Quarterly Progress Report April 1, 2019–June 30, 2019

Program for the Advancement of Malaria Outcomes

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

Submission Date: July 31, 2019

Submitted by: Dr. Caroline Phiri, PAMO Chief of Party

Mailing Address Private Bag E10, Lusaka, Zambia Street Address Mikwala House, Stand 11059 Off Brentwood Road, Longacres, Lusaka www.path.org

TABLE OF CONTENTS

LIST OF ACRONYMS 4 PROJECT OVERVIEW 6 EXECUTIVE SUMMARY 7 INTRODUCTION 11 BENCHMARKS AND ACHIEVEMENTS 12 OBJECTIVE 1: SUPPORT PROVEN MALARIA INTERVENTIONS IN ALIGNMENT WITH THE NATIONAL MALARIA STRATEGIC PLAN (NMSP) 2011–2016 AND THE FOLLOW-UP PLAN OF THE MOH 12 OBJECTIVE 2: STRENGTHEN MANAGEMENT CAPACITY OF PROVINCIAL AND DISTRICT MOH PERSONNEL TO PROVIDE SUPERVISION AND MENTORING TO IMPROVE DELIVERY OF PROVEN INTERVNETIONS 39 OBJECTIVE 3: STRENGTHEN PROVINCIAL AND DISTRICT HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) TO IMPROVE DATA REPORTING, ANALYSIS AND USE FOR DECISION-MAKING 41 SUCCESS STORY 54

LIST OF ACRONYMS AMF Against Malaria Foundation

ANC Antenatal care

BRITE Broad Reach Institute for Training and Education

CHW Community health worker

CSO Civil society organizations

DHO District health office

DQA Data quality audit

EDS Electronic data system

EHT Environmental health technician

EPI Expanded program on immunization

GRZ Government of the Republic of Zambia

HFCA Health facility catchment area

iCCM Integrated community case management

ICEMR International Centers of Excellence for Malaria Research

IPTp intermittent preventative treatment in pregnancy

IRS Indoor residual spraying

ITN Insecticide-treated net

LLIN Long-lasting insecticide-treated net

M&E Monitoring and evaluation

MACEPA PATH Malaria Control and Elimination Partnership in Africa

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

MTR Mid-term review

NHCs Neighborhood health committees

NMEC National Malaria Elimination Centre

NMESP National Malaria Elimination Strategic Plan

OPD Outpatient department

OTSS Outreach training and supportive supervision

PAMO Program for the Advancement of Malaria Outcomes

PBO Piperonyl butoxide

PHO Provincial health office

PMI President’s Malaria Initiative

SBC Social and behavior change

SMAG Safe motherhood action group

SMEO Surveillance, monitoring, evaluation and operations research

TOT Training of trainers

TWG Technical working group

WHO World Health Organization

PROJECT OVERVIEW Life of project September 30, 2015, to September 29, 2020

Reporting period April 1 to June 30, 2019

Target provinces Eastern, Luapula, Muchinga, and Northern

Target population 5,455,218 (Source: Central Statistics Office, 2018)

Implementing partners PATH (lead), Jhpiego, and BroadReach Institute for Training and Education

Key partners Zambian Ministry of Health (MOH), National Malaria Elimination Centre (NMEC), Provincial Health Offices (PHOs), District Health Offices (DHOs) and health facilities. Malaria Control and Elimination Partnership in Africa (MACEPA), Churches Health Association of Zambia (CHAZ), and other United States Agency for International Development (USAID) implementing partners.

Objectives (1) Support proven malaria interventions in alignment with the National Malaria Strategic Plan 2011–2016 and the follow-on plan of the MOH. (2) Strengthen management capacity of Provincial and District MOH personnel to provide supervision and mentoring for improved delivery of proven malaria interventions. (3) Strengthen Provincial and District health management information systems to improve data reporting, analysis, and use for decision- making.

Contract number AID-611-C-15-00002

EXECUTIVE SUMMARY The Program for the Advancement of Malaria Outcomes (PAMO), a Unisted States President’s Malaria Initiative (PMI) flagship malaria program, is supporting the Government of the Republic of Zambia (GRZ) to achieve as much progress as possible to reach its goal of eliminating malaria. Working in four provinces (Northern, Luapula, Eastern and Muchinga), PAMO targets 47 districts out of which six (Nchelenge, Chama, Mbala, Mambwe, Senga and Nakonde) are focus districts and three (Chadiza, Katete, and Sinda) are pre-elimination focus districts. This is the 2019 second quarter report covering activities implemented between April and June 2019. It highlights key achievements and challenges by objective and tasks as agreed in the year four workplan.

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

Task 1.0: Strengthen national technical working groups (TWGs): PAMO has provided technical and/or material support to the four TWGs; Vector Control, Case Management, Social and Behavioral Change, and Surveillance, Monitoring, Evaluation and Operations Research (SMEO) TWG. In the Vector Control TWG PAMO presented findings of the assessments of Long Lasting Insecticide Treated Net (LLIN) distribution during ANC. The assessment found major challenges with record keeping and logistics management and recommended strengthening those aspects. The Case Management TWG has identified the need for revising the iCCM training to make it more participatory and adult learner centered instead of the current lecture-based training. In the SMEO TWG various issues were discussed key among them was to identify the reason why in spite of high LLIN coverage (88.2%) in Luapula, parasite prevalence remained high at 30.4%. It was suggested that the NMEC should consider overlaying the MIS data with other data such as climatic conditions to figure out this disparity. In the SBC TWG the key discussion was around planning for World Malaria Day events.

Task 1.1: Strengthen insecticide-treated net distribution: PAMO focused on three activities; the first was the preparation for school-based distribution of LLINs. Through provincial and district planning meetings PAMO has set a target to distribute LLINs to 44,695 children currently enrolled in Grades one and four in 322 schools in Katete, Chadiza, Sinda and Nchelenge districts. The distribution will take place in the third quarter. The second activity was capacity building on continuous LLIN distribution through public health facilities and schools. PAMO supported provincial meetings during which participants were introduced to the NetCalc tool and trained on how to monitor and how to report on LLINs issued through public health facilities. The third activity was LLIN durability monitoring study. PAMO has collected second round data which will be compared to first round data that was collected in 2018 to establish both chemical durability and physical integrity of the nets. This information will be used for future LLIN distribution planning. PAMO also participated in the NMEC’s LLIN Task force which focused on planning for 2020/2021 mass distribution campaign.

Task 1.2: Improve access to quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment: PAMO focused on improving quality access to case management at community and health facility levels. At Community level, PAMO planned to train and deploy 1,379 CHWs in integrated community case management (iCCM), 40 iCCM trainers, and 115 iCCM supervisors. These targets have been met; 1,401 CHWs (102 percent of the target), 41 iCCM trainers, and 137 iCCM supervisors (119 percent of the target) have been trained. CHW are testing and treating malaria at community level using passive and

7 active case finding strategies. A total of 179,739 people have been tested (77,067 passive and 102,772 active cases) out of which 87,064 were confirmed malaria cases (42,702 passive and 34,362 active). Of the 87,064 confirmed malaria cases, 75,483 (98%) were treated (41,493 passive and 33,990 active). Some confirmed malaria cases were not treated but were referred to a health facility for further management.

To strengthen case management at health facility level PAMO conducts outreach training and supportive supervision (OTSS). This year the target is to conduct two rounds of provincial OTSS in health facilities with microscopes and two rounds of district OTSS covering health facilities using RDTs to diagnose malaria. PAMO has performed first round OTSS. In pre-elimination districts all the 10 hospitals while in the rest of the provinces 92.5% (86 out of 95) facilities with microscopes were visited. For district OTSS PAMO targeted 368 health facilities in the first round. In the second quarter we reached 256 (69.5%). The remainder will be reached in July 2019. The results of OTSS are encouraging. There are improvements in observational composite scores e.g. RDT observations improved from 89 percent in 2017 to 93 percent in 2019 and laboratory observation from 65 percent to 78 percent in the same period.

Task 1.3 Increase delivery of IPTP-SP as part of an integral package of ANC services: to prevent malaria in pregnancy IPTp-SP is important and yet the 2018 malaria indicator survey reports very low uptake. In the second quarter of 2019 PAMO focused on increasing community awareness of early ANC booking and the importance of IPTP. In nine districts of Northern province PAMO has oriented 451(221male and 230 female) members of Safe Motherhood Action groups (SMAGs) in the new WHO ANC guidelines. Part of the orientation was the clarification and the strengthening of the roles and responsibilities of SMAGs in promoting ANC attendance and the need for IPTp uptake to prevent malaria in pregnancy. Besides SMAGs orientation PAMO also supported community awareness activities using drama and community conversations in Lundazi and Vubwi districts to promote the uptake of IPTp. Twenty health facilities were targeted, and 3,815 people were reached with messages on IPTp and early ANC booking.

Task 1.4 Strengthen social behavior change implementation for malaria at health facilities and community level through community mobilization and community dialogues: For SBC activities PAMO focused on supporting the successful hosting of the World Malaria day activities particularly in Lufwanyama district (where the national event was held), Chama, Vubwi, Nchelenge, Mbala, Chadiza, Katete, and Sinda districts. PAMO provided material and technical support to implement various malaria SBC activities. The activities included bicycle relays themed as “Cycle to Eliminate Malaria” in Eastern Province; football tournaments in Luapula, Muchinga, and Northern provinces; community drama and community dialogues; and school quizzes and singing competitions. The activities in the four PAMO provinces turned out to be the main event for each of the provinces in which they were carried out.

Task 1.5 Strengthen malaria policies and guidelines: The NMEC embarked on conducting a midterm review (MTR) of the National malaria Elimination strategy 2017-2021. PAMO not only participated in both the thematic desk review that took place in Kabwe from April 29 to May 3 and the WHO external reviewers’ assessment that took place between May 13th and 17th it also compiled the MTR report. The report has since been produced and sent to the NMEC. The final MTR report will be finalized by the World Health Organization (WHO).

Task 1.6 Support civil society organizations and community-based organizations to implement malaria control activities: PAMO has sub-contracted 17 CBOs who are implementing

8 community level SBC activities in 23 districts1 using various community engagement approaches such as community dialogues, drama, school quiz competitions, and the champion communities’ approach. CBOs have oriented about 1,000 malaria agents in various champion communities who are providing door to door sensitization on malaria prevention approaches particularly regular and consistent use and care of LLINs.

Task 1.7 Conduct Operations research: In 2019, PAMO did not receive funding for operations research, therefore no operations research activities will be implemented this year.

Objective 2: Strengthen management capacity of provincial and district MOH personnel to provide supervision and mentoring to improve service delivery of proven interventions

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 actors: PAMO conducted a Malaria Health Systems Gap Analysis and a Management Capacity Assessment in 2016. Based on this, a management capacity-building plan was developed and implemented in 2019.

Task 2.2: Develop and implement a plan to strengthen management capacity as measured by set targets within each targeted province and district: Working through Broad Reach Institute for Training and Education (BRITE), a subcontractor under PAMO, the NMEC, and MOH, PAMO has strengthened the management capacity of PHO and DHO staff in all the four PAMO provinces. The target was to train 84 people (52 from MOH at province and district level; 10 from NMEC, and 12 to be trained as management mentors). Although the training for 10 NMEC staff has not taken place yet, PAMO has already reached its target; 72 MOH staff were trained instead of the planned 52 and 12 mentors were also trained bringing the total trained to 84. The overachievement is because in Northern Province the PHO requested to send additional staff to the training.

