The PMI Vectorlink Zambia 2020 End of Spray Report

THE PMI VECTORLINK PROJECT ZAMBIA

2020 END OF SPRAY REPORT

SPRAY CAMPAIGN: SEPTEMBER 29-NOVEMBER 18, 2020 Recommended Citation: The President’s Malaria Initiative (PMI)/VectorLink Project. Zambia 2020 End of Spray Report. Rockville, MD. The PMI VectorLink Project, Abt Associates. Contract: AID-OAA-I-17-00008 Task Order: AID-OAA-TO-17-00027 Submitted to: United States Agency for International Development/PMI Submitted on: December 22, 2020 Approved on: March 1, 2021

Abt Associates | 6130 Executive Blvd | Rockville, Maryland 20852 T. 301.347.5000 abtassociates.com

The views expressed in this document do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

THE PMI VECTORLINK PROJECT ZAMBIA END OF SPRAY REPORT SEPTEMBER 29–NOVEMBER 18, 2020

CONTENTS

Acronyms ...... iii Executive Summary ...... iv 1. Country Background ...... 1 2. Implementation of IRS Activities ...... 4 2.1 IRS Planning and Partner Collaboration ...... 4 2.1.1 Pre-Spray Planning Activities ...... 5 2.2 Training ...... 7 2.3 Spray Operations and Supervision ...... 7 2.3.1 Operations ...... 7 2.3.2 Supervision ...... 9 2.3.3 Operations Sites ...... 10 2.3.4 Community-based IRS ...... 10 2.3.5 Payment of Spray Personnel ...... 12 2.3.6 Procurement ...... 12 2.4 Insecticide Stock Management ...... 13 2.5 Information, Education, and Communication and Social Behavior Change Communication Activities and Results ...... 13 2.5.1 Advocacy Meetings with Chiefs and Influential Community Leaders ...... 14 2.5.2 Community Mobilization ...... 14 2.5.3 Print and Mass Media Communication ...... 15 2.5.4 Success Stories ...... 15 2.6 Post-Spray Activities ...... 15 2.6.1 Inventory Assessment and Demobilization ...... 15 2.6.2 Post-Spray Review Meetings ...... 15 2.7 Capacity-Building Efforts ...... 16 2.8 Gender Mainstreaming...... 17 3. Entomology ...... 18 3.1 Insecticide Susceptibility Tests ...... 18 3.2 IRS Spray Quality Assessment ...... 19 3.3 Residual Efficacy ...... 20 4. Environmental and Safety Compliance ...... 22 4.1 IRS Campaign Assessments and Preparations ...... 22 4.2 Incident Reports ...... 23 4.3 Demobilization and Waste Management ...... 24 4.4 COVID-19 Mitigation Efforts ...... 24 5. Monitoring and Evaluation ...... 25 5.1 Data Collection, Entry, and Quality Assurance ...... 25 5.1.1 Data Collection using Reveal ...... 25 5.1.2 Data Collection Verification ...... 26 5.2 mHealth Implementation ...... 26 5.3 IRS Campaign Results ...... 26

i 6. Challenges, Lessons Learned, and Key Recommendations ...... 29 6.1 Challenges ...... 29 6.2 Lessons Learned ...... 30 6.3 Recommendations ...... 32 Annex A: M&E Plan ...... 34 Annex B: 2020 Environmental Mitigation and Monitoring Report ...... 52 Annex C: Success Stories ...... 58

LIST OF TABLES

Table 1: USAID and PMI Support for IRS in Zambia, 2006 to 2020 ...... 1 Table 2: PMI VectorLink Zambia Partners ...... 5 Table 3: Targeted Catchment Areas by District ...... 6 Table 4: Number and Type of Full-Time GRZ and Seasonal Workers Trained, by Gender ...... 7 Table 5: Number of Seasonal Workers Hired to Support IRS Disaggregated by Gender...... 10 Table 6: Cost Analysis of Community-Based and Quasi-Community Based IRS ...... 11 Table 7: Insecticide Consumption in 2020, by Province ...... 13 Table 8: 2020 PMI VectorLink Zambia Incident Report Summary ...... 23 Table 9: Summary of 2020 PMI VectorLink IRS Campaign ...... 27 Table 10: Provincial Spray Progress and Coverage ...... 27 Table 11: District-level Spray Progress and Coverage ...... 27 Table 12: Reasons for Not Spraying Targeted Structures ...... 28

