African Development Community (SADC) malaria day held on November 25, 2020. Additional support was provided by giving promotional banners to use at the commemorative press conference, which was convened by NMCP in Harare. Due to COVID-19, no major commemorative functions were held to avoid large crowds.

3.3.5 COMMUNITY SBC Community SBC focused on completing outstanding CAC activities and training from Year 5.

3.3.6 CAC EVALUATE TOGETHER TRAININGS ZAPIM conducted CAC trainings in Matebeleland North on the “evaluate together” phase. These trainings reached 157 community members. The trainings were integrated with courtesy mentorship visits to mentorship sites (8 of the 10 sites). Questions on commodity status, IRS preparedness, and ANC booking rates were asked. During the eight site visits:  Stocks of malaria commodities were adequate;  Lukosi and Kanywambizi did not have a functional sphygmomanometer; and  New nurses had been employed but not trained in malaria CM. ZAPIM also administered a laboratory malaria testing checklist (ZINQAP) while conducting CAC in Hwange on the state of laboratory support to facilities. The laboratory had no transport to conduct laboratory assessment visits, so the district administration asked the Provincial Coordinator to administer the short questionnaire. Findings showed that clinics in Hwange were in need of microscopists. While conducting the mentorship visits, ZAPIM distributed personal protective equipment (PPE) for VHWs to the eight facilities visited, as well as others along the route. ZAPIM also helped with vaccine and essential medicines distribution. The DNO appreciated the support as oxytocin was out of stock at Sidinda clinic. At each facility visited, ZAPIM provided training on CD of LLINs and data collection tools, including coupon books for health workers at Simatelele and Siabuwa wards which benefited from ZAPIM support for LLIN distribution.

3.3.7 CAC DOCUMENTATION VISITS When ZAPIM set up the CAC teams for Binga and Hwange Districts at the beginning of 2019, four problems were identified across the 16 CAC teams. These problems were: high malaria incidence, late ANC bookings, low IRS coverage, and presence of breeding sites that were difficult for EHTs to identify. The results and discussions held following the visits showed that:  IRS room coverage generally increased in areas where CAC teams were active in mobilization;  Early ANC booking is improving across health facilities where CAC teams are active.  CAC teams identified breeding sites and in some facilities (e.g., Sinansengwe, Siabuwa, and Simanagani) and those were larvicided.  CAC teams conducted malaria sensitization meetings and minutes with attendance registers were seen.  Village-based malaria task forces were formed and were used during IRS to help the spraying teams by showing them all the households in the catchment area. This was to ensure that rooms to be sprayed were not missed, thereby increasing IRS coverage.  Health center committees and ward health teams knew some of their roles (e.g., procurement and being a link between the health facility and communities).

 CAC teams from Siabuwa, Lukosi, and Milonga have developed poultry projects. The Mwembe team has a goat project with two adult goats from community members fined by the chief for late ANC booking. This policy was advocated for by the team after CAC training.  Videos and photos were shot by a professional cameraman in Simatelele, Siabuwa, and Sinansengwe for a documentary on CACs and ZAPIM successes.

3.4 M&E AND OPERATIONAL RESEARCH 3.4.1 EPIDEMIC PREPAREDNESS AND RESPONSE GUIDELINES ZAPIM continued to refine the epidemic preparedness and response materials, taking into consideration inputs from NMCP and PMI. The trainings will be scenario-based to enhance practical application of the principles in the guidelines. ZAPIM shared the current version of the training materials with PMI and NMCP for their inputs.

3.4.2 MALARIA SM&E TRAINING MANUAL ZAPIM developed a near final version of the SM&E Training Manual and Power Point slides for the training, which were approved by PMI. ZAPIM shared the training materials with NMCP for their input and sign- off. NMCP has acknowledged receipt, but had not provided feedback by the end of the reporting period. ZAPIM developed the training materials with input from the Abt headquarters SM&E backstop for the project. Once NMCP signs-off the training materials, they will be used for SM&E training of health care workers. The manual and other training materials will enhance the quality of SM&E trainings and ensure quality implementation of malaria SM&E processes occur at all levels.