Objective 3 Strengthen provincial and district health management information system (HMIS) to improve data reporting, 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: A key activity in quarter two was to conduct Data Quality Audits (DQAs) to assess data quality in health facilities. The year four target is to conduct two rounds of DQAs in 259 health facilities. By the end of quarter two PAMO had completed one round of DQAs in all four target provinces reaching 268 health facilities. Key issues identified during DQAs that are being addressed include disparities between the data reported into the national HMIS and the data found in the source data documents, some degree of over- and under-reporting of malaria cases,

1 Mwense, Katete, Sinda, Chipata, Mwansabombwe, Chiengi, Chembe, Mpika, Mungwi, Chinsali, Sengahill, Samfya, Mansa, Nyimba, Nchelenge, Petauke, Mafinga, Isoka, Chadiza, Chipili, Kawambwa, Nchelenge, and Kasama

9 missing registers, and cases of clinical and confirmed malaria not clearly recorded in some cases. These issues are being addressed through OTSS and malaria data reviews.

Task 3.2 Assist with training for the roll out of DHIS2 in the targeted provinces and districts: In year four work plan the target is to train 161 MOH staff in HMIS. By the end of quarter two PAMO has trained 117 (72.7 percent of target). The target has not yet been met because trainings in Northern and Muchinga province are scheduled for the second quarter (July and August 2019). Besides training in HMIS, PAMO has also trained 65 PHO and DHO staff (55 males, 10 females) in how to properly use DHIS2 for their reporting. It is anticipated that the trainings will improve data quality at provincial and district levels.

Task 3.3 Provide technical/material assistance to DHOs, health facilities, and communities to strengthen malaria data analysis and use for planning and decision-making: To strengthen data analysis and use PAMO supports semi-annual malaria data reviews. In quarter two PAMO conducted malaria data reviews in the pre-elimination districts and three selected districts of Muchinga province (Nakonde, Chinsali, and Mafinga). Key lessons are ownership of health facility data by the staff is increasing; there is a need to disaggregate data when calculating incidence and other indicators, and the meetings provided a platform for peer learning and adoption of best practices presented.

INTRODUCTION

BACKGROUND The Program for the Advancement of Malaria Outcomes (PAMO) is a malaria activity program funded by the United States President’s Malaria Initiative (PMI) in Zambia. Designed to assist the Government of the Republic of Zambia (GRZ) in achieving as much progress as possible to reach its goal of eliminating local malaria infection and disease in Zambia, PAMO’s geographic focus is on four provinces: Eastern, Luapula, Muchinga, and Northern. These provinces are located in the northeastern part of Zambia and were selected due to the high malaria disease burden at project inception in 2015.

Recent national surveys of malaria burden and intervention coverage show progress across the country in delivering interventions and reducing malaria burden. While it appears that malaria prevalence among children under five years of age is declining, the results from the national Malaria Indicator Survey 2018 (MIS 2018) indicate that the four PAMO-supported provinces are still among the five highest malaria burden provinces in Zambia. The malaria prevalence rates in the PAMO-supported provinces justify the need for further investment in malaria control and elimination. In 2019, PAMO will continue to work closely with the MOH to further reduce the malaria disease burden in these four provinces.

PAMO provides technical assistance and material support to strengthen the capacity of the government to improve malaria outcomes in the four PAMO-supported provinces and their districts. To that end, PAMO established and maintains effective partnerships with the National Malaria Elimination Centre (NMEC), provincial health offices (PHOs), district health offices (DHOs), health facilities, communities, civil society organizations (CSOs), and other stakeholders and partners to ensure effective and sustained implementation and scaling up of internationally and nationally accepted strategies to fight malaria.

PAMO is currently in its fourth year of project implementation. During Year 4, PAMO will implement activities outlined in two work plans described below.

PAMO YEAR 4 WORK PLAN (JANUARY TO DECEMBER 2019) PAMO’s Year 4 work plan outlines PAMO’s support to the Ministry of Health (MOH); it is aligned strategically with Zambia’s National Malaria Elimination Strategic Plan (NMESP) 2017–2021 and the PMI FY2018 Zambia Malaria Operational Plan (MOP).

PAMO YEAR 3 WORK PLAN ADDENDUM (SEPTEMBER 2018 TO AUGUST 2019) PAMO is currently operating under a separate but complementary Year 3 work plan addendum that covers three pre-elimination districts (Chadiza, Katete, and Sinda) in Eastern Province and outlines the malaria pre-elimination activities being implemented there.

BENCHMARKS AND ACHIEVEMENTS

OBJECTIVE 1: SUPPORT PROVEN MALARIA INTERVENTIONS IN ALIGNMENT WITH THE NATIONAL MALARIA STRATEGIC PLAN (NMSP) 2011–2016 AND THE FOLLOW-UP PLAN OF THE MOH The NMESP places emphasis on key interventions such as sustained universal coverage of vector control interventions (distribution of LLINs, IRS, and larval source management), case management (diagnosis and treatment), MIP, health promotion (community engagement and SBC), surveillance, monitoring, evaluation, and operations research. PAMO has aligned its “tasks” and implementation of activities with the NMESP in order to contribute to the overall MOH goals and objectives. It is worth noting that, depending on the task being implemented, PAMO directs its support to either the national, provincial or district level.

TASK 1.0: STRENGTHEN NATIONAL TECHNICAL WORKING GROUPS (TWGS) PAMO provides technical and/or material assistance to the NMEC for national level technical working groups (TWGs). The national level TWGs for malaria are important structures that provide a platform to facilitate coordination and planning, and contribute to the development, dissemination, and mainstreaming of national strategic and technical guidance on malaria. There are four TWGs, namely Vector Control; Case Management; Surveillance Monitoring, Evaluation and Operations Research (SMEO); and SBC. By supporting these TWGs, PAMO contributes to better-coordinated and harmonized implementation of the national strategy under the leadership of the NMEC. PAMO’s Senior Advisor, Malaria, Policy, Strategy and Management (SPSMA) and technical specialists play an instrumental role in these TWGs. The TWG meetings are held quarterly. During this quarter, the Vector Control, Case Management, SMEO and SBC TWGs met. The key highlights of these meetings are outlined below.

VECTOR CONTROL Held on June 28, the focus of the second quarter Vector Control TWG meeting was indoor residual spraying, entomological surveillance, and larval source management. Regarding PAMO-supported activities, PAMO made a presentation on the joint (PAMO and NMEC) field assessment of LLINs in Northern and Luapula provinces. The presentation highlighted that the LLIN guidelines are not available in public health facilities, resulting in inconsistent reporting, poor record keeping, and serious discrepancies in the reporting format in the health facilities visited. Challenges in transporting the LLINs from the DHO to the health facilities were also widespread. PAMO is working with the NMEC to address these challenges. One of the first steps to take to address this is to make the LLIN Guidelines available in public health facilities. PAMO also plans to share the assessment in the Safe Motherhood TWG to improve on reporting of LLINs in antenatal (ANC) and expanded program on immunization (EPI) clinics.

Also, noteworthy, the Zambia Army informed the meeting that the NMEC and the Zambia Army have a cordial relationship. NMEC had provided free LLINs to all Zambia Defense Force units. The Zambia Army further stated that the malaria elimination agenda had the full backing of the high command of the army and that the army is ready to partner with the NMEC to implement malaria elimination activities.

CASE MANAGEMENT During the second quarter, PAMO provided logistical and technical support to the NMEC to hold two case management TWG meetings (a regular second quarter meeting and one addition meeting). The NMEC announced that the fifth edition of the Guidelines for the Diagnosis and Treatment of Malaria in Zambia can now be accessed on the NMEC website. These guidelines will be revised after the completion of the Midterm Term Review (MTR) of the NMESP has concluded.

The current iCCM CHW training curriculum needs to be revised to strengthen the module covering the use of rectal artesunate at the community level. It also needs to be amended to include a module on malaria community surveillance. Therefore, the Case Management TWG recommended that a meeting between the NMEC and the Child Health Unit be held to review and update the iCCM training curriculum and materials that include facilitators’, supervisors’, and CHWs’ handbooks. The TWG also noted that the training methods should be modified to a more participatory process to enhance knowledge acquisition using the adult learning approach used during CHW training instead of lectures and PowerPoint presentations. It is hoped that this methodology will enhance the training sessions and assist the CHWs to learn faster and easier. In addition, A CHW national profile has been developed that includes a table showing the CHW gaps for each of the districts in Zambia. This document was finalized and shared with all TWG members.

There has been a nationwide stockout of Sulfoxide-pyrimethamine (SP) for intermittent preventative treatment in pregnancy (IPTp). At the time of the meeting, stocks were not available at Medical Stores Limited. The NMEC’s Malaria Case Management Officer was tasked to follow up on the procurement of this commodity with the relevant authorities in the Ministry of Health (MOH). Lastly, a directive has been issued from the Minister of Health to scale up mass drug administration to 80 districts.

SURVEILLANCE, MONITORING, EVALUATION AND OPERATIONS RESEARCH The second quarter SMEO TWG was held on May 31, 2019. Highlights of the meeting included:

1. The 2018 Malaria Indicator Survey (MIS) results were shared and discussed.

o The NMEC reported that the 2015 MIS results have been adjusted slightly after an error with the coding and weighting was noted during some re-analysis of the data.

o The TWG members noted that despite high coverage of insecticide-treated nets (ITNs) in Luapula (88.2% of households have at least one ITN), parasite prevalence remained high at 30.4%. The Copperbelt recorded lower coverage of ITNs than Luapula (55.3% of households with at least one ITN) but parasite prevalence did not spike (7.7%). To try and understand what is happening in Luapula, PMI advised the NMEC to consider overlaying the MIS data with other data such as climatic conditions.

2. The NMEC is currently undertaking a Mid Term Review of the National Malaria Elimination Strategic Plan (NMESP) 2017–2021. The TWG members urged the NMEC SMEO unit to present the 2018 MIS data in the next MTR meeting. The recommendations from the 2018 MIS need to be incorporated into the MTR process and final report.

3. PMI provided an update on the upcoming PROACT Study. PMI reported that the study will be implemented by IMPACT Malaria. The study will commence once PMI and IMPACT malaria finalize the implementation budget and logistics.

4. PAMO reported that a baseline assessment for the three pre-elimination districts has been done and that the draft report has been shared with the NMEC. The NMEC will set a date for the dissemination meeting.

5. The World Health Organization (WHO) announced that they are currently compiling data for the World Malaria Report. WHO will share the data with the SMEO TWG before the report is published.

SOCIAL AND BEHAVIOR CHANGE (SBC) During the second quarter, the SBC TWG met frequently to prepare for World Malaria Day. PAMO provided logistical support to the NMEC to host these meetings. PAMO’s SBC specialist was part of the task team formulated by the NMEC to develop and review SBC materials for World Malaria Day as well as spearhead media engagement efforts for the various activities undertaken on World Malaria Day.

The task team met fortnightly from April 3 until the event date on April 25. During this period, artwork was prepared for various materials including t-shirts, bumper stickers, pop-ups, back drops, and banners. The task force also developed radio jingles and reviewed TV spots. These were all finalized and shared with media houses for airing in order to increase awareness of key malaria interventions.

TASK 1.1: STRENGTHEN INSECTICIDE-TREATED NET DISTRIBUTION During this quarter, PAMO began preparations for the school-based distribution of ITNs as part of its 2019 plan to support school-based distribution in four districts; Chadiza, Katete, and Sinda in Eastern Province and Nchelenge District in Luapula Province. The target is to distribute to 44,695 children who are currently enrolled in grades one and four in 322 schools (Table 1). Grades one and four are targeted because during a pilot conducted in 2016, it was observed that these two grades had the highest attendance numbers compared to other grades.