LIST OF FIGURES

Figure 1: PMI VectorLink-Supported IRS Provinces and Districts in 2020 ...... 3 Figure 2: Susceptibility Status of An. funestus s.l. and An. gambiae s.l. to Clothianidin, Chlorfenapyr, DDT, and Deltamethrin at PMI VectorLink Entomological Monitoring Sites, 2020 ...... 19 Figure 3: Mortality of An. gambiae s.s. Kisumu Susceptible Strain after Exposure to Fludora Fusion in Select Districts in the 2020 Campaign ...... 20 Figure 4: Mortality of An. gambiae s.s. Kisumu Susceptible Strain after Exposure to SumiShield in Select Districts in the 2020 campaign ...... 21

ACRONYMS

AIRS Africa Indoor Residual Spraying Project BMP Best Management Practices DCV Data Collection Verification form DDT Dichlorodiphenyltrichloroethane DEC Data Entry Clerk DHIS2 District Health Information System 2 DHO District Health Office ECO Environmental Compliance Officer EHT Environmental Health Technician GRZ Government of the Republic of Zambia HFCA Health Facility Catchment Area HLC Human Landing Catch ICEMR International Centers of Excellence in Malaria Research IEC Information, Education, and Communication IRS Indoor Residual Spraying ITN Insecticide-treated net M&E Monitoring and Evaluation METF Malaria Elimination Task Force MOH Ministry of Health MSP Mobile Soak Pit NHC Neighborhood Health Committee NGenIRS Next Generation IRS NMEP National Malaria Elimination Program PHO Provincial Health Office PMI President’s Malaria Initiative PMT Performance Monitoring Tracker PPE Personal Protective Equipment PSI Population Services International SBCC Social Behavior Change Communication SOP Spray Operator TDRC Tropical Disease Research Center TOT Training of Trainers TLA Team Leader Assistant USAID United States Agency for International Development WHO World Health Organization ZAMRA Zambia Medicines Regulatory Authority ZEMA Zambia Environmental Management Agency

iii EXECUTIVE SUMMARY

The U.S. President’s Malaria Initiative (PMI) has supported the implementation of indoor residual spraying (IRS) in Zambia since 2008. The PMI VectorLink Project, implemented by Abt Associates, is the current mechanism through which the United States Agency for International Development (USAID) funds IRS in Zambia. VectorLink Zambia conducted its 2020 IRS campaign from September 29 to November 18, 2020. The project targeted a total of 639,536 structures (later adjusted to 629,2551) in nine districts in Eastern Province, three districts in Copperbelt Province, and three districts in Luapula Province. The project used SumiShield 50WG (the neonicotinoid, clothianidin) in six districts in Eastern Province (Chipata, Lundazi, Mambwe, Nyimba, Petauke, and Vubwi) and Fludora Fusion (clothianidin and deltamethrin) in Copperbelt and Luapula Provinces and the remaining three districts in Eastern (Chadiza, Katete, and Sinda). Project achievements during the 2020 spray campaign included: • Sprayed 648,914 structures out of 672,581 structures found by spray operators (SOPs), resulting in 97% spray coverage. Protected 2,776,336 people, including 391,438 children under 5 years and 73,959 pregnant women. • Overall, 14,766 people were trained; 2,576 fell under the PMI criteria of those trained using USG funds, which only counts Spray Operators, Team Leaders, Supervisors, and Team Leader Assistants (TLAs). Females accounted for 43% of all staff hired to deliver IRS and 35% of supervisory positions. • Used 91,426 sachets of SumiShield to spray 331,325 structures in six districts in Eastern Province (3.6 structures per sachet) and 90,512 sachets of Fludora Fusion to spray 111,714 structures in three districts in Eastern Province, 100,651 structures in Copperbelt Province, and 105,224 structures in Luapula (3.5 structures per sachet). • Conducted wall bioassays within 24–48 hours of spraying and recorded 100% mortality of susceptible An. gambiae (Kisumu strain) on all wall surface types sprayed with both insecticides, signifying a high-quality spray. • Provided technical assistance to the NMEP in various aspects, including IRS monitoring and supervision in the seven urbanized Copperbelt districts, environmental compliance training, monitoring and supervision of dichlorodiphenyltrichloroethane (DDT) use in Northern, Muchinga, and Luapula Provinces, quality of spray assessment in three DDT districts, and procurement of sprayers and personal protective equipment (PPE). The project will dispose of all IRS wastes (empty insecticide sachets, used nose masks, damaged gloves, boots, and used plastic sheets) according to PMI best management practices (BMP) and Zambia Environment Management Agency (ZEMA) regulations.

