Quarterly Progress Report July 1, 2019–September 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: October 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 INTRODUCTION 7 BENCHMARKS AND ACHIEVEMENTS 7 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 7 OBJECTIVE 2: STRENGTHEN MANAGEMENT CAPACITY OF PROVINCIAL AND DISTRICT MOH PERSONNEL 21 OBJECTIVE 3: STRENGTHEN PROVINCIAL AND DISTRICT HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) TO IMPROVE DATA REPORTING 21 SUCCESS STORY 26

LIST OF ACRONYMS ANC Antenatal Care BRITE Broad Reach Institute for Training and Education CCI Community Champions Initiative 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 HCW Health Care Workers 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 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 MOGE Ministry of General Education MOH Ministry of Health MOP Malaria Operational Plan MRR Malaria Rapid Reporting MTEF Mid-term Expenditure Framework 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 RDT Rapid Diagnostic Test SBC Social and Behavior Change SMEO Surveillance, Monitoring, Evaluation and Operations Research TWG Technical Working Group WHO World Health Organization

PROJECT OVERVIEW

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

Reporting period July 1 to September 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

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 burden. While it appears that malaria prevalence among children under five years of age is declining, the results from the 2018 national Malaria Indicator Survey (MIS) indicate that apart from Eastern Province, the three other PAMO-supported provinces are still among the five provinces in Zambia with the highest malaria burden. The malaria prevalence rates in the PAMO-supported provinces justify the need for further investment in malaria control and elimination. In 2019, PAMO continues to work closely with the Ministry of Health (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 Programme (NMEP), 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 and this quarterly report covers activities implemented from July to September, 2019.

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 This objective has 13 Tasks aligned to the National Malaria Elimination Strategic Plan (NMESP) 2017–2021 in order to contribute to the overall MOH goals and objectives. This objective places an emphasis on key interventions such as sustained universal coverage of vector control interventions (distribution of long-lasting insecticide-treated nets [ITNs], indoor residual spray [IRS], and larval source management), case management (diagnosis and treatment), malaria in pregnancy (MIP), health promotion (community engagement and social and behavior change [SBC]), surveillance, monitoring, evaluation, and operations research. It is worth noting that, depending on the Task being implemented, PAMO directs its support at either the national or provincial/district level. Through Task 1.0 and 1.5, PAMO supports the NMEP at the national level by supporting national-level coordination, planning, and development of policies, strategies, and technical guidelines. Through the other tasks (namely Tasks 1.1, 1.2, 1.3, 1.4, 1.6, and 1.7), PAMO directs the bulk of its efforts to the sub-national level (i.e., by supporting the implementation of key NMESP interventions at provincial, district, health facility, and community level).

TASK 1.0: STRENGTHEN NATIONAL TECHNICAL WORKING GROUPS (TWGS) PAMO provides technical and/or material assistance to the NMEP 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 NMEP. PAMO’s technical specialists and senior advisor of malaria, policy, strategy, and management play an instrumental role in these TWGs. During this quarter, all four TWGs met; highlights of these meetings are outlined below.

CASE MANAGEMENT TECHNICAL WORKING GROUP The case management TWG, noting with concern a surge in malaria cases in Lusaka and Eastern provinces, called on the two provinces to intensify malaria prevention activities. The two provinces also reported a large number of clinical malaria cases despite availability of diagnostic tools. It was recommended that the two provinces identify the reasons for this so that appropriate interventions can be put in place to support health care workers to ensure every malaria case is confirmed before treatment. Intermittent preventive treatment in pregnancy (IPTp): Another issue discussed was data showing low national uptake of IPTp. This was attributed to the stock-out of Sulfadoxine Pyrimethamine (SP) in all health facilities across the country. The TWG was informed that although the World Bank had initially planned to procure SP it was not procured because the funds that were allocated for SP were redirected to an emergency Ebola outbreak. However, the NMEP is still working to mobilize funds through other partners to procure SP and ensure access to and utilization of IPTp services. Outreach training and supportive supervision (OTSS): During the TWG meeting, the NMEP reported that during the second quarter of 2019, all provinces had conducted OTSS to strengthen case management at health facility level. However, some OTSS data to enable a full analysis of health facility performance are missing except in the PAMO supported provinces of Northern, Luapula, Muchinga, and Eastern. The tablets containing the data have been recalled from the provinces to the NMEP monitoring and evaluation (M&E) team. However, there are still difficulties with retrieving the data. The capacity development officer from Northern Province and the senior M&E manager provided technical assistance to the National Malaria Elimination Programme (NMEP) in OTSS and troubleshooting the electronic data system (EDS) tablets. The NMEP will provide an update on this situation in the next TWG meeting. Mass Drug Administration (MDA): MDA was also discussed during the case management TWG meeting. It was reported that the government intended to implement MDA in ten provinces this year but due to unavailability of the drugs, the exercise has been deferred to 2020 and will take place in eight provinces. Two provinces (Southern and Western) will implement MDA in 2019 in six districts.

SMEO TECHNICAL WORKING GROUP The SMEO TWG meeting took place on September 30, 2019. Key points discussed include the following. Upcoming studies: PMI has given the go-ahead for two studies (both in Chadiza)—the ProACT Study and the ANC surveillance pilot—and the development of concept notes and protocols are under way to be submitted to the NMEP. To validate the ANC surveillance data, a household parasitemia survey will be conducted sometime in 2020 and will also serve as a baseline for the ProACT study. While PAMO will conduct the ANC pilot and the household parasitemia survey, the full ProACT study will be implemented by IMPACT Malaria. Discussion on community health worker reporting: Gaps in reporting were noted in iCCM work conducted by community health workers (CHWs). There is therefore a need to further strengthen CHW skills in data reporting. The other issue discussed was the index case follow-up. Partners were reminded to follow national guidelines on the number of index cases to be followed up so as to ensure rational use of rapid diagnostic tests (RDTs), and a need for the NMEP to review and update the active case detection protocol was identified. Currently, following up on an index case requires reaching about 140 meters around the index case. However, studies are showing that there is no value in doing so as most cases are concentrated at the home of the index case. There is therefore a need to revise the protocol so that CHWs only follow up on the index case household. Case based surveillance: Data collection tools have been developed with input from countries currently implementing case based surveillance. The next steps include engaging PHOs and DHOs on case based surveillance, developing a case investigation curriculum and training materials, testing tools, and deploying case investigation tools in selected areas of Southern Province.