TABLE 1: NUMBER OF CHILDREN TO RECEIVE A NET IN PRE-ELIMINATION DISTRICTS AND NCHELENGE

NUMBER OF STUDENTS NAME OF DISTRICT NUMBER OF SCHOOLS ENROLLED IN GRADES ONE AND FOUR

Chadiza 58 6,190

Katete 109 13,342

Sinda 82 10,334

Nchelenge 73 14,829

Totals 322 44,695

To prepare for school distribution, PAMO held a provincial workshop in Chipata in Eastern Province and a district workshop in Nchelenge in Luapula Province to orient staff from the MOH, Ministry of General Education, and representatives of media houses and traditional leaders on how to implement school-based distribution. The 2016 Zambia School-based Continuous Distribution Implementation Guidelines were used to explain the concepts of continuous distribution of LLINs. A total of 69 staff (54 males, 15 females) from the Provincial Education Office, PHO, District Education Board Secretaries’ offices and the DHOs participated. During the workshops, participants developed detailed district- specific plans based on the number of zones, number of schools in a given zone, and number of head teachers and class teachers for grades one and four. Importantly, the number of children in the targeted grades was quantified to develop the distribution target. In addition to this, a schedule for the orientation of the zonal heads and key MOH staff from health facilities was developed.

At the district level, PAMO worked with the MOH and Ministry of General Education to strengthen the school-based LLIN continuous distribution planning to local communities. Several meetings in which 161 people participated (45 in Chadiza, 58 in Katete, 37 in Sinda, and 21 in Nchelenge) were held with key stakeholders, particularly zonal school heads, environmental health technologists (EHTs), traditional leaders, and other district stakeholders. The outcome of these meetings was the development of detailed plans that will be implemented in the third quarter. The plans took the following into account:

• Distribution of guidelines on conducting preparatory meetings at zonal and school level. • Data collection tools to clearly forecast the number of LLINs and to document the number of LLINs required and distributed.

• SBC activities applicable to the school-based distribution system including the engagement of parents, traditional leaders, and children. • Logistics and supply chain, which focused on quantification of nets, transportation, storage, and distribution points. • The process of monitoring the distribution exercise by provincial, district, and NMEC officials.

STRENGTHENING CONTINUOUS DISTRIBUTION CHANNELS: SCHOOL BASED, ANC AND EPI CHANNELS PAMO also held provincial orientation meetings for PHO and DHO staff in Mpika for Muchinga Province and in Luwingu for Northern Province on LLIN continuous distribution channels, including distribution through ANC, EPI, and schools. Participants included staff from the MOH and Ministry of General Education. The MOH was represented by the provincial planner, the chief environmental health officer, district malaria focal point persons, and district planners from all district health offices while the Ministry of General Education was represented by nine district planners and the provincial education officer. Participants were introduced to the NetCalc tool and trained to monitor reporting of LLINs issued through ANC and EPI.

During the workshops, PAMO shared the key findings of the 2017 ANC assessment, which included poor record-keeping of LLINs distributed through ANC, poor logistics management for nets, storage limitation in some health facilities, and poor reporting to district and national level information systems on the number of nets distributed through ANC. MOH staff were encouraged to work on improving distribution, recording, and reporting on LLINs through ANC and EPI programs. MOH and Ministry of General Education officials agreed to strengthen collaboration between the two ministries to enhance continuous LLIN distribution. They agreed to start harmonizing school health plans with district health plans and to integrate malaria SBC activities in schools and communities in order to promote LLIN use among pupils and teachers.

LLIN DURABILITY MONITORING STUDY Following the 2017–2018 LLIN mass distribution campaign, PAMO began to conduct LLIN durability monitoring to collect country-specific information on the physical integrity and bio-efficacy of two types of LLINs (PermaNet® and Olyset®). This information will aid the national program to identify products that perform below expectations, when an LLIN no longer meets minimum WHO standards and needs to be replaced. Working with the NMEC, PAMO is tracking two durability indicators, physical integrity and bio-efficacy at 6- and 12-months post-distribution. The first round of data collection (six months post-distribution) was done in 2018 and the second round (12-months post-distribution) was done in April 2019. PAMO worked with the NMEC staff to conduct the second round of data collection in Katete and Lundazi in Eastern Province. A two-day reorientation workshop for data collectors held on March 27 to 29, 2019, preceded the data collection. Thirty data collectors (15 from Katete and 15 from Lundazi) collected the data.

Officers from the NMEC, PHO, DHO, and PAMO supervised the data collection to ensure that data collection standards were adhered to. Data collectors visited the same 150 households selected during the baseline survey to assess the same LLINs that were assessed during the baseline survey. All the households that were marked during the baseline survey were located. However, the data collection teams found that some of the LLINs that were marked during the baseline survey were missing from the

16 households. Following this data collection exercise, PAMO has engaged Tropical Health to analyze the data and build capacity of NMEC staff and others to conduct data analysis. This analysis will provide insight into performance of LLINs in the Zambian environment, the main factors affecting their durability and the extent to which LLINs were missing from the households during the second round of data collection.

PARTICIPATION IN THE LLIN TASK FORCE MEETINGS The NMEC-based LLIN Task force formed to plan for the 2020–2021 mass LLIN distribution campaign has several terms of reference. Key among them are quantifying the number of LLINs that will be needed for the mass distribution campaign, reengaging the Against Malaria Foundation (AMF) for the supply of 50 percent of the required number of nets, and developing mass distribution campaign timelines. PAMO’s chief of party, PATH’s LLIN specialist, program management specialist, and senior policy, strategy, and management advisor (SPSMA) have played an active role in the LLIN Task Force, participating in every meeting.

The key achievements of the task force in the second quarter include:

• Re-engaged AMF: By the end of the quarter, the task force successfully re-engaged AMF and the contracting processes are underway. It is important to mention that the re-engagement of the AMF is key for the success of the next mass distribution campaign, as without them there would be a shortfall of the nets required. The projected supply by other partners such as PMI were not enough to reach the desired target number of nets. • Quantified the LLIN need for the 2020–2021 mass distribution campaign: the NMEC made a strategic decision that at population level, IRS will cover 50 percent of the population and LLIN distribution will cover the other 50 percent. Based on that decision, 8 million nets will be required for the mass distribution. The task force is in the process of developing a coordination mechanism with the IRS task team to minimize overlaps between households that will be sprayed and household that will receive a net. • Developed a clear timeline for the campaign: The task force has developed a road map for the mass distribution campaign. The tentative plan has encompassed various elements including community engagement and SBC activities, logistics management including ensuring that the nets are delivered from suppliers directly to provincial and district warehouses instead of national warehouses in Lusaka for ease of distribution, and developing the distribution strategy that will include house to house distribution in urban areas and distribution points in rural areas.

TASK 1.2: IMPROVE ACCESS TO QUALITY OF MALARIA CASE MANAGEMENT IN PUBLIC HEALTH FACILITIES AND COMMUNITIES TO ENSURE PROMPT, ACCURATE DIAGNOSIS AND APPROPRIATE TREATMENT To improve access to quality malaria case management at the community level, PAMO planned to train and deploy 1,379 CHWs to provide iCCM services within their respective communities. PAMO also planned to train 40 iCCM trainers and 115 iCCM supervisors. In this quarter, PAMO completed all the trainings and reached all its targets. A total of 1,401 CHWs (102 percent of the target) have been trained (Table 2) and are now providing malaria services in their communities (see Table 3 on the number of people tested and treated for malaria by CHW), and 137 iCCM supervisors (119 percent of the target) have been trained (Table 4) and are actively supervising CHWS.

TRAINER OF TRAINERS IN ICCM AND SURVEILLANCE In early 2018, PAMO noticed that there was a shortage of iCCM trainers in PAMO-supported provinces; thus, trainers would come from other provinces and from the NMEC to conduct an iCCM training, increasing the cost of the training as well as the likelihood of scheduling conflicts for trainers. To resolve this, PAMO planned to train a mix of provincial and district iCCM trainers from the PAMO- supported provinces (Eastern, Luapula, Northern, and Muchinga). Working with facilitators from the NMEC and the PATH Malaria Control and Elimination Partnership in Africa (MACEPA), PAMO trained the first group of 12 (5F, 7M) in Eastern Province and in this quarter, a second training of trainers (TOT) was held in Mpika to train 29 (4F, 25M) MOH staff from Luapula, Muchinga, and Northern provinces. Apart from learning how to train CHWs and health workers (iCCM supervisors) in iCCM and malaria surveillance, attendees learned how to provide support to the respective provinces to supervise the iCCM program. In addition, the training enhanced the capacity of PHOs and DHOs to lead and conduct these trainings within their respective provinces and districts.

TRAINING AND DEPLOYMENT OF CHWS PROVIDING ICCM SERVICES During the second quarter, PAMO worked with the NMEC and MACEPA to complete the iCCM and surveillance trainings for CHWs using the approved curriculum. As mentioned previously, PAMO’s target in 2019 is to train 1,379 CHWs by the end of June 2019. During this quarter, PAMO trained 302 (215M, 87F) CHWs, from Chama, Katete, Mambwe, and Nakonde to accomplish its target. In Chama, PAMO partnered with Mobilizing Access to Maternal Health Services in Zambia to enhance the skills of CHW and health facility staff in the use of rectal artesunate for pre-referral treatment of severe malaria. This partnership produced a more comprehensive package for CHWs in Chama that should be integrated into the iCCM training. The current CHW training materials do not fully cover rectal artesunate topics therefore, as previously reported by PAMO in Task 1.0, a subcommittee of the Case Management TWG has been established to design a more comprehensive training module for training of CHWs in the use of rectal artesunate for pre-referral treatment for severe malaria. Once this training module is complete, it will be included in all the iCCM trainings. Table 2 shows the final result for the CHW training.

TABLE 2: CUMULATIVE RESULTS OF PAMO-SUPPORTED CHW TRAINING CHW Actual Number Trained Province District training % Achieved target Male Female Total

Eastern Mambwe 146 95 70 165 113%

Luapula Nchelenge 80 61 19 80 100%

Nakonde 165 142 23 165 100% Muchinga Chama 60 58 2 60 100%

Northern Mbala 145 93 52 145 100%

Senga Hill 80 59 21 80 100%

Chadiza 130 96 36 132 101.5% Pre-elimination Katete 294 181 113 294 100% districts Sinda 279 182 98 280 100.4%

Total 1,379 967 434 1,401 101.59%

MALARIA SURVEILLANCE DATA REPORTED BY COMMUNITY HEALTH WORKERS Following the training, CHWs have been deployed to test and treat malaria within their communities. In seven districts (Chadiza, Katete, Sinda, Nchelenge, Mpika, Nakonde, and Mbala) PAMO is supporting malaria surveillance by CHWs, who have been reporting data since March 2019. The newly trained CHWs in Mambwe, Chama, and Senga will commence reporting their data in July 2019. Table 3 shows the number of people that have been tested and treated at community level for the period March to May 2019. The data elements for malaria surveillance are based on passive and active case finding. Passive case management is when people go to the home of a community health worker to seek the service while active case finding is when the community health workers follow up a confirmed malaria case, also known as an index case, to test and treat family members and neighbors to the index case. A total of 179,739 people have been tested (77,067 passive and 102,772 active cases) out of which 87,064 were confirmed malaria cases (42,702 passive and 34,362 active). Of the 87,064 confirmed malaria cases, 75,483 (98%) were treated (41,493 passive and 33,990 active). Some of the confirmed malaria cases were not treated by CHW, they were instead referred to a health facility for further management due to the following reasons: they were pregnant, had symptoms of severe malaria, or the CHW had no treatment at the time.