1 This adjustment was based on the need to remove small floating islands located in Lake Mweru that constituted 5,607 structures, as well as documented ineligible structures in Nchelenge made of non-sprayable materials such as straw, sacks, and iron sheets.

1. COUNTRY BACKGROUND

USAID began funding indoor residual spraying (IRS) activities in Zambia in 2006. In 2008, the U.S. President’s Malaria Initiative (PMI) started supporting IRS in Zambia, covering 15 districts across four provinces. In 2011, following delays in World Bank funding for district IRS operations, PMI bridged the gap and funded IRS in 25 high-malaria burden districts. From 2012 to 2013, PMI focused its support in 20 districts in three provinces with the highest malaria incidence, targeting an estimated 530,000 structures (13 districts in Northern and Muchinga Provinces which were sprayed with bendiocarb and seven districts sprayed with Actellic). However, due to limited resources, the 13 districts did not receive the second spray round of bendiocarb as planned. The country switched to targeted spraying in 2014 to prioritize coverage of high-risk areas in 40 high-burden malaria districts, in line with Zambia’s 2011–2016 National Malaria Strategic Plan. These 40 districts included 15 districts in Luapula and Central Provinces which were funded by the United Kingdom’s Department for International Development. From 2016-2019, PMI IRS programs in Zambia benefited from Next Generation IRS (NGenIRS)/Unitaid co-funding, allowing the project to support IRS in 35 districts across Eastern, Luapula, Muchinga, and Northern Provinces. In 2017, the government officially launched the National Malaria Elimination Strategic Plan 2017–2021, which aims to transition Zambia from malaria control to malaria elimination. In the same year, PMI, the PMI-funded Africa Indoor Residual Spraying project (AIRS)/Zambia, and the Zambia Ministry of Health (MOH) agreed to continue IRS in the same 36 high-burden districts across Eastern, Luapula, Muchinga, and Northern Provinces (one district, Mbala, was split into two, which brought the total to 36 districts in 2017). In the 2017 campaign, AIRS Zambia sprayed 634,410 structures out of 676,188 structures found. In 2018, PMI VectorLink, together with Zambia’s National Malaria Elimination Program (NMEP), supported IRS in Northern, Luapula and Muchinga Provinces and three pre-elimination districts (Chadiza, Katete, and Sinda) in Eastern Province. In 2019, VectorLink sprayed 536,983 structures out of 598,732 structures found and provided technical assistance to the NMEP on the management of dichlorodiphenyltrichloroethane (DDT) in IRS districts previously supported by PMI in Northern, Muchinga, and Luapula Provinces. Table 1 provides a summary of USAID and PMI support for IRS in Zambia from 2006 to 2020. It is important to note that malaria burden in Zambia follows a pattern that is influenced by rainfall, temperature, and other environmental factors. The burden is lowest from June to August when the temperatures are low (average of 5°C) and highest from November to April when it is wet and the temperatures are high (average of 30°C). Because of this, timing of IRS is planned as close to the rainy season as possible before the proliferation of mosquito larval development sites due to the rains.

Table 1: USAID and PMI Support for IRS in Zambia, 2006 to 2020 # of # of USAID # of PMI # of Structures Persons Supported Supported Year Sprayed Protected Districts Districts Insecticide Used 2006 537,877 — 15 — DDT and pyrethroids 2007 657,219 — 15 — DDT and pyrethroids 2008 1,039,154 — 36 3 DDT and pyrethroids 2009 1,191,517 — — 36 DDT and pyrethroids 2010 740,699 2,721,166 — 25 DDT and pyrethroids 2011 814,706 3,351,158 — 35 Carbamates and pyrethroids 2012 460,358 1,710,833 — 20 Carbamates and organophosphates 2013 432,398 1,842,821 — 20 Organophosphates 2014 409,544* 2,000,824 — 40 Organophosphates 2015 519,598* 2,544,290 — 39 Organophosphates