VECTOR CONTROL TECHNICAL WORKING GROUP The vector control TWG met on September 27, 2019, and discussed the following key matters. IRS campaign status for 2019: The implementation funds for IRS were disbursed in September with the hope of beginning the campaign on October 2, 2019. By the end of August, 113 volunteers were trained as spray operators in seven out of ten provinces. The training in the remaining three provinces was scheduled to be completed by September 30—funds had been approved and were being disbursed for the remaining trainings. ITNs status 2019–2020: Sub-groups to effectively coordinate the ITNs campaign have been formed. The TWG was informed that the terms of reference have been reviewed for the subgroups that were formed. A monitoring tool was

8 created for use by all subgroups. The way in which the tool works was presented through a practical explanation. Once documents are developed using the M&E tool, they will be used to set work plans for all committees. Entomological surveillance and monitoring: It was reported that there are 23 sentinel sites out of which 7 are supported by Vectorlink, 12 by the Global Fund, and 4 by PATH-MACEPA. Furthermore, the entomological surveillance team has planned insecticide resistance spot check at government supported sites (pre-IRS), cone bioassays in two districts, data analysis on the net durability study (first week of November), and screening of houses in Nyimba prior to the rainy season (October).

SBC TECHNICAL WORKING GROUP The SBC TWG met in September and discussed terms of reference for the SBC TWG/stream. The SBC TWG was revamped this year to address gaps identified in the Mid-Term Review conducted by the NMEP. Other issues included the importance of standardizing and reviewing SBC materials which will be shared by all partners in malaria. Partners also made a presentation on the progress of implementation. The 2019 Southern African Development Community malaria day commemoration was also discussed.

TASK 1.1: STRENGTHEN INSECTICIDE-TREATED NET DISTRIBUTION

STRENGTHENING CONTINUOUS DISTRIBUTION CHANNELS: SCHOOL-BASED DISTRIBUTION IN CHADIZA, KATETE, SINDA, AND NCHELENGE. School-based distribution of Insecticide Treated Nets (ITNs) is one of the continuous distribution channels aimed at maintaining high coverage of ITNs in a particular district. The Zambia Continuous ITNs Distribution Implementation Guidelines state that school-based distribution should take place in July each year because it is school health and nutrition month and that nets should be distributed to students in grades 1 and 4. In July 2019, PAMO distributed ITNs to 43,119 students (19,993 boys and 23,126 girls) in four districts: three pre-elimination districts (Chadiza, Katete, and Sinda) in Eastern Province and in Nchelenge District of Luapula Province. The distribution took place in 324 schools among 23,856 grade 1 and 19,263 grade 4 students (Table 1). Table 1: Number of Children that received an ITN through School-based distribution channel.

Number Total Grade 1 Grade 4 Total Total District of ITNSs Boys Girls Schools Boys Girls Total Boys Girls Total distributed Chadiza 51 1,493 1,873 3,366 1,126 1,372 2,498 2,619 3,245 5,864 Katete 117 3,277 3,757 7,034 2,516 2,977 5,493 5,793 6,734 12,527 Sinda 83 2,224 3,238 5,462 1,833 2,604 4,437 4,057 5,842 9,899 Nchelenge 73 4,144 3,850 7,994 3,380 3,455 6,835 7,524 7,305 14,829 Total 324 11,138 12,718 23,856 8,855 10,408 19,263 19,993 23,126 43,119

Prior to the net distribution, PAMO worked with the provincial and district health and education officials to train grades 1 and 4 teachers in ITNs distribution. Topics of the training included an overview of the NMESP 2017– 2021, malaria incidence rates for the districts and provinces, school distribution process, and data capturing for effective reporting. During distribution, PAMO provided logistical support to the NMEC, PHO, and DHO to supervise the exercise in all four districts. The supervision provided an avenue for spot checks, data collection, and collation for various layers of the supervision teams. PAMO supported this process to build transparency and accountability at all levels of the distribution process and to provide a comprehensive data trail for the distribution of ITNs to students. To enhance knowledge among learners on the importance of net use, PAMO supported school quizzes, a fun and interactive way of educating students on basic information about malaria, malaria treatment, and the utilization of ITNs for malaria prevention.

ORIENTIATION OF GRZ STAFF ON CONTINUOUS DISTRIBUTION CHANNELS INCLUDING ANTENATAL CARE (ANC), EXPANDED PROGRAM ON IMMUNIZATION (EPI), AND SCHOOLS To sustain continuous ITN distribution through various channels, there is a need to ensure that key stakeholders are aware of those channels and are knowledgeable enough to support their implementation. In the third quarter of 2019, PAMO worked with the PHO in Eastern Province to orient relevant staff from the MOH and Ministry of General Education (MOGE) on concepts of continuous ITN distribution. The participants were selected from 9 out of the 13 districts in Eastern Province: Lundazi, Lumezi, Chasefu, Chipangali, Kasenengwa, Vubwi, Chipata, Nyimba, and Lusangazi. The three pre-elimination districts (Chadiza, Katete, and Sinda) were excluded because they were oriented in the second quarter. Twenty-seven officials (18 from MOGE and 9 from MOH) attended the meeting. MOGE officers included planners, district education standards officers, and district education officers, while MOH officers were malaria focal point persons from each of the nine districts. Prior to the actual meeting day, a joint NMEC, PHO, and PAMO team took a field visit to five health facilities—Lundazi Urban Centre in Lundazi District, Kakumba and Sikatengwa health centers in Lumezi District, and Hoya and Kanyanga rural health centers in Chasefu District. The purpose of the visit was to assess implementation of ANC and EPI continuous distribution channels in those health facilities. Issues arising from the field visit included a lack of ITNs distribution guidelines in health facilities, no stock control cards or registers to record ITN distribution at the health facilities at the time of the visit, and ITN distribution being either under reported or not reported at all on the health information aggregation (HIA2) forms. Generally there was poor data management at health facility level with regard to ITNs distribution through ANC and EPI. These findings were extensively discussed during the orientation meetings. At the close of the meeting, the PHO recommended that DHOs should orient all health facility staff on the continuous distribution strategy and the necessity of effective documentation; monitor the distribution of ITNs in the health facilities during the quarterly supervisory visits; ensure that health facilities use ITN distribution registers consistently; ensure that ITNs are delivered to the health facilities and not remain in DHO storerooms; and submit regular feedback reports on continuous distribution implementation to the PHO. At the end of the meeting, the NMEC shared electronic copies of the 2017 Guidelines on the Distribution and Utilization of Long-Lasting Insecticide Treated Nets for Malaria Prevention. PAMO printed and shared excerpts from the 2017 Guidelines (Annex 1B: ANC and EPI continuous distribution guidelines as well as Annex 1C School distribution guidelines).