TABLE 3: MALARIA SURVEILLANCE DATA REPORTED BY COMMUNITY HEALTH WORKERS

DATA MARCH 2019 APRIL 2019 MAY 2019

Passive number tested 9736 32242 35089

Passive number 4788 16796 21118 positive

Passive number 4833 15725 20935 treated

Index cases followed 1908 3887 3723 up

Active houses visited 5550 10076 8201

Active number tested 22381 45310 35081

Active number 6736 14266 13360 positive

Active number treated 6772 14061 13157

RDT stocks (RDT 9216 18662 16241 balance on hand)

TRAINING HEALTH FACILITY STAFF AS INTEGRATED COMMUNITY CASE MANAGEMENT (ICCM) SUPERVISORS To ensure CHWs effectively deliver services in their communities, PAMO has trained health facility staff as iCCM supervisors. PAMO’s target in 2019 is to train 115 supervisors in nine districts. In the first quarter, 108 had been trained, and the remaining 29 (23M, 6F) were trained during the second quarter. The table below shows the final result for the iCCM supervisors’ training (Table 4).

TABLE 4: CUMULATIVE RESULTS OF PAMO-SUPPORTED ICCM SUPERVISORS’ TRAINING Actual achieved Province District Target % Achieved Male Female Total

Eastern Mambwe 9 15 5 20 222%

Luapula Nchelenge 4 4 0 4 100%

Muchinga Nakonde 11 8 1 9 81.81%

Chama 4 5 0 5 125%

Northern Mbala 4 11 3 14 233%

Senga 8 5 3 8 100%

Pre-elimination Chadiza 20 20 1 21 105% districts Katete 32 23 9 32 100%

Sinda 23 17 7 24 104.3%

Total 115 108 29 137 119.13%

EQUIPPING, SUPERVISING, AND MONITORING CHWS Equipping, supervision, and monitoring are important elements to enhance the performance of CHWs. Following the training of CHWs, PAMO provided the CHWs with various supplies to help them implement iCCM and surveillance activities more effectively. The supplies that each CHW were provided was based on need.

Further, in each of the PAMO provinces, the iCCM program is being monitored closely by the NMEC, PHO, and DHOs. PAMO has been able to provide logistical support to the MOH to conduct visits to the CHWs in their respective health facility catchment areas (HFCAs). Table 5 shows the achievements of the trained CHWs so far.

TABLE 5: BREAKDOWN OF CHW SUPPLIES

Province District No. of CHWs No of CHWs No of CHWs No of CHWs provided with provided with provided with provided with enablers2 starter kits3 bicycles mobile phones for reporting

Chadiza, Eastern (pre- Katete & 706 706 706 142 elimination) Sinda

Eastern (Main) Mambwe 146 0 0 19

2 Enablers include Branded Apron, T-shirt and cap 3 Starter kits include A pair of Scissors, yellow disposal biohazards bag, clear plastic bags, safe disposal containers (for sharps), 10 liter plastic container with a handle, a small plastic cup, a box of latex gloves, a bar of soap (preferably Dettol soap), a small bottle of hand sanitizer, and a back pack (bag). MOH provides ACTs & RDTs

Luapula Nchelenge 149 149 105 25

Chama & Muchinga 225 225 0 35 Nakonde

Mbala & Northern 225 225 0 39 Senga

Total 1,451 1,305 811 260

PROVINCIAL OUTREACH TRAINING AND SUPPORTIVE SUPERVISION ROUNDS During this quarter, PAMO conducted provincial outreach training and supportive supervision (OTSS) rounds in all the PAMO provinces. OTSS is a quality assurance scheme that aims to improve providers clinical and laboratory skills. Provincial OTSS is focused on health facilities that offer malaria microscopy services. Accurate diagnosis of malaria and reduced reliance on presumptive treatment are crucial components of quality malaria case management. OTSS assessments are conducted by trained laboratory and clinical supervisors on a regular basis and changes in health facility staff performance are measured over time. PAMO supported OTSS rounds include an intermittent preventative treatment in pregnancy (IPTp) evaluation tool used to assess, supervise, and mentor ANC staff providing malaria in pregnancy (MIP) services.

In the pre-elimination districts, OTSS activities now cover all the health facilities. The first step taken during the first quarter was to train laboratory personnel and DHO staff to work as OTSS supervisors. Only new PHO staff were trained as OTSS supervisors because PAMO has been working with the PHO to conduct OTSS in Eastern Province since 2016, but in only three different districts. Following the training of OTSS supervisors, PAMO, working with the PHO and DHOs, conducted OTSS rounds in ten facilities (100 percent achievement) which have malaria microscopy services. During the OTSS rounds, 51 health facility staff (32 males, 19 females) involved in malaria diagnosis and treatment were mentored by the OTSS supervisors.

In the rest of Eastern Province and the other PAMO provinces, PAMO worked with the PHO to conduct provincial level OTSS rounds. Eighty-six out of 93 health facilities (92.5 percent) were visited by the Provincial OTSS teams during the first round. The full target could not be achieved because six of the health facilities are no longer offering malaria microscopy services as a result of staff attrition and one health facility was closed because the roof was blown off during the last rainy season. Some of the key issues encountered during the Provincial OTSS are listed below:

Positive findings:

• Microscopes in the health facilities were functional and the laboratory reagents including Giemsa stain were available. • The laboratories were clean and staffed with qualified personnel. • Clinicians took adequate patient history and examined patients appropriately. In some parts of the country, OTSS supervisors • Infection prevention standards were posted on the travel by boat to reach health facilities wall. • Malaria treatment guidelines were available in the screening rooms.

Challenges:

• Prolonged stock-outs of sulfadoxine-pyrimethamine (SP). • The OTSS teams randomly selected a few patients’ names in the clinical register and checked to see if these names were in the laboratory registers. They found that some names recorded in one type of register were missing in the other. • Some rapid diagnostic tests (RDTs) were not labelled correctly, and in some instances the health workers did not wait long enough before reading the results.

DISTRICT OTSS ROUNDS PAMO worked with the DHOs located in the PAMO provinces to conduct OTSS in health facilities that do not offer malaria microscopy services. In the second quarter, PAMO managed to reach 256 out of 368 health facilities overall. This represents an achievement of 69.57% for the first round. This activity was incomplete in Eastern and Northern provinces, which will complete their district OTSS rounds in the third quarter.

In the three pre-elimination districts (Chadiza, Katete, and Sinda), PAMO worked with the respective DHOs to conduct district OTSS in all the 71 health facilities. This is the first time that district OTSS has been conducted in all health facilities. All facility staff present at the time of the visit were assessed and mentored to strengthen their ability to perform RDT tests and improve their clinical skills (patient care and clinical observations). The most notable challenge in all the health facilities was the prolonged stock- out of SP, which is negatively affecting IPTp coverage, and the stock-out of injectable artesunate.

In the rest of the health facilities in the PAMO-supported provinces, a number of challenges were noted during the OTSS rounds, including:

• Stock-outs of artemisinin-based combination therapy (ACTs) and RDTS in some health facilities in Luapula. • Prolonged stock-outs of SP in all health facilities visited. • Lack of job aids in some health facilities and new staff not aware of the new ANC guidelines. • Some clinicians did not take the patient’s history adequately and some did not use the RDTs correctly.

Action taken to rectify the challenges:

• The DHO agreed to arrange for logistics management training for new staff in health facilities where stock-outs of ACTs and RDTs were noted. The stock-out of ACTs and RDTs were a result of staff not placing orders in time. • As for the stock-out of SP, nothing could be done because there is a nationwide stock-out of this drug. • DHOs agreed to try to develop job aids for health facilities and orient new staff on the new ANC guidelines during clinical meeting. • Clinicians’ skills (history-taking and use of RDTs) will be strengthened through mentorship.

OVERVIEW OF OTSS RESULTS FOR ALL PAMO PROVINCES Since 2017, PAMO has conducted six OTSS rounds to support 285 health facilities initially and increased to 368 by the fourth year of the project. Approximately 1,140 health care workers have been mentored during these OTSS rounds. So far, the results are encouraging; there are improvements in observational composite scores. RDT observations improved from 89 percent in 2017 to 93 percent in 2019 and laboratory observation from 65 percent to 78 percent in the same period. Adherence scores have also shown steady improvement. Adherence to testing prior to treatment was 85 percent% in 2017 and increased to 88 percent in 2019. Adherence to positive test results improved from 75 percent to 80 percent while negative test adherence improved from 73 percent to 81 percent. Generally, OTSS may have helped enhance the quality malaria case management. Even the MOH HMIS data shows that clinical

24 diagnosis of malaria cases in PAMO-supported provinces have declined from 16 percent in 2015 and 20 percent in 2016 to 3 percent in 2018, which by May 2019 was hovering around 5 percent. These results are illustrated in Figure 2 below.

Figure 2: Consolidated OTSS composite scores for PAMO-supported provinces, 2017–2019

100 91 93 89 88 90 85 80 80 81 80 81 77 78 80 75 75 77 74 73 70 65

0 5. Adherence to 6. Adherence to 1. Clinical 2. RDT 3. Laboratory 4. Testing Prior Positive Test Negative Test Observation Observation Observation to Treatment Results Results Year 2017 80 89 65 85 75 73 Year 2018 77 91 74 81 75 77 Year 2019 80 93 78 88 80 81

Year 2017 Year 2018 Year 2019

MALARIA CLINICAL MEETINGS IN THE PRE-ELIMINATION DISTRICTS In the pre-elimination districts, PAMO provided technical and material assistance to each of the respective DHOs to hold the first quarterly malaria clinical meetings. The district malaria clinical meeting was held on April 23 at Nyanje Mission Hospital in Sinda District. The meeting was attended by 55 people (38 males and 19 females) comprising NMEC and Sinda DHO staff.

Key issues and highlights include:

• The DHO shared the district malaria profile for the fourth quarter of 2018 and the first quarter of 2019. The data showed that health facilities closest to the border are recording the highest number of cases. • Four case studies were discussed in order to provide an opportunity for the health facility staff to strengthen their knowledge about malaria case management.

• The case management officer from the NMEC oriented health facility staff on the 2017 Guidelines for the Diagnosis and Treatment of Malaria in Zambia.

Example of a case study

Patient name: C.T Age: 31 years old Sex: Female Marital Status: married Religion: Christianity Residential address: East park.

Patient presented to OPD with History of being unwell for one week. She complained of palpitations for 1 week, fever and headache for 4 days followed by backache and vomiting. The patient had no neck stiffness and did not complain of convulsions. The patient is married and does not take alcohol nor smokes. She has never suffered from diabetes, hypertension, epilepsy nor asthma. The patient was pregnant and her last menstrual period on 5th March 2019. She attended first antenatal care at 30 weeks of pregnancy. This was her first pregnancy and no history of draining nor vaginal bleeding during pregnancy. She could feel the baby moving in her womb. Review of the other systems did not reveal any abnormality. The patient reported that she at ANC she was tested for HIV, syphilis and these were found to be negative. Her hemoglobin was checked, and it was 12.9g/dl. She was given folic acid, ferrous sulphate, sulfadoxine pyrimethamine and mebendazole for prevention of anemia, and malaria and for worm treatment respectively.