3.4.3 WEEKLY VHW MOBILE REPORTING PILOT IN MBIRE DISTRICT ZAPIM provided financial and technical support for weekly mobile reporting by VHWs in Mbire District. Support included procurement of airtime for each VHW to use Open Data Kit (ODK) and/or SMS to report malaria cases, deaths, and availability of commodities at the VHW level. The completeness of reports from VHWs improved compared to the previous quarter, as some VHWs who had challenges operating the ODK mobile application system were encouraged to use SMS for reporting. All the VHWs were able to report on a weekly basis during the quarter. For continuity, the district and health facilities were encouraged to consider continuing to provide VHWs with airtime from results-based financing resources.

3.4.4 ROUTINE EVALUATION OF AUDIO BOOK IN CHIKUNDA LANGUAGE ZAPIM supported the routine evaluation of an audio book in the Chikunda language, checked the availability and functionality of the audio books in the community, as well as dissemination of malaria messages. The team conducted a desk review of treatment records and medical seeking behavior in the community, stock status of antimalarial commodities at health facility and at community levels from 2017 to 2020, and IRS and LLIN coverage by village. The team met with Chief Chapoto, the Ward Councilor, VHWs, church leaders, and village heads who were involved in dissemination of information through the audio book.

Specific objectives were to:  Evaluate the physical condition, functionality, and sound quality of the audio book after two years of use;  Conduct an inventory of all the devices that were distributed by location;  Review health facility and community reports on the audio book;  Check use of the audio book by gender and by village;  Check if there were increases in ANC early bookings and demand for LLINs from pregnant mothers; and  Determine early medical seeking behavior for children under five years who reported for medication within 24 hours of onset of fever from the Doma people. Methodology:  Met with the Chief and outlined the purpose of visit;  Met with health staff on the purpose of the visit;  Gathered all documentation on the audio book for analysis;  Conducted physical checks of the audio book;  Played all the audio books to determine sound quality; and  Reviewed clinical records by village on ANC, malaria in under five years, referrals, and VHW data by village. Key findings: The audio books were evaluated on availability, functionality and audibility. Table 16 analyzes the status of the audio books.

Table 16: Functional status of Chikunda audio books in Chapoto, November 2020

Distributed Seen Functional Not functional Lost Misplaced Audible

27 devices 22 15 7 1 4 15

Review of the records showed a decrease in malaria cases among children under five years of age in Chapoto Ward from 2017 to 2020. See Figure 7.

Figure 7: Decline in malaria cases in children under 5 years of age in Chapoto Ward, 2017-2020

600

500

400

300

200

100

0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2017 2018 2019 2020 The audio book was laucched in Chapoto on 28th June 2020

Figure 8 shows the coverage of the Chikunda audio book by gender and by village in Chapoto Ward of Mbire District. Figure 8: Chikunda audio book coverage by gender and by village, November 2020

1400 1328

1200 1017 1000

800

600 543 420 379 400 343 311 280 228 262 164 172 200 140 56 81 0 Mariga Chansato Chiruhwe Chiramba Nyaruparo Males Females Totals

3.4.5 MALARIA ELIMINATION REVIEW AND PLANNING MEETING The project’s Acting COP attended an elimination review meeting in Bulawayo. The meeting was held in two clusters for all the provinces and districts in elimination. The meeting reviewed progress by provinces and districts towards malaria elimination, as well as challenges and lessons learned. Best practices were

shared and recommendations made for improving malaria elimination work in Zimbabwe. Table 17 shows the major challenges, and recommendations from the meeting. Table 17: Key elements, challenges, and action plans from the elimination review and planning meeting, November 2020

Key element Current challenges Action Plan Responsibility Low  Limited microscopy capacity in  Increase coordination among  Lab proportion of most elimination districts leading existing facilities and continue Scientist(to microscopy coordinate) to delays and not conducting resource lobbying at national level tests  NMCP microscopy