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

CLINICAL MEETINGS IN PRE-ELIMINATION DISTRICTS In the third quarter of 2019, PAMO reached its 2019 target of supporting the MOH to hold two clinical meetings in each of the pre-elimination districts of Chadiza, Katete, and Sinda. A total of 263 health care workers (HCWs) (116 female and 147 male) participated in the second round of clinical meetings that took place in each of the pre-elimination districts. In Chadiza, the meetings were attended by 92 HCWs (35 females and 57 males), in Katete by 96 (41 female and 55 male) and in Chadiza by 75 HCWs (40 female and 35 male). Participants included clinical officers, nurses in the outpatient department, midwives, laboratory personnel, pharmacy staff, and district information officers. The purpose of the clinical meetings was to provide a platform for district hospitals and health facility staff to discuss challenges and identify solutions on how to improve on quality of care in malaria services. During the clinical meetings, national malaria diagnosis and treatment guidelines were discussed and HCWs were encouraged to adhere to prescribed standards. At the national level, PAMO has developed a harmonized work plan and a malaria scorecard that helps to track progress on malaria indicators at national, provincial, and district levels. Participants were shown the provincial and district malaria scorecard results, which focused on malaria case management, ITNs, and IPTp use. The results enabled HCWs to appreciate how their performance in each district was contributing toward achieving provincial and national indicators. Following the scorecard presentations, HCWs took time to discuss the challenges they face in malaria case management and identified some of the solutions to resolve those challenges. Some of the technical issues discussed included a presentation by a pediatrician from the provincial team that reminded participants that ferrous sulphate supplements must not be given to patients presenting with anemia caused by malaria because these patients have high levels of iron due to a breakdown of red blood cells associated with malaria. The meetings also served as a platform for improving the referral system between district hospitals and health centers for further patient management, particularly for severe malaria in order to reduce mortality attributed to malaria.

One lesson learned from the clinical meetings is that when patients are referred from health centers to hospitals, they are subjected to a repeat RDT, therefore leading to the risk of double counting confirmed malaria cases. The meetings resolved that recipient hospitals should not repeat malaria testing with an RDT, which should contribute to accurate reporting and correct information for the purpose of quantification.

DISTRICT AND PROVINCIAL OUTREACH TRAINING AND SUPPORTIVE SUPERVISION (OTSS) AND MENTORSHIP IN THE PRE-ELIMINATION DISTRICTS PAMO worked with the PHO and the respective DHOs to conduct provincial and district OTSS in the pre-elimination districts. This was the second round, completing the target of two rounds of OTSS planned in 2019. In the three pre- elimination districts, PAMO targeted all 69 non-microscopy facilities (30 in Katete, 18 in Chadiza, and 21 in Sinda) and all 11 microscopy facilities (three in Katete, five in Chadiza, and three in Sinda). All non-microscopy and microscopy facilities received OTSS visits. The OTSS team mentored 207 HCWs (128 male and 79 female) in non-microscopy facilities and 53 (30 males, 23 females) in microscopy in effective case management of malaria that included the proper use of RDTs and microscopes for malaria diagnosis, effective treatment of every confirmed malaria case, and on provision of high quality of care to patients. The OTSS team also followed up on some of the challenges they identified in the first round to see whether they have been addressed. Key among them were: • SP stock out: In the first round, SP was completely stocked out in all health facilities. A check during the second round revealed no change in the stock levels. All health facilities had no SP, a situation that severely affected IPTp uptake and use. • Drugs for severe malaria: In the first round of OTSS, it was noted that although injectable artesunate and quinine were available, they were not in sufficient quantities in all the pre-elimination districts. As a result, the management of severe malaria cases was negatively affected. However, during the second round, there has been a marked improvement. Both injectable artesunate and quinine were available in sufficient quantities, improving the capacity of health facilities to successfully manage severe malaria. Comparing the results between the first and second round of OTSS, the results generally show an improvement in adherence to a high standard of care. To measure improvement in health care worker skills in case management, PAMO uses a composite score methodology calculated as a percentage on six key performance indicators—three based on health care worker diagnostic and clinical care observations (microscopy [laboratory], RDT, and clinical observations) and three are based on review of health facility registers to ascertain HCWs’ testing and treatment behavior (adherence to testing prior to treatment, adherence to positive test results, and adherence to negative test results). For the diagnostic and clinical care observations, PAMO set an optimal target score of 90% and a minimum of 75%. Scoring below the minimum target indicates very poor performance requiring immediate attention, while scoring above the minimum toward 90% indicates good performance in need of further support, and scoring 90% and above indicates very good performance that is encouraged to be sustained. For the register review, PAMO set only one standard: 90%. Scoring below that score means very poor testing and treatment behavior by HCWs. In pre-elimination areas, the results of the second round of OTSS show general improvement in HCW adherence to required standards (e.g., clinical observation composite scores improved from 75% in first round to 85% in the second round; while adherence to positive test results and negative test results improved from 87% to 98% and from 86% to 99%, respectively—Figure 1). In spite of improvements in the majority of the performance indicators, PAMO observed a marginal decline in RDT observation which dropped from 91% to 89% between the first and second round and testing prior to treatment score from 92% to 88%. These results have been discussed with the provincial and district health offices, and further mentoring support is being provided to health facilities that did not perform well during the second round. In year 2 of pre-elimination – scheduled for the period September 2019 to September 2020 - PAMO has planned to continue to support the PHO and DHOs to conduct OTSS to sustain adherence to prescribed standards.