1 # of # of USAID # of PMI # of Structures Persons Supported Supported Year Sprayed Protected Districts Districts Insecticide Used 2016 559,550 2,626,718 — 35 Organophosphates 2017 634,410 3,005,878 — 36 Organophosphates 2018 491,873 2,504,775 — 26 Organophosphates 87,617 313,401 — 3 Neonicotinoids (SumiShield) Total 579,490 2,818,176 — 29 Organophosphates and Neonicotinoids 2019 383,183 1,519,927 — 9 Neonicotinoids (SumiShield) 153,800 753,261 — 11 Neonicotinoids (Fludora Fusion) Total 536,983 2,273,188 — 20 Neonicotinoids (SumiShield and Fludora Fusion) 2020 317,589 1,441,314 - 9 Neonicotinoids (Fludora Fusion) 331,325 1,335,022 - 6 Neonicotinoids (SumiShield) Total 648,914 2,776,336 - 15 Neonicotinoids (SumiShield and Fludora Fusion) *Includes PMI and DFID funded areas. In 2020, VectorLink targeted 639,536 structures for IRS in 15 districts—93,935 structures in the three rural districts in Copperbelt Province (Lufwanyama, Masaiti, and Mpongwe), 104,247 structures in three northern districts in Luapula Province (Chiengi, Kawambwa, and Nchelenge) and 427,6610 structures in nine districts in all of Eastern Province. Additionally, VectorLink provided technical assistance to NMEP in monitoring and supervision of IRS in the seven urbanized Copperbelt districts, environmental compliance training, monitoring and supervision of DDT use in Northern, Muchinga and Luapula Provinces, quality of spray assessment in three DDT districts and procurement of sprayers and PPE (see Section 2.7 for details). Figure 1 is a map of the PMI VectorLink-supported provinces and districts in 2020. VectorLink’s overall target was adjusted to 633,929 structures three weeks prior to the start of the campaign after removing small floating islands located in Lake Mweru that constituted 5,607 structures initially included in the target. These islands constitute temporary structures made from straw which usually get flooded during the rainy season. Additionally, during the campaign, the target was adjusted to 629,255 structures to remove 4,674 ineligible structures initially included in Nchelenge.

Figure 1: PMI VectorLink-Supported IRS Provinces and Districts in 2020

3 2. IMPLEMENTATION OF IRS ACTIVITIES 2.1 IRS PLANNING AND PARTNER COLLABORATION In 2020, VectorLink Zambia IRS activities fell under two broad categories: 1. Technical assistance to the NMEP and MOH, through support with environmental compliance training and supervision in the Government of the Republic of Zambia (GRZ) targeted DDT districts in Luapula, Muchinga, and Northern Provinces; support to the NMEP to procure selected IRS equipment; technical support with planning and implementing IRS in the seven urbanized Copperbelt districts (Ndola, Kitwe, Luanshya, Chingola, Chililabombwe, Mufulira and Kalulushi); and fostering public private partnerships in Copperbelt, particularly with Mopani and Konkola Copper Mines, and; 2. Implementation of IRS in the 15 targeted PMI-supported districts and entomological monitoring in seven targeted districts (see Figure 1). VectorLink Zambia provided technical assistance to the NMEP, provincial health offices (PHOs), and district health offices (DHOs) in all areas of IRS implementation in the 15 selected districts. VectorLink sprayed Nchelenge, Chiengi, and Kawambwa districts of Luapula Province under an agreement with the NMEP, whereby the GRZ provided Fludora Fusion left over from their 2019 Global Fund/GRZ-supported campaign, while VectorLink funded all operational costs. The 2020 campaign was planned for 30 operational days (September 29 to November 10). The campaign ran for 30 days in 14 of the 15 PMI-supported districts and for 35 days in Nchelenge District, due to challenges encountered (see Section 6 for details). Based on consultation with the NMEP and evidence-based guidance from the Insecticide Resistance Management Technical Working Group, VectorLink Zambia deployed SumiShield (a clothianidin-based insecticide) in six districts in Eastern Province and Fludora Fusion (clothianidin and deltamethrin) in Copperbelt Province, Luapula Province, and the three pre-elimination districts in Eastern Province. The project conducted blanket spraying in all districts except: (1) Katete and Chipata, where urban health facility catchment areas (HFCAs) were excluded due to high rates of refusal; (2) Mambwe and Petauke, where rural communities within the core protected game management area were excluded in line with environmental compliance guidelines; (3) Nyimba, where areas included in the World Health Organization (WHO)-funded AFROII2 vector control study as well as the remote area west of the Luangwa River were excluded; and (4) Chiengi, where some HFCAs will be sprayed by Kaputa district under the GRZ campaign (because of its close proximity). Consistent with the NMEP’s “mosaic” approach to vector control, each of these non-IRS areas were designated for ITN distributions in the 2020-21 mass campaign. Epidemiological and entomological research findings from the NIH-funded ICEMR research station in Nchelenge recommended expanding IRS coverage to include islands and the hinterland, to improve impact, and therefore VectorLink increased its IRS target in Nchelenge from 38,000 structures in 2019 to 48,945 structures in 2020. Additionally, epidemiologic and entomologic monitoring data collected since 2012 indicate limited impact of IRS to date (Hast et al, 2019). The target was later adjusted to 38,664 structures after removing ineligible structures (due to their straw building materials) in the hinterland. Based on the NMEP operational criteria, previous IRS campaigns typically excluded the islands of Kilwa and Chisenga as well as farming settlements in the hinterland. However, in 2020, these two islands were targeted for spray. The project subcontracted international partners BAO Systems, Dimagi LLC, PATH, and Population Services International (PSI). Locally, the project subcontracted Akros to support geospatial systems for planning,