Physical Examination On further examination patient, was conscious, lying comfortably on the couch. She was febrile (Temp 38.5) and very pale. She did not present with jaundice nor cyanosis. The chest examination was clear but found to have increased heart rate with a hemic murmur. Vital statistics showed: Blood Pressure = 112/68mmHg; Respiratory Rate 18b/min; Pulse Rate= 112cycles/min; Weight = 68kg The abdominal examination revealed a distended abdomen in line with the gestational age of pregnancy. The fetal heartbeat was heard, and it was normal. An examination of the vaginal os revealed it was closed A diagnosis of Severe Malaria with Anemia in Pregnancy was made

Plan of management Investigation were done and found as follows: Malaria RDT = Positive; Hemoglobin was tested using haemocoels and it was found to be 3.3g/dl. The facility does not have laboratory services and therefore the MP slide, Full blood count and sickling tests were not done. Blood was collected for grouping and cross match to be done at the hospital.

Treatment The patient was started on treatment before being referred to Hospital. The patient given a loading dose of 1360mg of quinine infused in 500mL of 5% Dextrose, as the facility did not have injectable artesunate. She was also given Paracetamol 1g orally start dose and folic acid 5mg orally one a day for two weeks. An IV access was set up and she was referred to Chadiza hospital for blood transfusion and further management.

EXTERNAL COMPETENCY ASSESSMENT OF MALARIA MICROSCOPISTS PAMO funded the participation of two MOH biomedical scientists in the Africa Medical and Research Foundation (AMREF) to undergo the External Competency Assessment of Malaria Microscopist (ECAMM) from May 20 to 24.

The assessment was held in Nairobi at the AMREF main campus. Twelve participants from three countries (Zambia, Ghana, and Kenya) attended the training. The two candidates funded by PAMO were from Muchinga (one male) and Luapula Province (one female).

TASK 1.3: INCREASE DELIVERY OF IPTP-SP AS PART OF AN INTEGRAL PACKAGE OF ANC SERVICES

HEALTH FACILITY ORIENTATION OF SMAGS TO ANC/IPTP TO PROMOTE UPTAKE OF ANC/IPTP IN COMMUNITIES The PHO with support from its partners continues to strive to provide malaria prevention and treatment services in a bid to reduce malaria disease burden and complications resulting from malaria during pregnancy. Currently IPTp 3+ coverage in Northern Province stands at 73.5 percent, dropping sharply to 12 percent for IPTp 4+ (MIS 2018). The province is striving to maintain high IPTp coverage in line with the new WHO recommendations which have increased IPTp doses from three to four or more. WHO recommends that a pregnant woman start IPTp as early as possible in the second trimester of pregnancy (preferably at 13 weeks gestation) and thereafter receive IPTp every four weeks until delivery.4

Northern Province needs to continue increasing coverage of IPTp by encouraging early ANC attendance, through appropriately targeted messaging to encourage women to make the required number of ANC visits. Community volunteers such as the safe motherhood action groups (SMAGs) have been working in the province to promote the uptake of SP within the community. With the understanding that the SMAGs are already being used to encourage women to deliver at the health facility, they are well-placed to encourage pregnant women to attend ANC early and take SP as required. It is for this reason that PAMO worked with nine districts to orient SMAGs to create demand and increase uptake of these services in low performing HFCAs. The districts from Northern province which were included in this activity were Luwingu, Nsama, Mpulungu, Lunte, Mbala, Kasama, Mungwi, Senga Hill, and Chilubi.

These districts critically analyzed their data related to IPTp coverage and identified five health facilities with either the highest IPTp dropout rate or the lowest IPTp uptake. PAMO worked with the Northern PHO maternal and child health coordinators to orient SMAGs in the nine districts on the new WHO ANC guidelines and discuss the roles and responsibilities of SMAGs in promoting ANC attendance and the need for IPTp. Other topics discussed were prevention of malaria in pregnancy, encouraging women to take IPTp and providing pregnant women with a free ITN. The messages were delivered in a way that was understandable to the SMAG members, some of whom have low literacy levels.

4 https://www.who.int/reproductivehealth/news/antenatal-care/en/

The total number of SMAG members oriented by health facility were (221 Male and 230 female).

Results/findings:

− SMAGs were informed about the six doses and a minimum of eight contacts a pregnant woman should make. − Directly observed therapy was encouraged as some women don’t take the SP on their own. − Pregnancy registration at or before 13 weeks was also emphasized.

Successes:

− PAMO managed to orient SMAGs in all the targeted health facilities and successfully managed to provide all the logistics for training − All the trained SMAGs were provided with thick books to use as registers for data collection and reporting

Challenges:

− Most districts and health facilities are facing a shortage of SP − Many more SMAG members needed to be oriented but only 50 per district were targeted − SMAGs have more than one register and this could lead to confusion during reporting

Recommendations:

− The PHO and the Clinton Health Access Initiative should be engaged to develop an addendum on the already existing SMAGs pregnancy register so that information is entered and extracted from one register − IPTp-SP and ITNs should be made available in all facilities. − DHO should advocate for more resources to orient other SMAGs in the remaining facilities − A follow-up activity should be conducted in two months to check on the implementation.

COMMEMORATION OF SAFE MOTHERHOOD WEEK PAMO joined Mbala DHO to commemorate Safe Motherhood Week, during which LLINs were provided to pregnant women in all 20 health facility catchment areas in the district that had not received LLINs because their health facilities did not have them in stock.

In order to increase awareness during the Safe Motherhood Week, community drama groups performed to ensure that the messages on the importance of IPTp and use of LLINs were disseminated. SMAG members also conducted health education to the pregnant women during the outreach sessions in the communities. The activities were integrated with the cancer screening services, prevention of mother to child transmission services, and postnatal services to all women that attended the static and outreach service points during the week.

SUPPORTED LUNDAZI AND VUBWI DISTRICTS TO CONDUCT SOCIAL BEHAVIOR CHANGE ACTIVITIES TO PROMOTE IPTP UPTAKE From June 3 to 7, 2019, PAMO supported SBC activities in Lundazi and Vubwi districts to promote the uptake of IPTp. Twenty health facilities were targeted, and 3,815 people were reached. The activity included drama performances and meetings with SMAGs in each health facility to discuss their activities. In addition, discussions were held with the health facility staff on how they were performing with regard to IPTp administration for pregnant women. The prolonged shortage of SP in health facilities is hampering these activities.

TASK 1.4: STRENGTHEN SOCIAL BEHAVIOR CHANGE IMPLEMENTATION FOR MALARIA AT HEALTH FACILITIES AND COMMUNITY LEVEL THROUGH COMMUNITY MOBILIZATION AND COMMUNITY DIALOGUES

COMMEMORATION OF WORLD MALARIA DAY The PAMO SBC team at the national and provincial level supported World Malaria Day activities on 25 April in Lufwanyama, Chama, Vubwi, Nchelenge, Mbala, Chadiza, Katete, and Sinda. PAMO provided material and technical support to implement various malaria SBC activities. This included the production of SBC material to commemorate this event in the four provinces, this included T-shirts, caps, branded soccer balls, trophies, banners etc. The activities included bicycle relays themed as “Cycle to Eliminate Malaria” in Eastern Province; football tournaments in Luapula, Muchinga, and Northern provinces; community drama and community dialogues; and school quizzes and singing competitions. The activities in the four PAMO provinces turned out to be the main event for each of the provinces in which they were carried out.

MEDIA ENGAGEMENT In May, PAMO held a one-day media engagement meeting in Luapula which drew participants from the PHO, DHOs, and all media houses in Luapula (KFM, Radio Yangeni, Radio Bangwela, Luapula radio, and Muvi TV). Thirteen (nine male and four female) attended the meeting, which was held to encourage media personnel to cover more malaria control and elimination activities and to raise awareness. The PAMO Social Behavior Change (SBC) Specialist and Luapula PAMO Community Engagement and Mobilization Officer (CEMO) led the workshop. The media houses pledged to commence airing malaria programs. Other media engagement meetings ae planned for the third quarter

SCHOOL QUIZ GAMES PAMO has been conducting school quiz games in all the four provinces. The purpose of this activity was to educate adolescents about the importance of sleeping under an LLIN by using a fun and participatory method. PAMO provided the necessary technical and material support to hold these events. This activity was held to improve knowledge levels among school going children and the communities they come from. The school children are expected to carry these messages to their households. The messages were aimed at improving care seeking behaviors for malaria and other health issues, increase LLIN use amongst adolescents, increase demand for and acceptance of malaria diagnosis and treatment and increase acceptance of IRS. PAMO also met with the school authorities to encourage them to form “malaria elimination clubs” for continued SBC, advocacy and community involvement in order to increase the uptake and utilization of malaria elimination interventions. As a result, many of the schools which participated in the school quiz games agreed to develop action plans outlining their SBC plans and activities in the schools and surrounding communities.

PAMO works with sub-contracted civil society organizations to conduct many more SBC activities, details of this are provided below (Task 1,6)

TASK 1.5: STRENGTHEN MALARIA POLICIES AND GUIDELINES

MID-TERM REVIEW OF THE NATIONAL MALARIA ELIMINATION STRATEGIC PLAN 2017–2021 PAMO staff participated in the Thematic Desk Review of the MTR, which was held in Kabwe from April 29 to May 3. Thereafter, the WHO external reviewers arrived in Zambia to join the field validation activities (May 13 to 17). PAMO joined the field validation activities in Muchinga and Northern provinces. A second retreat (May 20 to 24) was held in Kabwe and was led by the senior advisor, who provided critical technical support and strategic guidance to this process. PAMO staff then joined the NMEC, PMI, and others in a workshop to finalize the MTR report. Various sections of the MTR report have been written by different people and the process of compiling the final report has begun. PAMO played a key role in writing and consolidating the MTR report. This four-day meeting was productive in the sense that key components of the report were completed. The process of finalizing the report will be spearheaded by the WHO.

TASK 1.6: SUPPORT CIVIL SOCIETY ORGANIZATIONS AND COMMUNITY-BASED ORGANIZATIONS TO IMPLEMENT MALARIA CONTROL ACTIVITIES. In a bid to strengthen implementation of social behavior change activities, PAMO has contracted 17 CSOs to support DHOs in Mwense, Katete, Sinda, Chipata, Mwansabombwe, Chiengi, Chembe, Mpika, Mungwi, Chinsali, Sengahill, Samfya, Mansa, Nyimba, Nchelenge, Petauke , Mafinga, Isoka, Chadiza, Chipili, Kawambwa, Nchelenge, and Kasama. PAMO’s support to the CSOs has enabled implementation of community-level SBC activities that form part of the district community engagement plans that were developed by the respective DHOs in 2017 as a result of technical and material assistance provided by PAMO.

During the period under review, the following activities were implemented:

• Orientation of community change champions/malaria agents on the champion community initiative. • Orientation of traditional leaders on key malaria interventions. • Orientation of religious leaders on key malaria interventions. • Orientation meetings for teachers on key malaria interventions. • Orientation of drama groups on key malaria messages. • Door-to-door sensitization and data collection for increased awareness on malaria among community members. • Community dialogues to increase awareness on key malaria interventions. • Quiz competitions in schools to increase knowledge on key malaria interventions. • Focus group discussions on malaria. • Drama performances to mobilize communities for community dialogues. • Community meetings to review reports/data. • Village meetings on malaria prevention and elimination strategies for one day during community village meetings in all project catchment areas. • World Malaria Day commemoration events. • Development of action plans and the launch of the champion community’s initiative.