Timely  Non-functional and inadequate  Accelerate distribution plan for  NMCP notification of android tablets at health facility devices that have been procured cases  District Medical levels upon their receipt Officer (DMO)  Non-provision of data for sending  Provinces to share updated lists of reports – some supplied cell #s cellphone numbers used for data were being rejected (e.g., wrong reporting numbers, disconnected)

Case  Fuel - inconsistent supply and  Ensure supply of fuel is consistent  Admin investigation non-acquittal where it is provided with consumption, as well as rate  Procurement  Inadequacy of motorcycles – the timely acquittals and Team compensation available fleet is inadequate, and  DHE requires repairs  NMCP made a call for provinces to send requests for servicing of motorcycles – Provinces to provide required documentation to facilitate the servicing to occur  Integrate with other partners and continue mobilization

Capacity Health workers have training gaps  Limited funds for training – NMCP  PEDCO/ PEHO building on: made a call for provinces to  Director NMCP  Enhanced surveillance conduct orientation of health  Foci investigation and response workers on elimination before the  Data analysis and GIS end of 2020 using Global Fund  Continue resource mobilization and innovation

Foci  Limited entomological capacity to  Use clusters/focal persons to  DEHO management complement case investigation conduct entomological delays  PEDCO findings surveillance in active foci  Rigid process for activating  Improve coordination and response and unavailable enhance communication among all resources at local level levels to unlock foci response resources

Key element Current challenges Action Plan Responsibility Data quality  Unclear protocol for handling  Add actively found cases to the  DMO issues cases detected through active OPD registers only if they are  NMCP surveillance symptomatic  Modify DHIS2 to allow tracking of symptomatic and asymptomatic cases

Low  Patients administered with single  Conduct training for newly  NMCP primaquine low dose primaquine are below recruited health workers on CM administration  Directorate of the set targets in all the districts protocols, and continuous Pharmacy due to knowledge gap refreshers for existing staff Services  Sporadic stock-outs of primaquine  Pharmacy to distribute primaquine in some health facilities based on the historical consumption pattern and consider seasonality

Lunch  Non-submission, late payment,  Districts to submit complete  DHE allowances and incomplete paperwork to paperwork to province – the facilitate payments of lunch submitted paperwork should align allowances for health workers with the financial standard operating procedure requirements to facilitate ease of processing by NMCP

4. GENDER

ZAPIM trainings and SBC materials are gender sensitive. Services provided in ZAPIM-supported districts are accessible to both men and women equally. Pregnant women are more vulnerable to malaria; ZAPIM therefore ensures pregnant women are provided with LLINs and SP during ANC visits in ZAPIM- supported districts. In addition, ZAPIM recognizes the important role women play in the care of children, particularly those under five years of age. ZAPIM’s gender activities aim to empower women with knowledge and skills to better protect themselves and their families against malaria and to seek early treatment for illness.

5. ENVIRONMENTAL COMPLIANCE

ZAPIM ensures its activities do not harm the environment. In this regard, the project focuses on three areas:  Generation of medical waste at both the health facility and community level;  Disposal of LLINs and solid and liquid waste; and  Management of public health medicines and commodities.

5.1 MEDICAL WASTE If ZAPIM does not properly handle, store, and dispose of the medical waste that health facilities and community CM generate, there is a risk of disease transmission. During this quarter, ZAPIM technical staff supported community health workers in infection prevention through mentorship calls. During community CM supportive supervision, EHTs reoriented VHWs on proper handling of medical waste and the need to take medical waste to health facilities each month for proper disposal. ZAPIM uses supportive supervision visits to mitigate identified gaps in handling and disposing of medical waste, and to ensure implementation of suggested measures. The distribution of LLINs generates solid waste from the packaging. Considering the high volume of LLINs the program distributes, there is potential harm to the environment from failing to follow proper disposal procedures. In addition, household washing of nets may contaminate water sources if communities do not know the techniques for the proper disposal of water from LLIN washing. To mitigate the negative environmental effects of liquid and solid waste, ZAPIM trained VHWs and other health workers on the proper disposal of LLIN waste in all 12 supported districts during this quarter. Proper disposal requires cutting LLIN packaging into small pieces and burying the pieces in a pit 50-100 cm deep away from water bodies. Households should not wash nets in rivers or dams, but rather in a container with water. The water should then be disposed of in a pit. ZAPIM provided this information to all community members in the 12 supported districts during LLIN distribution and CD training during the reporting period.