2 The study aims to EVALUATE the impact of screening of doors in reducing the number of mosquitoes entering houses (http://afroii.icipe.org/).

targeting, and delivery of IRS in select districts. Other, non-contractual local partners included Tropical Disease Research Center (TDRC), ZEMA, the University of Zambia, Zambia Medicines Regulatory Authority (ZAMRA), and mining companies (Konkola and Mopani copper mines), as well as civic, community, and church leaders. Table 2 summarizes the roles of local and international partners.

Table 2: PMI VectorLink Zambia Partners Partner Role International Subcontractors Worked with the home office VectorLink M&E Specialists and Zambia M&E Team to ensure the system (VectorLink Collect database) met Zambia’s specific requirements. BAO Systems provided BAO Systems technical support to ensure that IRS and entomology data could be efficiently entered, synced, analyzed, and stored into the DHIS2-based VectorLink Collect database Implemented mHealth activities including mobile-based Performance Monitoring Tracker (PMT), Dimagi LLC smartphone-based spray supervision system, and bulk SMS job aids. Continued to provide technical assistance to NMEP for visualization development and data review to support vector control decision-making under the PMI VectorLink integrated data analytics and PATH visualization activity. To lead this activity, PATH hired and seconded a full-time Vector Control M&E Officer to strengthen the NMEP’s IRS and ITN data collection and management. Provided technical support on behalf of VectorLink to the NMEP to plan and implement the 2020 - PSI 2021 mass ITN distribution campaign. Local Subcontractors Supported IRS operations in Chadiza and Nchelenge districts through implementation of Reveal, a Akros tool which supports planning, targeting, and recording delivery of IRS activities in real time. Assisted with satellite-based enumeration and mapping in the other 13 operational districts. Local Partners Functioned as main partner in planning and management, implementation, supervision and NMEP/MOH monitoring of the program. ZEMA Ensured compliance with local Zambia environmental laws. ZAMRA Supported environmental compliance through incineration of IRS waste materials. University of Served as strategic partner on the IRS technical working group. Zambia Shared entomologic monitoring data with the Technical Working Group to support vector control TDRC decision-making, particularly in Nchelenge district in Luapula Province. Konkola and Engaged in joint IRS planning and training with VectorLink. Additionally, Mopani Copper Mines Mopani Copper supported environmental compliance through incineration of IRS waste materials from Luapula and Mines Copperbelt. Private sector Served as strategic partners on the IRS technical working group. Specific companies included First companies Quantum, Indeni Oil Refinery, Zambeef, and Zambia Sugar. Local and Helped increase acceptance of IRS in the community. traditional leaders

2.1.1 PRE-SPRAY PLANNING ACTIVITIES VectorLink worked closely with the NMEC and provincial and district health offices to carry out various pre- spray activities including geographical reconnaissance, structure enumeration, micro-planning meetings, stakeholder advocacy meetings, logistical needs assessments, data center assessments as well as recruitment and training of spray personnel. Since PMI VectorLink supported IRS on Chisenga and Kilwa islands in Nchelenge district for the first time this year, the team conducted geographical reconnaissance and pre-season environmental assessments of the two islands to ascertain the type of boats to be used, distance and time required to cross Lake Mweru to the islands, and to assess the presence of any sensitive receptors (areas where inhabitants are susceptible to the