COMMUNITY CHANGE CHAMPIONS/MALARIA AGENTS ON CHAMPION COMMUNITIES’ INITIATIVE During the period under review, CSOs conducted 101 meetings to orient approximately 1,000 community change champions from communities surrounding 101 health facilities. The community change champions were identified by the health facility staff and through existing community structures including NHCs and SMAGs. The selected volunteers were tasked with the responsibility of spearheading the champion community’s initiative, which encourages community ownership and fosters identification of local solutions to address health issues including in malaria. The two-day orientation meetings were facilitated by DHO, CSO, and facility staff and covered the following topics:

• Overview of the national malaria elimination strategy. • Overview of the district malaria profile. • The champion community initiative. • SBC products and materials on the initiative. • How to use the flip chart. • Setting community targets and action planning. • Monitoring and reporting—data collection tools.

The oriented community change champions were assigned areas of operation (zones). Additionally, they were empowered with enablers including notebooks, pens, job aids, flip charts, t-shirts, umbrellas, and gumboots.

The oriented change champions showed enthusiasm and pledged commitment to ensure accurate messages on malaria were disseminated for malaria-free communities. The champions also requested the MOH consider providing bicycles as an alternative means of transport to aid their movements to distant communities.

Community change champions pose for a photo after attending an orientation meeting on the Champion Communities initiative in Eastern Province.

ORIENTATION OF TRADITIONAL LEADERS ON KEY MALARIA INTERVENTIONS CSOs supported facility staff to conduct one-day orientation meetings for at least 500 traditional leaders—mostly headmen—on key malaria interventions. The meetings aimed to empower the leaders with correct information discuss their involvement in supporting the malaria elimination agenda. The orientation meetings involved discussions around myths and misconceptions on malaria interventions. The facilitators of the meetings, who included district health promotions officers and environmental health technologists, affirmed the benefits of early health-seeking behavior and correct utilization of ITNs for malaria elimination to be achieved in their various communities. Oriented traditional leaders committed to holding village meetings to increase awareness on malaria and calling community members to action to ensure increased uptake of services including ITNs and IPTp for pregnant women. They in turn received a copy of the traditional leaders’ briefs on the ten actions leaders should take to support the malaria elimination agenda. They also received handouts on key malaria messages and presentation handouts on highlights of the national malaria elimination strategy. Traditional leaders were encouraged to support the champion community initiative and to play a role to ensure community change champions were availed opportunities to speak about malaria during village meetings.

ORIENTATION OF RELIGIOUS LEADERS ON KEY MALARIA INTERVENTIONS During the period under review, CSOs supported DHOs and facility staff to conduct meetings to orient at least 120 religious’ leaders in the CSO catchment areas across the four provinces. The orientation focused on the national malaria elimination strategy and other key concepts on malaria and its key interventions. The facilitators engaged the leaders on some of the common practices that are barriers to the uptake of malaria services such as the fact that some religions do not allow their congregants to get any conventional medicines for the treatment off malaria. Religious leaders were also encouraged to promote early health-seeking behaviors by going to get treated whenever they experienced signs or symptoms of malaria. Some of the religious leaders pledged to conduct health talks in their churches and allow facility staff to speak about malaria during their services in church.

ORIENTATION MEETINGS FOR TEACHERS ON KEY MALARIA INTERVENTIONS During second quarter, CSOs in collaboration with the DHO and District Education Boards (DEBs) identified and oriented 169 teachers from schools surrounding 29 health facilities in CSO catchment districts The teachers were selected from schools within the CSO catchment areas. The one-day orientation meetings focused on increasing awareness on the national malaria strategy, key malaria interventions, and the role of teachers in ensuring correct messages are disseminated within their communities. The teachers expressed satisfaction for being engaged in the malaria elimination program and committed to helping disseminate malaria information in schools and SBC materials on malaria if made available.

DRAMA GROUP PRESENTATIONS ON KEY MALARIA MESSAGES During the period under review, PAMO-supported CSOs collaborated with DHOs and health facility staff to facilitate meetings to orient local drama groups on key malaria elimination interventions. The two-day meetings were facilitated by health promotion officers and environmental health technologists and focused on the national malaria elimination strategy, basic skills in drama including script writing, facilitation, creating plays, performing songs and dances, and determining one’s audience. Key messages on key malaria interventions were also shared to empower participants with correct malaria information in readiness for the community drama performances used as a community mobilization strategy. A total of approximately 144 drama members were oriented across the PAMO supported areas.

DOOR-TO-DOOR SENSITIZATION AND DATA COLLECTION FOR INCREASED AWARENESS ON MALARIA AMONG COMMUNITY MEMBERS CSOs and facility staff supported community change champions to continue sensitizing communities using the door-to-door approach and to provide counseling on the need for increased utilization of ITNs and IPTp uptake. They also collected data to check for progress on number of women receiving IPTp, the number of people sleeping under ITNs, and the number of parents taking their A community change champion during a household visit. children to test for malaria when presented with a fever or other malaria signs and symptoms.

QUIZ COMPETITIONS IN SCHOOLS TO INCREASE KNOWLEDGE ON KEY MALARIA INTERVENTIONS To increase knowledge levels among pupils in schools, CSOs supported implementation of intra- and inter-school quiz competitions conducted in several schools around CSO catchment facilities. The district education boards, district health officials, and health facility staff facilitated the quizzes. Quiz cards on malaria were used to guide the competitions and winning teams were rewarded with various prizes, which included school bags, books, t- shirts, branded stickers, and branded wristbands. The school quiz games revealed the low levels of malaria knowledge among school-going children, especially in the pre-elimination districts. This clearly shows the need to revamp malaria clubs in schools as a channel through which to disseminate malaria information. The district education board expressed gratitude to PAMO and partners for supporting the quiz competitions and encouraged the Ministry of Health to consider re-introducing these activities in all the schools.

COMMUNITY DIALOGUES TO INCREASE AWARENESS ON KEY MALARIA INTERVENTIONS In collaboration with DHO, CSOs supported facility staff to conduct community dialogues in all PAMO- supported provinces. Approximately 15,000 people were reached during the dialogues. Although several discussions from the dialogues revealed that many people had knowledge on malaria, misconceptions on malaria transmission still existed. The facilitators utilized the platform to dispel myths and misconceptions. Facilitators also shared key messages on malaria interventions and encouraged community members to improve and demonstrate early health-seeking behavior.

GROUP DISCUSSIONS CSOs supported DHOs and health facilities to conduct group discussions on IPTp, encouraging pregnant women to share the reasons they shunned antenatal clinics to access IPTp. Multiple participants said they were afraid of losing their babies once people in the village knew that they were expecting. A discussion on ITNs revealed that some community members, particularly in Eastern Province, had been spreading Community change champions facilitating a group discussion on ITNs. rumors that the new ITNs contained bed bugs. The facilitators dispelled the myths and shared the benefits of using ITNs as well as the benefits of IPTp.

DRAMA PERFORMANCES TO MOBILIZE COMMUNITY DIALOGUES In collaboration with DHOs, CSOs supported environmental health technologists to coordinate drama performances. The drama performances were conducted prior to the implementation of other activities to mobilize communities to participate in other planned activities such as community dialogues and meetings at which key malaria interventions and messages were discussed and passed. Local volunteers oriented on drama and malaria key messages were used to disseminate key malaria messages in an “edutainment” manner.

The drama highlighted real-life situations that were barriers to malaria programming, including religious beliefs, traditional practices, and general poor health-seeking behavior by community members. This activity was well-received by community members who were given an opportunity to ask questions on malaria, and the EHTs were readily available to give responses and dispel myths and misconceptions where possible

VILLAGE MEETINGS ON MALARIA PREVENTION AND ELIMINATION STRATEGIES In the second quarter, oriented community change champions were supported to participate in village meetings. The village meetings were a platform to discuss key challenges related to the uptake of key malaria interventions and the utilization of medical commodities for malaria prevention and treatment by community members. The local headmen took advantage of the crowd to reinforce punishments for villagers that were found abusing ITNs or refusing to have their homes sprayed. The community members were encouraged to have their surroundings cleared of breeding sites and to ensure every member of their household—especially pregnant women and children—sleeps under long-lasting insecticide-treated nets and visits a health facility whenever they have symptoms of malaria. In addition, people were encouraged to allow those who come to spray their houses.

A local headman shares key messages on ITNs during a dialogue.

COMMUNITY MEETINGS TO REVIEW REPORTS/DATA Facility health staff hold one-day meetings with the community change champions to discuss data on malaria indicators in order to validate that the reported data were accurate and complete. During these meetings, the facility also disclosed the zones with high malaria burden and discussed the need to focus some SBC activities in those areas for increased utilization and uptake.

WORLD MALARIA DAY COMMEMORATION EVENTS CSOs supported DHOs and facility staff to coordinate and implement various World Malaria Day activities in their catchments. The World Malaria Day commemoration took place on April 25 and included drama performances, community dialogues, quiz competitions, bicycle relays in Eastern Province, football tournaments, distribution of SBC materials, including t-shirts, brochures, stickers, and banners. It drew political and civic leaders, traditional and religious leaders, MOH officials, other line ministry officials and the general public who not

36 only benefited from key messages on malaria but also participated in various activities including singing, bicycle relay, sack races, and quiz competitions.

MONITORING AND SUPERVISION OF COMMUNITY CHANGE CHAMPIONS CSOs, in collaboration with DHOs and health facility staff, conducted monitoring and supervision activities which included onsite visits to the community change champions’ villages to see how they were conducting activities such as door-to-door sensitization and counseling on malaria. The monitoring team also paid courtesy calls on the traditional leaders to learn how the SBC programs were being implemented in their villages. At least 57 monthly monitoring and supervision activities were conducted by all 17 CSOs. Some of the CSOs utilized the visit to provide mentorship to the change champions on data collection tools for monitoring and evaluation as well as on how to use the distributed the flip chart job aids.

COMMUNITY ACTION PLANS DEVELOPMENT AND LAUNCH OF THE CHAMPION COMMUNITIES’ INITIATIVE Following the orientation of DHOs, CSOs, and community change champions on the Champion communities’ initiative, the two CSOs serving the pre-elimination districts supported communities to develop community action plans. The community plans developed during the launch of the initiative were a road map for implementation of SBC activities in support of the champions’ initiative. During the planning, communities were encouraged to set their own targets on set indicators. It was also an opportunity to ensure that traditional leadership were engaged in the initiative for increased ownership and leadership of the malaria elimination agenda in their communities.

Key challenges Recommendations

There are some gaps in the CSO reports, some PAMO to urgently plan to orient CSOs on lack complete statistical data on specific activities reporting and revise reporting template to and other reported data is not disaggregated by ensure complete and accurate reporting by Gender CSOs

Lack of transport for champions in distant areas PAMO provincial offices to coordinate with resulting in late submission of reports by DHOs to leverage on bicycles supplied to community change champions communities for other malaria programs

Lack of identification for some community change There is a need to print additional T shirts and champions IDs for community change champions

Data collected by community change champions in Need to harmonize tool with the health some facilities not been used for decision making promotions tool that feeds into the district reporting for MOH

Inadequate SBC materials in communities Print and supply more materials

Inconsistent malaria messages given by champions PAMO to provide consistent key messages and in different communities products and spearhead onsite mentorship of champions on use of materials

TASK 1.7: CONDUCT OPERATIONS RESEARCH In 2019, PAMO did not receive funding for operations research, therefore no operations research activities will be implemented this year.