5.2 MANAGEMENT OF PUBLIC HEALTH MEDICINES AND COMMODITIES ZAPIM supports activities at both the health facility and community levels where medicines and commodities are distributed, including malaria medicines, testing kits, syringes, and gloves. There is a risk of children ingesting improperly secured medicines. Medicines may also expire, and using expired medicines may result in poor treatment outcomes. It is therefore necessary to have good medicine and commodity management practices in place. Through malaria supportive supervision, mentorship and training, ZAPIM teaches health workers and VHWs about the proper storage of medicines and ways to avoid drug expiration (e.g., quantification of stocks and proper handling of expired drugs). To ensure correct communication of information on the management of medicines and commodities, pharmacists

and pharmacy technicians are part of the malaria CM training team. ZAPIM procured and distributed lockable medicine boxes for VHWs in Mbire District in Year 4.

6. CHALLENGES RECOMMENDATIONS, AND LESSONS LEARNED

ZAPIM staff mostly worked from home during this quarter due to the national lockdown to prevent the spread of COVID-19. The team had minimum travel into the field to implement activities, and where staff did travel, it was under strict COVID-19 mitigation measures as permitted by relaxation in the national lockdown measures for essential services. To mitigate the limitations imposed by lockdown, the project developed innovative ways to offer remote support to the provinces and districts. For example, the ZAPIM team transitioned quickly to teleworking. This ensured both the safety of staff and the continuity of some technical activities. To ensure that staff could continue to work efficiently during the pandemic, staff were provided with additional data bundles for internet connectivity at home. This enabled staff to stay in touch and participate in important meetings with the Abt home office, PMI, and NMCP. The project also started using other cost-effective means of information sharing, such as the Abt and ZAPIM WhatsApp group. WhatsApp platforms were used mainly to share safety and security updates, or to discuss technical issues. During this quarter, ZAPIM implemented activities through the MOHCC structures at provincial and district level. In addition to offering logistical support, ZAPIM also provided virtual mentorship and support calls to VHWs to ensure continued implementation of CM and community CM activities in the context of COVID- 19. This enabled the ZAPIM team to understand malaria activities taking place in the field and the challenges experienced, and to provide technical guidance and suggestions to address the challenges. A common challenge encountered by mentorship teams was limited cellphone network coverage in certain areas. This resulted in one facility not being able to participate in any mentorship calls. During the first month of calls, larger hospitals focused on facility readiness and found it difficult to make time for mentorship calls. In comparison, it was relatively easy to schedule calls for smaller facilities. Airtime is expensive; without provision of airtime, district and provincial mentors felt they were unable to continue the calls. ZAPIM therefore provided mentors with airtime. The experience demonstrated that remote mentorship can be an effective and efficient approach. District mentors recommended that the approach is continued in conjunction with in-person mentorship visits where the situation allows. Remote mentorship could also be an efficient way to expand support to additional facilities. ZAPIM learned that ensuring LLINs are available at all times when needed at the health facility level is important in building community confidence in the program. To this effect ZAPIM ensured uninterrupted supply of adequate stocks of LLINs to health facilities for continuous distribution. The project supported the delivery of enough LLINs for CD to last until May 2021 in the 12 supported districts.