Figure 1: OTSS Results in Pre-elimination districts.

120 98 99 100 91 92 85 89 88 87 86 79 80 75 64 60

0 Clinical RDT Observation Laboratory Score Testing Prior to Adherence to Adherence to Observation Treatment Score Positive Test Negative Test Results Results

Jan to Jun 2019 (Baseline) Jul to Dec 2019

COMMUNITY CASE MANAGEMENT OF MALARIA In the second quarter report, PAMO reported that it completed the training and deployment of 1,379 CHWs who are providing iCCM services within their respective communities. In quarter three, PAMO continued to support DHOs and health facility-based CHW supervisors to support CHWs to carry out their services. Health facilities provided malaria case management supplies—RDTs, ACTs, sharp boxes, and biohazard bags for medical waste disposal—while PAMO provided t-shirts, aprons, a cell phone, and air time for monthly malaria surveillance data reporting. Based on the data provided by CHWs, between July and September, 172,514 people were tested for malaria (101,781 passive cases and 70,733 active cases) out of which 43,108 (24.9%) were confirmed malaria cases (31,666 passive and 11,442 active cases). Almost all (97% or 42,236) of those that were confirmed to have malaria were treated with ACTs. Those that were not treated were referred to the next level of care due to either being pregnant, potentially having severe malaria, or because the CHW did not have an ACT in stock at the time.

Figure 2: Number of people tested and treated by CHWs – July to September 2019.

200,000

180,000 172,514

160,000

140,000

120,000 101,781 100,000

80,000 70,733

60,000 43,108 42,236 31,666 40,000 31,161

20,000 11,442 11,075

0 Total Tested for malaria Total Malaria Positive Total Treated with ACTs

Passive Cases Active Cases Totals (Passive + Active)

To avoid overuse of RDTs, the Permanent Secretary in charge of technical services at Ministry of Health issued a letter guiding that CHWs should follow up only up to five index cases per month. PAMO has been mentoring and supporting DHOs to ensure that this message reaches CHWs and that they abide by the guideline and follow up on a limited number of index cases. In the third quarter, PAMO observed that CHWs are generally adhering. In most cases, they are following up an average ranging from one to four cases per month. Table 2 shows the average number of index cases followed up by CHWs. Table 2: Average number of index cases followed by CHWs every month.

District March April May June July August September Chadiza 0 1 0 2 2 3 3 Katete 3 4 4 3 2 2 1 Sinda 0 4 3 4 2 2 1 Mpika 3 2 1 1 1 1 1 Nakonde 0 0 2 0 2 1 1 Mbala 1 1 2 2 1 1 1 Nchelenge 3 5 4 3 2 1 1

Figure 3 shows the number of households visited, the index cases followed up, and the average number of index cases per community health worker in Katete District. It shows that each CHW is following up a limited number of index cases, fulfilling the MOH guideline. Figure 3: Number of index cases followed up and the average number of index cases per CHW, Katete District.

2000 1736 1800 1600 1357 1405 1400 1261 1268 1194 1200 1020 986 916 1000 864 747 800 650 600 505 391 400 200 3 4 4 3 2 2 1 0 March April May June July August September

Number of index Cases followed up Number of Houses Visited Average number of index cases per CHW

TASK 1.3: INCREASE DELIVERY OF IPTP-SP AS PART OF AN INTEGRAL PACKAGE OF ANC SERVICES During the quarter under review, no activities relating to this task were implemented.

TASK 1.4: STRENGTHEN SOCIAL BEHAVIOR CHANGE IMPLEMENTATION FOR MALARIA AT HEALTH FACILITIES AND COMMUNITY LEVEL THROUGH COMMUNITY MOBILIZATION AND COMMUNITY DIALOGUES In the third quarter of 2019, PAMO’s SBC and communication activities focused mainly on community level activities to raise awareness on malaria and the importance of the use and uptake of malaria proven interventions at community level. The key activities implemented include: airing radio spots, printing SBC materials, conducting community dialogues, conducting school quiz competitions and debates, holding an orientation of radio personalities on key malaria interventions for malaria elimination, supporting community change agents, and implementing the Champion Communities Initiative (CCI). Each of these activities are briefly explained below.

USE OF MASS MEDIA: ORIENTATION OF MEDIA PERSONNEL AND AIRING RADIO SPOTS TO CREATE AWARENESS ON KEY MALARIA INTERVENTIONS

In the first quarter (January–March 2019), PAMO contracted 19 radio stations across the four supported provinces to help build capacity of media personnel from these stations to effectively deliver and disseminate key malaria messages through media platforms. In the third quarter, PAMO, in collaboration with the NMEC and PHO, conducted a one-day orientation meeting focused on raising awareness among 19 media personnel (13 males and 6 females) on the national malaria elimination strategy and the key malaria interventions being implemented in Zambia in general and in PAMO-supported provinces in particular. Additional training was provided to help media personnel adequately facilitate airing of malaria radio jingles and discussion programs.

PAMO, with support of the 19 radio stations, has continued to air radio spots as a way of disseminating PAMO member of staff listens to a radio spot at one of the radio key messages on proven malaria interventions. So far stations to monitor the airing of the spots a total of 2,000 radio spots have been aired both in English and local languages (Bemba and Nyanja) for easy comprehension by the target audience. The radio spots focus on encouraging people to sleep under ITNs, seek malaria services early, and encourage pregnant women to seek early ANC and take their prescribed IPTp doses.

PRINTING OF SBC MATERIALS PAMO has printed SBC materials to support implementation of the champion communities’ initiative (see example in Figure 4). A total of 3,000 materials have been printed which include flip charts, job aids, quiz cards, stickers, wrist bands, and posters. These materials have been useful in sensitizing communities on key malaria interventions. Furthermore, materials such as job aids have been used to help community change champions to facilitate focus group discussions, health talks, and other community meetings on malaria.

Figure 4: Materials printed by PAMO.