OBJECTIVE 2: STRENGTHEN MANAGEMENT CAPACITY OF PROVINCIAL AND DISTRICT MOH PERSONNEL TO PROVIDE SUPERVISION AND MENTORING TO IMPROVE DELIVERY OF PROVEN INTERVNETIONS PAMO’s second objective focuses on strengthening the management capacity of provincial and district managers.

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 ACTORS PAMO conducted a Malaria Health Systems Gap Analysis and a Management Capacity Assessment in 2016. Based on this, a management capacity-building plan was developed and implemented in 2019.

TASK 2.2: DEVELOP AND IMPLEMENT A PLAN TO STRENGTHEN MANAGEMENT CAPACITY AS MEASURED BY SET TARGETS WITHIN EACH TARGETED PROVINCE AND DISTRICT PAMO is working to strengthen the management capacity of PHO and DHO staff. This includes strengthening the individual’s ability to plan, budget, and implement all areas of the malaria program, including resource allocation, financial management, personnel management, training, supervision, commodities, logistics, communications, monitoring, and evaluation. In the second quarter, PAMO, working through the Broad Reach Institute for Training and Education (BRITE), worked on the following activities:

• Management capacity training of selected MOH district staff in Northern, Luapula, Muchinga, and Eastern provinces. Participants were trained on management skills, mapping their districts, simulating Malaria Action Task Force (MATF) meetings by documenting and recording meeting discussions, developing strategies for recruiting additional community stakeholders into participating in the MATF, and developing an initial business plan to fund the MATF meetings and activities. • Training of management mentors in Luapula, Muchinga, and Eastern provinces. Three MOH members of staff from each of the provincial cohorts were selected to participate in a two-day management mentorship training program. • Online training and mentoring of trainees from Northern, Luapula, Muchinga, and Eastern provinces. The trainees were orientated and signed up on a BRITE e-learning platform for a two-month online training course in management comprising six modules namely, Project Management (PMD); Administrative Management; Management, Leadership and Mentorship; Planning and Problem Solving; Strategic Information Management; and Community Health Management

TABLE 6: OVERVIEW OF MANAGEMENT CAPACITY BUILDING TRAINING

TOTAL NUMBER TOTAL NUMBER TRAINED AND WHO HAVE LOCATION CADRE TARGET ENROLLED INTO COMPLETED COMMENT ONLINE ONLINE TRAINING TRAINING TO PROGRAM DATE

MOH, Local Authority and All PAMO Line Ministries in provinces Luapula, 48 60 52 Complete (main Northern, program) Muchinga & Eastern Provinces

MOH staff based Pre- in the pre- elimination elimination 14 12 12 Complete districts districts

Lusaka NMEC Officers 10 0 0 Planned for Q3

All PAMO Management 12 12 12 Complete provinces Mentors

Total 84 84 76

CHALLENGES

Poor internet connectivity in rural parts of the country for the online training posed a continuing challenge.

OBJECTIVE 3: STRENGTHEN PROVINCIAL AND DISTRICT HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) TO IMPROVE DATA REPORTING, 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

DATA QUALITY AUDITS PAMO provided technical and material assistance to the MOH to conduct data quality audits (DQAs) in 268 health facilities with data quality challenges. The purpose of the DQAs is to improve the quality of data by bridging the disparities between data reported in HMIS and source data documents. Apart from conducting the routine DQA, the PHO and DHO staff used the opportunity to reorient health facility staff on recommended data capturing processes and source documents.

TABLE 7: OVERVIEW OF THE HEALTH FACILITIES VISITED DURING THE DQA

NO. OF HEALTH % YEAR 4 NO. OF NO. OF FACILITIES % ACHIEVEMENT PROVINCE TARGET (NO. PLANNED ROUNDS VISITED ACHIEVEMENT (HEALTH OF HEALTH ROUNDS IN CONDUCTED IN THE (ROUNDS) FACILITIES FACILITIES) YEAR 4 SO FAR FIRST VISITED) ROUND

Eastern (main 45 2 1 45 50% 100% program)

Eastern (pre- 79 2 1 66 50% 83.5% elimination)

Luapula 45 2 1 67 50% 148.9%

Muchinga 45 2 1 45 50% 100%

Northern 45 2 1 45 50% 100%

Total 259 10 5 268 50% 103.5%

Positive findings include:

− DQAs were implemented successfully in all the targeted health facilities. − The DQA team took time to mentor health facility staff to help them improve the quality of their reporting. − All health facility staff were found in the facilities and were ready to participant in the exercise. − Most of the source documents (i.e., outpatient department registers, rapid diagnostic test registers) were available and carbon copies of reports for the all the months under audit were located. In the previous DQAs, a number of source documents were reportedly missing.

Key issues encountered and action taken to address them:

− There were disparities between the data reported into the national HMIS and the data found in the source data documents. The PHO requested the DHOs provide more frequent supportive supervision and mentorship on data management to help health facility staff improve reporting. − Some health facilities lack a proper system to compile reports. The PHO and DHO supervisors requested the health facility staff work together and assign the role of compiling the required reports to more than one person so the data can be verified and reconciled by more than one person before they are sent to the DHO. − In large health facilities, there were inconsistencies in data entry between the various registers. This was mostly a result of poor communication and information sharing between health facility staff. The DHO encouraged the health facilities to hold monthly data review meetings within health facilities to review and improve their data. They were also advised to form a group or team to compile weekly and monthly reports to minimize and possibly eliminate errors in data entry from the source documents on the aggregation/reporting forms. − The facilities visited had common challenges, such as over- and under-reporting of malaria cases, missing registers, and cases of clinical and confirmed malaria not clearly recorded. Health facility staff were advised to make weekly summaries of malaria data so that errors are minimized at the time of compiling the monthly reports. Malaria data are usually bulky, thus tedious to compile and enter. − Registration staff in the outpatient department (OPD) and other key registration points (such as the laboratory) do not understand the importance of registration of every service offered, including RDTs. − Staff do not clearly write “CONFIRMED MALARIA” when they have a positive test result either by RDT or microscopy.

MALARIA SURVEILLANCE DQA IN NCHELENGE The PAMO team worked with the MOH to conduct a DQA of health facility malaria rapid reporting (MRR) and CHW surveillance data in Nchelenge. The malaria surveillance DQA was conducted in all health facilities within the districts. The CHWs were asked to report to the health facility with their Component D registers (i.e., passive and active registers). Two groups of DQA facilitators split up to conduct the DQAs.

Figure 3: Map showing locations of trained CHWs in Nchelenge district

Summary of the general findings of the audits:

• MRR data audits were not easy to conduct in most health facilities because of a lack documentation at health facilities (MRR reports not filed in most health facilities).

• Component D data had minor issues (mostly totaling issues); otherwise the data was generally accurate, matching the data in the DHIS2 system. • Health facilities that had CHWs who were trained last year (in 2018) but had their data entered in DHIS2 this year scored poorly in timeliness because the system scored those reports as reported late. • The few health facilities that had MRR data and audits conducted on them had no data accuracy issues.

Consolidated scores for the malaria surveillance DQA:

1. Reporting (% of months for which data has been audited that data was reported into the DHIS2): 95% 2. Accuracy month (% of months for which all data elements were reported accurately into the DHIS2: 51% 3. Accuracy data element (% of all data elements reported accurately into the DHIS2: 80% 4. Completeness (% of months for which there were no data elements missing in DHIS2 reports): 95% 5. Timeliness (% of months for which data was reported into the DHIS2 by the due date): 64%

TABLE 8: KEY ISSUES ENCOUNTERED AND RECOMMENDATIONS TO ADDDRESS THE ISSUES

ISSUE ANALYSIS RECOMMENDATION

The District malaria Health had no MRR reporting forms elimination officer to ensure Missing filed weekly MRR at they were just reporting direct in the health facility staff are facility level phones. Not documentation supplied with these forms and are filing reports

To PAMO Lusaka to Most CHWs complained of poor Problematic Phones consider buy more spare phone batteries that were draining fast batteries batteries to replace the before they could finish sending reports finished ones

Most CHWs complained of the phones PAMO to consider procuring Inappropriate Phones charges which socket pins that were adaptors they will enable the charges incompatible with sockets used in use of the chargers Zambia

CHWs complained of the distances PAMO & DHO to help in they cover with transport when CHWs bags and Bicycles meeting the communities carrying out their duties and lack of need bags for carrying their commodities

MALARIA SURVEILLANCE DATA REPORTING BY COMMUNITY HEALTH WORKERS PAMO supports malaria reporting surveillance activities in order to improve routine data flow from health facilities and communities. Nine districts have been selected for implementation of malaria surveillance activities in the context of malaria rapid reporting (MRR) and community reporting (see Figure 3). To guarantee effective and efficient data management, DHIS2 for community-level malaria surveillance at the NMEC, established by MACEPA and the MOH, is used to receive and manage the CHW work force, surveillance data, and reporting system. For malaria surveillance to function effectively, data quality support must be provided and invested in. The figure below shows the districts where iCCM and malaria surveillance have been rolled out.

Figure 3: Map showing locations of MRR and malaria surveillance reporting

Figure 4: Enlarged map of the pre-elimination districts showing MRR and malaria surveillance reporting

The following data elements: Passive Number Tested, Passive Number Positive, Passive Number Treated, Index Cases followed up, Active Houses Visited, Active Number Tested, Active Number Positive, Active Number Treated, and RDT stocks: RDT Balance on hand are reported on a monthly basis. The table below summaries the data for the period and illustrates the progress that the CHWs are making. This is depicted in the graph below (Figure 4).

Figure 4: Malaria surveillance data reporting by community health workers

PAMO-supported component D data reporting 50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 RDT Index Passive Passive Passive Active Active Active Active stocks: Cases Number Number Number Houses Number Number Number RDT followed Tested Positive Treated Visited Tested Positive Treated Balance up on hand March 2019 9736 4788 4833 1908 5550 22381 6736 6772 9216 April 2019 32242 16796 15725 3887 10076 45310 14266 14061 18662 May 2019 35089 21118 20935 3723 8201 35081 13360 13157 16241

March 2019 April 2019 May 2019

TASK 3.2: ASSIST WITH TRAINING FOR THE ROLL OUT OF DHIS2 IN THE TARGETED PROVINCES AND DISTRICTS.

DISTRICT HEALTH INFORMATION SYSTEM (DHIS2) TRAINING PAMO provided material and logistical support to the MOH to train 65 (55 males, 10 females) PHO and DHO staff to use DHIS2. The training was held to increase access to and the use of HMIS data among MOH and PAMO staff, reduce the dependency on district health information officers to extract data for program officers, improve competence in data analysis among health information officers, and enable tracking and quarterly reporting on the performance of specific HMIS malaria indicators. Thirteen (12 male and 1 female) new PAMO staff were also trained. All those who were trained were given login credentials for DHIS2.

HMIS TRAINING FOR HEALTH FACILITY STAFF PAMO provided financial and logistical support to the MOH to train health facility staff in HMIS data management and reporting. Held in Petauke, the training focused on building staff capacity to understand patient flow, how to capture patient data in registers (OPD, IPD, RDT), and how to report these data elements on the Health Information Aggregation (HIA) forms. Twenty-five (16 male and 9 female) health facility staff from Petauke were trained in HMIS.