ANNEX A: PMP INDICATORS/YEAR 5 MILESTONE MATRIX

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps districts such as Mudzi, Mutoko, UMP, Shamva, Guruve and Rushinga also reported a high number of cases. CM Proportion of PMP 35% 80% 37% 37% N/A In total, 348,050 women who (MIS 2012) confirmed cases received two were reported in or more doses the country. of IPTp during ZAPIM- ANC supported districts (e.g., Mudzi, Mutoko, UMP, Shamva, and Rushinga) also reported a high number of cases. CM Proportion of PMP 68.8% N/A 50% (ZDHS, 50% N/A The figure of 50% under-5 (MIS 2012) 2015) is according to children who the 2015 sought Zimbabwe treatment Demographic and within 24 hours Health Survey of onset of (ZDHS). The fever new National Malaria Control and Elimination Strategic Plan (NMCESP) is still being costed and

The indicator was not well reported in the 2016 MIS preliminary report, and therefore the 2015 ZDHS report was used as a reliable source. CM Percentage of PMP 99.8% 100% 98% 94.4% 94.4% MOHCC and suspected (HMIS 2016) VHWs to malaria cases continue that receive a encouraging parasitological communities test that any suspected malaria case should be tested.

Health facilities and community- based health workers should continue to exhibit high

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps compliance and acceptable practices. Health workers are adhering to the guidelines and this is a good practice. CM Percentage of PMP 93% 100% 65.2% 95% 95% Results show the confirmed (HMIS 2016) level of access to malaria cases treatment of that receive deserving cases first-line for first-line antimalarial treatment. The treatment indicator only according to captures ACTs; national policy other anti- malarials given to complicated cases are not documented in the DHIS2. CM+ Number of PMP 896 200 36 190 95% Implementation CCM health workers, Year 1 affected by delay including ZAPIM in project VHWs, trained Annual funding. In this in malaria case Report) quarter 72 health management care workers (ACTs, trained out of a MIP/IPTp, target of 80 and RDTs, 118 VHWs out microscopy,

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps medicines of a target of management) 120. CM Number of PMP 0 (2016) 15 15 0 100% All district plans districts with feed into the outbreak provincial plan. response plans CM Functional Year 5 0 (2016) 1 1 1 100% All trainings Database to training milestone entered in the be maintained database Database.. for all future (TrainSMART) trainings for the current trainings and future trainings CM NMCP CM/MIP Year 5 1 (2016) 1 1 1 100% One subcommittee milestone subcommittee quarterly meeting held in meetings this quarter. supported Subcommittee meetings resolved issues on community single dose primaquine. CM Number of CM Year 5 0 (2016) 0 500 0 0% Training tools and MIP milestone and job aids were training tools provided for all and job aids the cadres printed trained during this quarter. There were no new materials printed in this quarter but all

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps the training materials and job aids were provided for all the training in this quarter from the materials produced early in Year 5 CM Number of on- Year 5 0 (2016) 10 0 5 50% Mentorship the-job in- milestone activities person l converted from mentorship physical visits to sessions to five calls in keeping districts with COVID-19 regulations. CM Number of Year 5 0 (2016) 0 0 0 0% Could not take national milestone place due to mentorship COVID-19 review meetings conducted CM Number of Year 5 2 (2016) 1 2 1 100% All provinces malaria death milestone conducted death investigation/ audit meetings. malaria death Mashonaland East audit meetings did the meeting with NMCP, in this quarter hospitals, and PMDs, DMOs, and Matrons in attendance

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps CCM Number of Year 5 0 (2016) 0 350 0 100% ZAPIM provided training milestone all the facilitators manuals and job and participants aids (facilitators training manuals and participant for the trainings manuals, to be conducted. medicine supply Target reduced and from 1,320 to accountability 350 due to register, RDT budget contrains job aid, and There were no monthly new materials reporting book) printed in this printed quarter but all the training materials and job aids were provided for all the training in this quarter from the materials produced early in Year 5 CCM Number Year 5 0 (2016) 0 1,600 0 100% ZAPIM procured VHWS milestone PPE for VHWs provided PPE to enable them items procured to continue by ZAPIM offering services as this has been impacted by the COVID-19 pandemic.. There were no new PPE