COMMUNITY DIALOGUES To increase awareness and promote utilization of malaria services by community members, PAMO supported DHOs and health facility staff to conduct community dialogues in eight districts—Mbala in Northern Province, Vubwi in Eastern Province, Nchelenge and Chembe in Luapula Province, Chama in Muchinga Province, and Chadiza, Katete and Sinda in Eastern Province. The objective of community dialogues is to enable community members to have a conversation on how communities can adopt proven malaria interventions as a norm in their communities in order to eliminate malaria. To facilitate the dialogues, PAMO developed a community dialogue guide to be used by community malaria agents and health care workers to conduct a dialogue. Community members participate in a community dialogue in Mbala In the quarter under review, PAMO supported 70 community dialogues in eight districts holding ten dialogues in Chama, ten in Mbala, ten in Vubwi, four in Nchelenge, six in Chembe, ten in Chadiza, ten in Katete, and ten in Sinda. A total of 7,429 people (3,880 males and 3,372 females) participated in these dialogues as shown in Table 3.

Table 3: Number of people that have participated in community dialogues.

District Male Female Total Mbala 177 154 331 Vubwi 303 246 549 Nchelenge 95 98 193 Chembe 281 489 770 Chama 1,450 1,136 2,586 Pre-elimination districts 1,751 1,249 3,000 Totals 3,880 3,372 7,429

During the dialogue meetings, community members identified many barriers to malaria elimination they felt needed to be addressed: • Inadequate ITNs in the households. • Lack of adherence to malaria treatment. • Some community members sharing malaria drugs with family members leading to incomplete treatment. • Some structures going unsprayed during IRS campaigns. • HCWs sometimes running out of ACTs and RDTs to test and treat malaria at the community level. • The long distance to health facilities to access medical services. • Failure to use ITNs every night by some community members due to different reasons such as ITNs causing itching and difficulty breathing while under a net. • Abuse and misuse of ITNs by some community members. • Refusal of IRS due to a perceived increase in infestation of fleas, bedbugs, cockroaches, and mosquitoes after spraying. • Some pregnant women failing to only take one dose of SP for IPTp. • Late ANC booking, leading to pregnant women receiving SP late. • Late health seeking behavior by community members, especially children under five.

Participants at each of the community dialogues identified possible solutions to address these challenges and encouraged each other to ensure malaria is eliminated. Health care workers, local neighborhood health committee members, and traditional leaders assisted participants to explore actions that communities ought to take to contribute to eliminate malaria in their communities. Solutions recommended included: • Ensuring household heads encourage all members of the household to sleep under a net. • Ensuring malaria is treated within 24 hours of the onset of symptoms. • Pregnant women going for ANC within the first trimester of the pregnancy. • Allowing IRS in homes. • Keeping environments clean at all times.

Key recommendations were also made to the DHO and health facility staff to improve effective delivery of malaria services at community level. These include the need to engage traditional leaders and NHCs in planning for IRS campaigns and the need for awareness creation activities to share key malaria messages on prevention and treatment of malaria.

SCHOOL DIALOGUE TO SENSITIZE ADOLESCENTS ON ITN UTILIZATION AND OTHER MALARIA INTERVENTIONS To increase knowledge levels on malaria among school-going children, PAMO supported DHOs to hold school quiz competitions and debates in 20 schools (ten schools in Mbala district and ten in Nchelenge). In both districts, 4,195 students (1,959 girls and 2,236 boys) participated in the quiz comprising 2,595 students (1,344 males and 1,251 females) in Mbala District and 1,600 (892 males and 708 females) in Nchelenge. DHOs in collaboration with District Education Boards identified schools around high burden health facilities to participate in the quiz. DHOs utilized the malaria quiz cards developed by PAMO. Winners of the quiz received prizes which included exercise books, school bags, mathematical sets, and mosquito nets. All participating teachers and pupils were given Malaria Ends With Me stickers and wrist bands.

PAMO also supported MOGE to conduct debates on malaria. The debates took place in Vubwi District in 12 schools and were held over a three-day period during which 10 students per school debated various motions (Table 4).

Table 4: Motions debated by students on key malaria interventions in Vubwi district.

MOTION FOR AGAINST 1 Is it possible to eliminate malaria in Vubwi District Mbozi Primary Zozwe Primary by 2021? 2 Is malaria a killer disease in Zambia? Vubwi Primary Mzigawa Primary 3 Is malaria treatment easily accessible in Vubwi Mbande Primary Chigwe Primary District? 4 Is the distribution of insecticide treated nets to Zozwe Day Mbande Day communities a colossal misuse of resources? 5 Is conducting indoor residual spraying a sheer Mbozi Day Chigwe Day waste of resources in Zambia? 6 Will malaria prevention and elimination strategy Vubwi Day Matemba Day aid to elimination malaria in Zambia

At the end of the debate session, a member of staff from the DHO summarized key messages under each motion and also clarified any myths and misconceptions on key malaria interventions, particularly on ITNs, IRS, and malaria test and treat services. The competition revealed that knowledge levels on malaria were low among some school-going

17 children and therefore the debates provided an opportunity to increase knowledge and encourage young people to uptake and use proven malaria interventions.

PARTICIPATION AT THE RBM INTERNATIONAL CONFERENCE The RBM Partnership to End Malaria held its fifth SBC annual meeting in Maputo in Mozambique from September 10–12, 2019, which was attended by participants from 28 countries. PAMO’s SBC specialist presented a poster focusing on sharing lessons and the experience PAMO has gained in the use of the Champion Community Initiative (CCI) approach in pre-elimination districts. CCI is an innovative community engagement approach that harnesses community leadership and fosters community participation in identifying malaria issues, develops interventions and targets to address those issues, and sets actions to resolve them. Upon reaching their targets, the community is celebrated as a champion community. Several conference attendees viewed the poster and expressed interest in the CCI approach.

PAMO staff also met with the PMI SBC specialist (pictured, right) based at the US Centers for Disease Control and Prevention, who expressed enthusiasm for PAMO’s efforts in advancing SBC strategies in Zambia.

PAMO staff (left) with PMI SBC specialist (right) during the RBM partnership meeting in Maputo, Mozambique.