In the pre-elimination districts, after conducting a rapid assessment, health facility staff from 61 facilities were selected for training. The training was divided into two workshops conducted between April 24 and 26 in Sinda and May 2 and 4 in Chadiza. The training was conducted by the senior health information officer with support from the district health information officer from the pre-elimination districts. Sixty-seven (43 male, 24 female) health facility staff were trained across the pre-elimination districts. The expected outcome of this training is improved data quality in terms of timeliness, accuracy, and minimized errors being submitted into the DHIS2 platform for data analysis, leading to high quality data-based decision-making.

TABLE 9: OVERVIEW OF HMIS TRAINING

Province Training Actual Number Trained % Achieved target Male Female Total

Eastern 25 16 9 25 100%

Luapula 25 14 11 25 100%

Muchinga 25 0 0 0 0%

Northern 25 0 0 0 0%

Pre-elimination 61 43 24 67 109.8% districts

Total 161 73 44 117 72.7%

TASK 3.3: PROVIDE TECHNICAL/MATERIAL ASSISTANCE TO DHOS, HEALTH FACILITIES, AND COMMUNITIES TO STRENGTHEN MALARIA DATA ANALYSIS AND USE FOR PLANNING AND DECISION-MAKING.

MALARIA DATA REVIEW MEETINGS The main purpose and objective of the activity was to review malaria data indicators for selected districts. Data from the fourth quarter of 2017 was compared with data from the fourth quarter of 2018

50 and data from the first quarter of 2018 was compared with data from the first quarter of 2019. The data review meetings were held in all the PAMO provinces. Selected malaria indicators and data elements such as confirmed malaria, RDTs done, incidence rates, case fatality rates, and others were reviewed. The malaria data reviews not only provided an opportunity for the respective districts to appreciate the efforts they are making toward malaria elimination but also provided data on which zones in each health facility catchment areas were reporting high rates of malaria and what can be done to intensify prevention activities in those zones and health facilities.

In the pre-elimination districts, the data review meetings were held over two days in each district. The meetings were held between May 27 and June 1. The target participants were EHTs (or data focal point persons) and in-charges from all health facilities in the respective districts. A total of 210 (146 males, 64 females) health facility staff participated in the meetings. These round 1 data review meetings provided a critical programming precedent for future data reviews meetings. The meetings also provided key learning highlights, which should influence meeting process management, especially the templates. Among the key lessons learned and observations:

• There was a need to disaggregate data in line with client origins based on the codes in the register to address the population numbers on the numerator and denominator when calculating incidence and other indicators. • The meetings provided a platform for peer learning and adoption of best practices presented. • The districts understood their data better and were able to identify the health facilities in need of increased support.

The meetings concluded with action points for the PHO, DHO, and health facility teams. It is anticipated that the data review processes and/or interactions will lead to greater health facility staff ownership of the data, the setting of goals, and the adoption of best practices and strategies to address identified challenges. Furthermore, the action points developed and adopted will provide a platform for ongoing self-reflection and improvement in data management and utilization for decision-making.

In Muchinga Province, PAMO supported the semi-annual data review meeting for Nakonde, Chinsali, and Mafinga. In addition to the usual review of data, PAMO introduced a concept aimed at strengthening attendees’ management skills through a discussion around a PAMO presentation on strategic information management using skills acquired through the BRITE management training. The meeting stressed the importance of critically examining information in order to recognize opportunities for improving efficiency, performance, and impact and emphasized that the goal of strategic information management is to improve outcomes/results.

OVERVIEW OF HMIS DATA ELEMENTS AGGREGATED FOR THE PAMO PROVINCES The table below compares data for the first quarters in PAMO supported provinces from 2015 to 2019. Clearly, all critical data elements show steady decline in malaria burden from 2015 to 2019.

TABLE 11: HMIS KEY DATA ELEMENTS

Jan to Jan to Jan to Jan to Jan to Mar Mar Mar Mar Mar 2015 2016 2017 2018 2019

1 Deaths Clinical Case of Malaria 1 to Under 5 21 10 8 3 4 Years

2 Deaths Clinical Case of Malaria Over 5 Years 30 11 0 4 3

3 Deaths Clinical Case of Malaria Under 1 Year 14 0 0 2 2

4 IP Discharge Clinical Case of Malaria 1 to 1,151 633 274 136 155 Under 5 Years

5 IP Discharge Clinical Case of Malaria Over 5 1,469 931 324 217 106 Years

6 IP Discharge Clinical Case of Malaria Under 1 734 338 86 37 48 Year

7 OPD 1st Attendance Clinical Case of Malaria 41,434 46,020 29,735 6,333 8814 1 to Under 5 Years

8 OPD 1st Attendance Clinical Case of Malaria 78891 104178 63423 14025 19241 Over 5 Years

9 OPD 1st Attendance Clinical Case of Malaria 16702 15165 9264 2374 3189 Under 1 Year

10 Deaths Clinical Malaria In Pregnancy 6 2 1 1 0

11 IP Discharge Clinical Malaria In Pregnancy 179 115 36 37 68

12 OPD 1st Attendance Clinical Malaria In 2472 2257 1193 652 722 Pregnancy

13 Deaths Confirmed Malaria 1 to Under 5 Years 154 141 93 40 84

14 Deaths Confirmed Malaria Over 5 Years 129 107 76 56 75

15 Deaths Confirmed Malaria Under 1 Year 80 48 27 52 33

16 IP Discharge Confirmed Malaria 1 to Under 5 5055 5292 4357 3325 3085 Years

17 IP Discharge Confirmed Malaria Over 5 Years 5485 6019 4730 4218 3333

18 IP Discharge Confirmed Malaria Under 1 Year 2292 1707 1523 2011 1694

19 OPD 1st Attendance Confirmed Malaria 1 to 196392 212889 220307 152356 175373 Under 5 Years

20 OPD 1st Attendance Confirmed Malaria Over 329684 426151 436303 364365 435102 5 Years

21 OPD 1st Attendance Confirmed Malaria 63913 70753 63028 38285 46217 Under 1 Year

22 Deaths Confirmed Malaria In Pregnancy 5 19 6 5 13

23 IP Discharge Confirmed Malaria In Pregnancy 582 714 445 434 533

24 OPD 1st Attendance Confirmed Malaria In 7982 9472 8758 7893 10324 Pregnancy

25 Clinical malaria 143103 169660 104344 23821 32352

26 Confirmed malaria 611,753 733,312 739,653 573,040 675,866

27 Percentage of clinical cases 19% 19% 12% 4% 5%

Clinical malaria cases for quarter 1 (January–March) from 2015–2019 appear to have been reducing from the baseline percentage of 19 percent in 2015, to 12 percent in 2017, 4 percent in 2018, and 5 percent in 2019.

SUCCESS STORY

CHANGE CHAMPIONS CONTRIBUTING TOWARD MALARIA CONTROL AND ELIMINATION EFFORTS IN MUCHINGA PROVINCE Prior to the introduction of the Change Champions Initiative in Mpika, Chinsali, Isoka, and Mafinga districts in Muchinga Province, there were gaps in social behavior change communication and community mobilization activities. These hindered efforts to increase uptake, acceptance, and utilization of malaria treatment and prevention services at the community and household level. PAMO engaged Civil Society Organistions (CSOs) in these districts to spearhead SBC activities through the establishment of community MATFs but due to unclear guidelines on roles and responsibilities, no reports were produced describing what malaria elimination efforts were being done at the community level. Similarly, it was difficult to track SBC efforts at the NHC and facility level due to a lack of well-defined community systems aligned to SBC interventions and malaria elimination efforts. It was equally difficult to find simple action plans at the community level to confirm community collective planning and activity implementation. Furthermore, there was a lack of appropriate IEC materials to use during community forums like integrated health talks during prenatal care and under-five clinics, group education sessions, community widespread meetings, traditional ceremonies, community theater, and door-to-door home visitations at the household, NHC, health facility, and the community at large.

HOW PAMO INVESTMENT THROUGH THE MODEL OF CHANGE CHAMPIONS REINVENTED THE WHEEL TO CHANGE THE PICTURE ABOVE In November 2018, the PAMO project working in Muchinga Province and in CSO-supported districts introduced the model or concept of Champion Communities as a springboard for the acceleration of SBC interventions on malaria elimination at the household and community level. The initiative allowed DHOs, health facilities, and communities to identify, select, and orient change champions as catalysts for community-level SBC programming and interventions for the meaningful uptake and utilization of malaria elimination services by households and communities at large. The PAMO project through CSOs, DHOs, and health facilities, invested donor resources tailored toward capacity-building of change champions on how to use the malaria elimination flip charts, understanding of their roles and responsibilities, how to complete reporting tools and issues of reporting timelines and filing of monthly data. The capacity building process also included the development of a simple action plan to track activity implementation. This process of capacity-building of change champions was well-managed by DHOs and health facility staff to ensure sustainability of the initiative and the CSOs and PAMO staff provided the oversight and technical assistance required to achieve program objectives.

Furthermore, PAMO resources allocated to CSOs were used to support community-level SBC interventions allowing change champions to integrate SBC interventions on malaria elimination within or through the already existing Ministry of Health structures such as adhering to reporting protocols and participating in quarterly review meetings organized by health facilities. PAMO resources were also used by CSOs to support ongoing mentoring and support of change champions in the areas of action plan development and reporting.

The capacity building orientations provided to change champions helped them acquire skills and competencies to develop simple community action plans outlining SBC activities to be carried out at the

54 household and community level. This approach helped in accelerating the implementation of visible and meaningful SBC interventions by change champions in the CSO supported districts in Muchinga province. Today, change champions can boast of massive results arising from the numbers of people being reached through the dissemination of key malaria elimination messages to the target populations in the targeted communities and districts.

HOW THINGS ARE NOW AFTER IMPLEMENTATION OF THE CHANGE CHAMPION APPROACH During CSO monitoring in the month of July 2019, Mildred Chipimo, the health center in-charge for Muyombe Rural Health Center, had this to say: “We are more than happy and ever thankful to ROCS and PAMO for bringing the change champion initiative to Muyombe. As a facility, we have seen tremendous results because of the change champion sensitization on malaria in the NHC zones. From the monthly reports we are now seeing an increase in the number of under-fives sleeping under ITNs unlike in the past. This is happening because the champions do conduct door to door home visitations to encourage households allow children under five to sleep under ITNs every night. The project officer under ROCS, is now a seasoned change champion for malaria elimination in Mafinga District and through the district reports we have seen that the change champions are doing a lot on malaria sensitization. The picture now has changed because we have seen an increase in terms of the numbers of people being reached with key messages on malaria elimination. We are confident that come 2021 malaria will be a thing of the past in Muyombe and the country as a whole.”

The initiative has produced 704 malaria change champions, out of which 387 are female and 317 are male. These change champions are driving SBC interventions at household and community level on malaria elimination. We have also noticed that they are the most dependable malaria agents when it comes to the implementation of community level SBC interventions on malaria elimination. In the first quarter of 2019 (January to March), change champions’ contribution in terms of number of people reached with key messages on malaria elimination stood at 12,350 (from project source documents) out of which 7,201 were females whereas 4,049 were males. In line with the foregoing, at facility level change champions have been tasked with the responsibility of reporting on the most critical indicators on malaria elimination. This practice happens on a monthly basis and their contribution in the quarter under review was as follows:

• Populations who slept under an ITN: 8,594 (project source documents). • Number of under-fives tested for malaria by community health workers in their respective NHC zones: 847 (project source documents) • The number of pregnant women who slept under an ITN: 489 (project source documents). • The number of children under five of years of age who slept under ITNs: 2,921 (project source documents). • Reports of fever prevalence for children under five years of age: 1,055 (project source documents).