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps procurements in this quarter. LLIN Proportion of PMP 49% 85% 54% (MIS N/A N/A The indicator is population that (MIS 2012) 2016) not reported slept under an every quarter or insecticide yearly. treated net the previous night LLIN Proportion of PMP 8% N/A 17.5% (ZDHS N/A N/A It is important to NMCP and children under- (ZDHS 2010- 2015) note the different partners to 5 who slept 11) 33% methologies used scale up under an LLIN 49.6% (MIS 2016) for MIS and interventions the previous (MIS 2012) ZDHS. that promote night net usage among children. LLIN Proportion of PMP 49.1% N/A 36% N/A N/A Only 36% of NMCP and women of (MIS 2012) (MIS 2016) women slept partners to child-bearing under an LLIN scale up age who slept the previous interventions under an LLIN night, which was that promote the previous a substantial net usage night decrease among compared to the women aged 49% in the 2012 15-49 years. MIS. LLIN Proportion of PMP 46.4% N/A N/A N/A N/A The baseline and The National households in (MIS 2012) results are Malaria M&E ZAPIM target national. Plan is being districts with finalized and one or more will inform the LLINs targets.

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps LLIN LLIN CD PMP 10 (Year 1 12 11 12 100% COVID-19 All targeted system rolled ZAPIM affected the district are out in ZAPIM Annual activity now doing target districts Report) CD and will be done throughout the year. LLIN Net durability PMP 0 (2016) 1 1 0 100% Report was . study findings finalized and produced and approved. recommendatio ns adopted for future distribution planning LLIN Integrated Year 5 1 1 1 100% Strategy Once vector milestone developed and approved, management awaiting health staff strategy finalization and will be developed approval. trained.Finaliz ation affected by COVID-19. LLIN Number of PMP 1,358 (2016) 120 0 108 90% Implementation people (LLIN affected by distributors) COVID-19. trained in LLIN Restrictions on continuous and gatherings . The mass target was a distribution carryover from Year 5 to the no cost extension perod.

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps LLIN Number of PMP 573,950 20,000 100,505 31,433 157% The target of 20 LLINs (2016) 000 set was distributed exceeded as (mass + CD) more people were able to get LLINs through CD when lockdown measures in the country were relaxed. LLIN Number of Year 5 N/A 14 14 10 71% Implementation . wards covered milestone affected by for LLIN COVID-19 follow-up visits Pandemic. by health facility staff and VHWs 2 weeks after mass distribution. LLIN Number of Year 5 N/A 8 5 4 50% Implementation districts milestone affected by covered to COVID-19 identify and Pandemic. map special populations LLIN Number of Year 5 N/A 20 0 10 50% Implementation community milestone affected by mobilization, COVID-19 net follow-up Pandemic as visits/meetings gatherings in all wards that continued to be are benefiting restricted..

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps from the LLIN distribution. LLIN Number of Year 5 N/A 8 0 10 125% This was done in LLIN data milestone the LLINs quality districts.The assessments DQAs were then conducted followed by targeted ss done by the District Health Executives. LLIN Number of Year 5 N/A 4 0 12 300% More districts district-level milestone were covered supportive due to a change supervision in visits focusing implementation on health approach.Instead facilities and of five day wards supportive visit conducted per district this was reduced to a three day visit in order to cover more districts. LLIN Number of Year 5 1 (2016) 0 0 0 0% Implementation ZAPIM will vector control milestone affected by not be able to subcommittee COVID-19 support meetings Pandemic . subcommittee supported meetings before project end.

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps SBC Number of PMP 1,066 (2016) 370 0 276 74.6% Implementation persons trained affected by in SBC COVID-19 Pandemic. Target was revised from 720 to 370. SBC Rapid PMP 0 (2016) 1 0 0 100% No KAPS were The results assessment- conducted in will be used as Knowledge, Year 5. NMCP, evidence for Attitude and with ZAPIM implementing Practice support, required Surveys (KAPS) conducted an programmatic of the Mbire assessment to decisions. community systematically completed identify the drivers of high malaria transmission in Angwa Ward in Year 4. SBC Commemorati Year 5 1 (2016) 1 0 1 100% ZAPIM on of the milestone supported and SADC attended the Community SADC malaria Malaria Day day press supported conference held by the MOHCC in November 2020.