TASK 1.5: STRENGTHEN MALARIA POLICIES AND GUIDELINES

PARTICIPATION IN MID-TERM EXPENDITURE FRAMEWORK MEETINGS At the national level and in all four PAMO-supported provinces, the PAMO teams participated in the national and provincial level mid-term expenditure framework (MTEF) meetings held in August 2019. The objective of these annual meetings are to launch the annual MTEF, review the performance of the respective province, and disseminate MOH technical updates to guide the finalization of the MTEF plans. PAMO’s role in these meetings was to provide technical support to the MOH at various levels.

MALARIA SCORECARD ORIENTATION MEETING IN NORTHERN PROVINCE With multiple partners supporting the MOH’s efforts to achieve its goal of eliminating malaria, a need was identified to develop an online harmonized work plan platform and a malaria scorecard to track progress. The NMEP, with support from PAMO through the Senior Advisor for Policy, Strategy and Management, has developed the online platform. At the national level, the tool enables the NMEC to make decisions based on data, while at the local level it permits provincial and district offices to input their interventions and visualize their progress toward achieving set targets. The information in the malaria scorecard is used for decision-making. In 2019, PAMO planned to train provincial and district health officials in all four target provinces in the use of the harmonized work plan and malaria scorecard. In quarters one and two of 2019, PAMO trained MOH staff in Eastern, Luapula, and Muchinga provinces and now in the third quarter PAMO has trained staff in Muchinga Province, completing its target. In Northern Province, PAMO trained PHO staff and district health directors, district information officers, and malaria focal point persons from Kasama, Senga, and Mbala on how to update the information in the online work plan and how to track their performance through the malaria scorecard. They were also trained on how to use the malaria scorecard for their district and provincial planning for malaria programs. As was done in the other three provinces, the PHO and district staff that attended the training will then orient their counterparts in other districts to ensure that all the districts in the province are not only knowledgeable about the system, but are able to use it regularly.

At the district level, besides MOH staff, PAMO also oriented two community-based organizations contracted by PAMO and are implementing malaria SBC activities to ensure that their SBC plans are included in the district plans so they can be included in the online harmonized national work plan.

FINALIZATION OF THE MIDTERM REVIEW REPORT In 2019, the NMEP conducted a mid-term review (MTR) of the NMESP 2017–2021. PAMO provided technical and logistical support to the NMEP to finalize the report. A three-day meeting was held from September 11 to 13 where a smaller team comprised of staff from NMEC, WHO, PAMO, and MACEPA met to complete the report.

The key lessons learnt from the MTR are: • Significant progress was made in reducing malaria mortality from 15.2 per 100,000 population in 2015 to 7 per 100,000 population in 2018, exceeding the target which was set at 9 per 100,000. Following an upsurge experienced in 2016, progress has been made in reducing malaria incidence from 382 per 1000 population in 2016 to 311 per 1,000 in 2018. However, this fell short of the target of 191 per 1,000 in 2018. The reliability of both incidence and mortality rate indicators are somewhat hampered by challenges with population denominators which are known to often have discrepancies between official census estimates and local head counts conducted by health officials. • The National Malaria Elimination Business Plan 2018–2020 estimated a gap of approximately US$100 million. The drivers were iCCM and MDA (Business Plan). During the period under review, malaria funding both from government and partners has shown some increase but the resource gap for achieving the goals remains. • The NMEP has achieved milestones for vector control (2017 and 2018) as outlined on page 37 of the NMESP. The percentage of households with at least one ITN and/or sprayed by IRS in the last 12 months increased from 78% in 2015 to 84% in 2018 (MIS 2018). The NMEP also managed to implement a ITNs mass distribution campaign as planned, maintained coverage, and piloted and rolled out school-based distribution. However, reporting of routine distribution of ITNs continues to be suboptimal. • The milestones for case management as per NMESP were achieved; however, this was not the case for malaria in pregnancy (challenges still remain with the availability of SP) and MDA (NMESP). The NMEP has also built capacity for case management at community level but saturation has not yet been achieved (NMESP). In addition, the rollout of pre-referral treatment using rectal artesunate has commenced. • There has been steady and good progress made in SBC; however, there is a need to understand lack of progress in prompt care-seeking behavior. • For surveillance, monitoring, evaluation, and operations research, the MTR found that enhanced surveillance has been rolled out but not to scale. Population denominators are negatively affecting stratification, which guides the planning of key interventions.

TASK 1.6: SUPPORT CIVIL SOCIETY ORGANIZATIONS AND COMMUNITY-BASED ORGANIZATIONS TO IMPLEMENT MALARIA CONTROL ACTIVITIES

MONITORING AND SUPERVISION OF CIVIL SOCIETY ORGANISATIONS AND COMMUNITY CHANGE AGENTS PAMO has contracted 17 CSOs who are implementing SBC activities in 23 PAMO-supported districts. The aim of the monitoring activities was not only to check on the quality of the SBC activities being carried out at community level but also to ascertain community involvement in all activities and CSO collaboration with DHOs and health facility staff. The visits were also an opportunity to verify the data sent in the monthly reports and to monitor adherence to high standards of financial stewardship. PAMO staff worked in conjunction with the DHO staff to conduct three monitoring visits—one each month in the quarter, during which additional communication materials including t-shirts, flip charts, quiz cards and ITN brochures were distributed to each community-based organization for onward use in the community. The team also re-oriented the CSOs on how to document success stories and emphasized the need for regular reporting by community change champion and malaria agents that they work with.

To ensure NMEC involvement in CSO support, PAMO in the third quarter supported a special monitoring visit by the NMEC staff and the PHO staff to all the four provinces to familiarize themselves with the SBC activities implemented by CSOs. During the visit, the NMEC and PHO staff reviewed CSO scopes of work and checked on the progress CSOs have made in accomplishing their work plans. They also visited communities to witness community activities, particularly community dialogues, school quizzes, and work done by community malaria agents and community champions.

Additionally, the USAID/PMI PAMO activity manager visited the pre-elimination districts to monitor activities

19 implemented there. This included visits to the health facility to check on outcomes of OTSS, community field visits to see the how CHWs are implementing iCCM, a visit to the CCI initiative to see how community volunteers conduct household level education on uptake and use of proven malaria interventions. He also interacted with DHO staff and community volunteers to understand the needs of the malaria program in their respective districts.

ONSITE MENTORSHIP AND CAPACITY STRENGTHENING OF CSOS AND COMMUNITY CHANGE AGENTS.

To enhance uptake and use of proven malaria interventions at community level, PAMO has trained and deployed community malaria agents, whose role is to educate the community on malaria elimination strategies. To empower community malaria agents with accurate information on malaria, PAMO developed a flip book—a job aid containing accurate information on malaria—to be used during community education activities. PAMO also developed reporting tools to ensure that community malaria agents accurately report on their activities.

In the third quarter, PAMO oriented 393 community malaria agents on how to use the flip book and the use of data collection tools in Northern Province in Senga, Mungwi, and Kasama districts; in Eastern Province in Chipata and Vubwi districts; and in pre-elimination districts of Sinda, Community Malaria Agents being oriented by PAMO staff to the use of Katete, and Chipata. reporting tools for effective reporting of their activities Consistent monitoring and mentorship visits have contributed to an improvement in reporting, effective implementation of SBC activities at household level, and improved reporting by community champions.

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 PAMO’s second objective focuses on strengthening the management capacity of provincial and district managers to effectively manage malaria elimination programs.

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 has worked 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. During this quarter no activities were implemented because the project targets were achieved by the end of the second quarter.

However, PAMO supported the second Provincial Integrated Meeting in Muchinga Province, which was held in Nakonde District. During this meeting, key malaria performance indicators that measure performance on incidence rate and case fatality rates were discussed. Furthermore, at this meeting, PAMO’s support to CSOs was acknowledged by the province. The CSOs’ contributions in Mpika, Isoka, Chinsali, and Mafinga have been well-received and appreciated by the PHO.

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

TASK 3.1: PROVIDE TECHNICAL/MATERIAL ASSISTANCE TO DHOS, HEALTH FACILITIES AND COMMUNITIES TO IMPROVE THE TIMELINESS AND ACCURACY OF HMIS REPORTING

MALARIA DATA AUDITS IN THE PRE-ELIMINATION DISTRICTS In its quest to improve data quality for better decision-making, both at district and health facility level, in pre-elimination districts, PAMO supported malaria data audits in 118 health facilities from August 12–20, 2019. To track progress, the team of data auditors went to the same health facilities that were audited in December 2018 at the onset of the first year of the pre-elimination program that included health facilities from Chipata and Petauke which currently are not part of the pre-elimination districts. The breakdown of the number of health facilities visited in each district is: 16 in Petauke, 23 in Chipata, 24 in Sinda, 33 in Katete, and 22 in Chadiza. The audit team comprised staff from NMEC, PHO, and DHO from across Eastern Province and PAMO staff. DHO staff were swapped to avoid them from auditing their own facilities. The main objectives of the audit were: (1) to determine the quality of data reported at facility level, (2) to identify potential gaps or weaknesses in data collection and reporting, (3) to review that information in the data collection source documents (OPD, IPD, tally sheets) tally with the information reported in the HMIS system, (4) to learn of challenges in data management, and (5) to share lessons learned and find solutions to identified gaps.

In conducting the audit at each health facility, the audit team used the following registers: RDT register, Blood slide register (at facilities that perform microscopy tests), Out-patient department register, HIA1 and HIA2 forms, and the CHW registers as source documents. They then compared the information in these registers with the information that is stored on the HMIS system as reported by each health facility to measure five data quality indicators: • Reporting rates: Measures whether health facilities reported every month in the last six months. • Data accuracy month: The percent of months for which all data elements were reported accurately into the HMIS.

• Accuracy data element: The percent of all data elements reported accurately into the HMIS. • Completeness: The percent of months for which there were no data elements missing in HMIS reports. • Timeliness: The percent of months for which data were reported into the HMIS by the due date.

In pre-elimination districts, the reporting rate has remained at 100%, which means all health facilities are sending in their reports every month. Data accuracy monthly has improved from 2% in 2018 to 26% in 2019 and accuracy on data elements improved from 49% at baseline in 2018 to 74% during the follow-on data quality audit (DQA) (Figure 5).

Although improvements have been recorded, more needs to be done to strengthen data quality at health facilities and PAMO will continue to support DHOs and PHOs to mentor health care workers in health facilities to ensure they are adhering to reporting standards so that accurate information is recorded to enable effective decision-making.

Figure 5: Results of data quality audits in pre-elimination districts.

120% 100% 100% 99% 100% 93% 80% 74% 70% 60% 49%

40% 26% 20% 14% 2%

2018 (Baseline) 2018 (Baseline) 2018 (Baseline) 2018 (Baseline) 2018 (Baseline) 2018

2019 (Follow-on) 2019 (Follow-on) 2019 (Follow-on) 2019 (Follow-on) 2019 (Follow-on) 2019 Reporting rates Data Accuracy Accuracy Data Data Completeness Timeliness Monthly Element

The general observations after the DQA are that health facilities find DQAs helpful to strengthen their ability to report accurately and expressed interest to see improvements in the next round of DQAs; using data from the HMIS system, some facilities are displaying the graphs and other statistics on malaria trends in their health facility to help with planning and some facilities had poor record keeping with some source documents missing or not well maintained.

TASK 3.2: ASSIST WITH TRAINING FOR THE ROLL OUT OF DHIS2 IN THE TARGETED PROVINCES AND DISTRICTS. In the year four work plan, PAMO targeted to train 161 MOH staff in health management information systems (HMIS). PAMO has been working with PHO and DHOs to conduct training to train district health information officers, district health planners and health facility staff to strengthen their ability to report, analyze and use malaria data for decision making. PAMO in conjunction with PHO and DHO’s selected staff to be trained through a rapid needs assessment which was conducted by PAMO in the first quarter of 2019. The aim of HMIS training is to strengthen staff abilities to report, analyze and use data for decision making. After the training, staff are expected to effectively use the recommended data capturing approaches and use recommended source documents for routine and periodic reporting. During this quarter, PAMO carried out the last training sessions in Muchinga and Northern provinces. Training in these two provinces, means PAMO has now completed all planned HMIS training for 2019. The cumulative results are shown in Table 5 below.