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps SBC World Malaria Year 5 3 (2016) 0 0 0 0% No World Day Campaign milestone Malaria Day supported in 3 Campaigns provinces scheduled before project end. SBC Number of Year 5 N/A 0 0 Implementation IPTp messages milestone affected by delay developed and in project funding disseminated and need to spread costs to cover no cost extension. Target was revised from 4 to 0. SBC Number of Year 5 0 (2016) 16 0 16 100 The community community milestone dialogue dialogues approach was meetings in modified to high malaria- include burden wards supporting of of Binga and MOHCC driven Hwange malaria dialogues Districts ZAPIM was an active technical partners in 23 Hwange & 16 Binga ward dialogues. CAC members trained by ZAPIM participated in the above.The

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps key dialogue topic was IRS, treatment seeking and early ANC booking.. CAC members who participated further cascaded sensitization to community level by conducting saml meetings at at village and household level SBC National-level Year 5 0 (2016) 1 0 0 0% ZAPIM started ZAPIM will be malaria milestone supporting this a key partner branding initiative in Year supporting initiative to 4 and has this process in operationalize continued the cost strategy 7 of throughout Year extension. Malaria 5 and the no cost Communication extension Strategy period.. SBC Number of Year 5 0 (2016) 0 0 0 0% Materials for all promotional milestone HCC distributed materials in this quarter to procured for the supported HCC members HCC members were printed earlier in year 5. There were no new CAC promotional

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps materials procured in this quarter. M&E Malaria SM&E Year 5 0 (2016) 1 0 1 100% ZAPIM continued The training training manual milestone to support the materials will revised revision of the be used for manual and malaria SM&E finalized the trainings in training materials the country. which now await signing from MOHCC. M&E Number of Year 5 N.A 80 0 0 0% The training Once finalized SM&E training milestone manual will be and approved, manual printed printed and NMCP, and distributed distributed once ZAPIM, and it has been other partners finalized. Target will use the reduced to 80 standardized due to budget. manual to train health workers in SM&E. M&E Number of PMP 10 (2016) 80 0 0 0% Could not districts and happen as health facility training depend staff trained in on finalized M&E, training materials supportive acceptance and supervision, sign off by NMCP epidemic alert and MOHCC. protocols (EPR/IDSR)

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps M&E ZAPIM M&E Year 5 0 (2016) 1 0 1 100% The M&E M&E database database milestone database was will continue updated updated on a to be updated regular basis. throughout the year and used to monitor the performance of the project. M&E Revised EPR Year 5 0 (2016) 0 80 0 100% Target revised EPR guidelines guidelines milestone from 65 to 80. shared with printed and provinces and distributed districts. Training of health care workers on the new EPR guidelines will occur in future when the training materials are finalized. M&E Number of Year 5 0 (2016) 0 0 0 0% The MEPR rapid response milestone training materials team members need finalization trained in the before trainings revised EPR can begin. guidelines Therefore target revised from 56 to 0.

Targets/ Benchmarks Results Percentage Baseline Year 6 Target YR 5 Annual Year 6 of Annual Comments/ Indicator/ (year and (Oct 2020– Results Quarter 1 Target Problems # Milestone Type source) March 2021) (Oct 2020) Results Achieved Encountered Next steps M&E Number of Year 5 0 (2016) 186 186 186 100% VHWs milestone supported with airtime for weekly mobile data reporting M&E Number of Year 5 0 (2016) 0 0 0 0 Implementation ZAPIM will surveillance, milestone affected by not be able to M&E, and COVID-19 support any Operations pandemic. subcommittee Research Target revised meetings subcommittee from 2 to 0. before the meetings project ends supported M&E Project Year 5 N/A 1 0 0 0% To be achievements, milestone implemented lessons learned, as planned. best practices, Achievements and challenges and lessons documented learned will be included in end of project report. Elimi- Foci database Year 5 N/A 1 1 1 100% Lupane District nation updated milestone has an updated foci database Elimi- Number of Year 5 N/A 1 1 1 100% National nation malaria milestone Elimination elimination Review meeting review held in meetings. November 2020