Table 5: Number of MOH staff trained in HMIS

Achievement Geographic Location Target % achieved Male Female Total

Eastern 1 (Main) 25 16 9 25 100%

Luapula 25 14 11 25 100%

Muchinga 25 16 9 25 100% Northern 25 14 11 25 100%

Eastern 2 61 43 24 67 109% (pre-elimination) Total 161 103 64 167 103%

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. PAMO supported a second round of malaria data reviews in pre-elimination districts. Participants in the reviews were environmental health technicians (EHTs) and health facility in-charges from all health facilities in Chadiza, Katete, and Sinda districts. Data CHWs from all facilities were also invited for a one-day meeting at a separate venue to review their registers and troubleshoot phone problems. Facility staff presented their data to the group and this was followed by a plenary session where questions and clarifications were asked regarding the presentation.

During the review meeting it was discovered that some facilities still had a high number of cases while others reported low cases. Facilities bordering other districts such Nyaluwiro on the Petauke border reported high incident rates compared to others not along the border, indicating a high number of malaria cases from Mozambique. The facilities along border areas have been advised to keep track through registers of foreign cases versus local cases. The following were noted as successes: • Facilities owned and understood their data. • Lessons were learned from each other and best practices were adopted. • Districts noted facilities that required more support and close supervision. • Data CHW challenges and concerns were addressed. It was discovered that some facility staff and Data CHWs had problems with sending reports due to phone challenges. The PAMO surveillance team is working on addressing the problems with the phones.

PROGRESS ON SOME SELECTED INDICATORS IN PAMO SUPPORTED PROVINCES As part of the support to strengthen the use of data, PAMO works with provincial and district health information officers to collate and analyze information from the HMIS and share it with the provincial and district health management teams to enhance decision-making on malaria interventions and plans. Below is a report of two indicators—clinical malaria and malaria incidence in all provinces.

Clinical malaria cases PAMO is observing a reduction in clinical malaria cases (Figure 6). This trend is positive and ought to be accelerated in order to further reduce the clinical malaria cases. Reduced clinical malaria cases imply that there is a reduction in presumptive treatment and an increase in testing of suspected cases to ensure prudent use of ACTs.

Figure 6: Trend in clinical Malaria cases in PAMO supported provinces.

3,000,000 2,540,551 2,425,649 2,271,621 2,500,000 2,134,330 1,960,408 2,000,000

1,500,000

1,000,000 557,634 399,360 500,000 293,326 64,108 113,340 0 2015 2016 2017 2018 2019

Malaria Clinical Cases Malaria Confirmed Cases

Malaria incidence in PAMO supported provinces Monitoring the incidence of malaria is essential to tracking progress toward malaria elimination. PAMO has continued to support PHOs and DHOs to regularly track data on malaria incidence at provincial, district, and health facility levels to enable informed decisions on what ought to be done to further drive incidence rates down toward pre-elimination and then to elimination. Although incidence shows a downward trend in four PAMO-supported districts (Figure 7), it still remains a concern. There is therefore a need to continue implementing proven interventions in all four provinces to further reduce malaria incidence.

Figure 7: Trends in malaria incidence in PAMO-supported provinces.

700

600 610

500 397 429

347 404 400 396 344 350 300 307 295

200

100

0 2015 2016 2017 2018 2019

Eastern Province Luapula Province Muchinga Province Northern Province Average for the four provinces

SUCCESS STORY

Village headman brings malaria services closer to his people

It is a Monday morning. Jealous Kankomba, headman for Kaputo village in Nchelenge district of Luapula province, is preparing to attend to his third client, a 40 year old man, who says has not been feeling well the last few days. He feels weak and is unable to walk all the way to Kefulwa rural health centre - 5 Kms away from his village. If he has malaria and is not treated immediately he could die. Many people in Zambia still die from malaria mainly because of delayed diagnosis and treatment. To ensure that malaria diagnosis and treatment is close to people’s homes, PAMO has supported the Ministry of Health to train community health workers (CHWs) to provide integrated community case management of malaria at community level. Jealous, whose village has 188 households with an estimated population of 1,395, is one of the 276 trained CHWs in Nchelenge district. Born in 1964, he is providing malaria services to residents in his village.

“When the PAMO project came, I was asked to volunteer and be trained as a CHW. I did not hesitate. I am very happy that I am a traditional leader and a community health care worker at the same time because my focus is helping my people to be healthy and prosper.” Jealous says.

A peasant farmer growing cassava and maize, he is known in his community as “ba doctor” because of his skill, availability, and ability to diagnose and treat malaria just like health care workers at health facilities do. On a daily basis he provides malaria services mainly at his home. On average he attends to 80 to 100 clients every month who go to his house to seek services.

“People come to my house sometimes even at night. I could be asleep and I just hear a knock; it could be a woman asking for help as the child has a fever and is crying. I just wake up and assist them. I am very lucky that my family supports me a lot in this work and it gives me a lot of satisfaction to assist others this way.”

Between July and September 2019 he tested 303 people that went to his house seeking services out of which 147 tested positive and he provided treatment to all of them. Besides treating people at home, once every month, Jealous identifies up to five index cases (people that he tested positive for malaria) and follows them up to their homes. While there, he tests their family members and neighbors. Among those he found positive he followed up 6 index cases and visited a total of 116 households and 362 people out of which 134 were found with malaria. He provided malaria treatment to all them. To sustain his work, Kefulwa rural health centre regularly provides him with rapid diagnostic tests (RDTs) and Artemisinin combination therapy (ACT) for malaria diagnosis and treatment.

Jealous is optimistic about eliminating malaria. Living in Nchelenge a high burden malaria district with 355 malaria cases in a 1000 population in 2018, he thinks that one day malaria will be eliminated.

“Here, where we live,” he explains, “malaria is very high. A lot of people suffer from it. But I am confident that with the programs we are implementing now we can reduce malaria and hopefully one day we will only remember that there was a disease called malaria in Zambia.”