5 adverse effects of pesticides), and determine the environmental compliance mitigation measures needed to conduct IRS on the islands. Additionally, the project undertook geographical reconnaissance in eight districts in Eastern Province (Chadiza, Chiengi, Chipata, Katete, Lundazi, Nyimba, Petauke, and Sinda), two districts in Copperbelt (Lufwanyama and Mpongwe), and Nchelenge (mainland) to inform the establishment of new operations sites required to improve operational efficiency. Three months prior to the campaign, VectorLink collaborated with the NMEP and held micro-planning meetings in each of the three target provinces. The meetings served to finalize district targets, fine-tune training plans, determine commodities and human resource needs, and discuss infrastructure, transportation, and management support for the campaign. Prior to the meeting, districts populated a microplanning template developed by the project highlighting communities that would be prioritized for either IRS or ITNs. Districts used the number of structures found during the 2019 spray campaign (for those districts where VectorLink sprayed) and updated/enumerated Reveal maps from Akros (for both new districts – Kawambwa and Chiengi and districts whose maps were last updated in 2017), to determine the number of target structures by catchment area. During the microplanning meetings, these maps (plus input from the districts based on physical count) served as the basis for estimating the final targeted structures. Additionally, VectorLink partnered with the PATH MACEPA project and Akros to support IRS districts and provided technical assistance on the use of GRID33 maps to inform decision-making during the microplanning process. Similarly, VectorLink shared a microplanning template with NMEP to use for IRS planning in non- PMI supported IRS districts. Table 3 shows 2020 targeted HFCAs per district.

Table 3: Targeted Catchment Areas by District Total Eligible Eligible Targeted Structures Eligible Structures in Structures in HFCAs per HFCAs per Reported by Structures in Targeted Non-Targeted District District District Districta District HFCAs HFCAsb Eastern 304 289 480,301 439,935 427,661 12,274 Chadiza 21 21 24,346 22,800 22,800 0 Chipata 68 64 131,662 124,632 122,297 2,335 Katete 34 31 47,195 33,977 32,392 1,585 Lundazi 54 54 86,460 78,344 78,344 0 Mambwe 21 19 22,929 22,715 22,215 500 Nyimba 21 19 29,205 27,810 21,545 6,265 Petauke 47 44 76,631 68,631 67,042 1,589 Sinda 26 26 50,732 50,332 50,332 0 Vubwi 12 12 11,141 10,694 10,694 0 Copperbelt 76 76 103,385 93,935 93,935 0 Lufwanyama 20 20 31,652 22,952 22,952 0 Masaiti 30 30 32,805 32,305 32,305 0 Mpongwe 26 26 38,928 38,678 38,678 0 Luapula 43 42 123,281 114,893 112,333 2,560 Chiengi 12 11 47,155 46,623 44,063 2,560 Kawambwa 16 16 29,271 24,932 24,932 0 Nchelenge 15 15 46,855 38,664 38,664 0

3 The Gates-funded GRID3 project made available, free-of-charge, a set of maps of all districts in the country which included fine-scale population and structure estimates. Akros provided technical assistance to produce and pilot customized maps that could inform Zambia’s joint IRS and ITN campaigns. All partners then collaborated in distribution the maps and training vector control planners at national, provincial and districts levels.

Total Eligible Eligible Targeted Structures Eligible Structures in Structures in HFCAs per HFCAs per Reported by Structures in Targeted Non-Targeted District District District Districta District HFCAs HFCAsb Grand Total 423 407 706,967 644,089 629,255 14,834 a Districts used head count population data to estimate total eligible structures. This data together with 2019 found structures and Reveal data was triangulated to arrive at the total structure estimate per district. b Based on discussions with districts and considering the NMEP criteria for IRS, certain HFCAs such as urban areas (Katete and Chipata) with very high refusal rates, and areas with scanty and dispersed structures such as farm blocks were not targeted. c In line with environmental compliance guidelines, HFCAs in Petauke and Mambwe that fall within the core game protected areas were not targeted due to environmental concerns.

2.2 TRAINING Before spray operations began, VectorLink Zambia collaborated with DHOs to train personnel involved in IRS. Table 4 lists the personnel trained in different categories disaggregated by gender and training duration. Additionally, in July 2020, VectorLink conducted a capacity building workshop for Copperbelt IRS managers and national level master trainers focusing on standard IRS protocol in planning and implementation. The workshop was designed to address challenges encountered during the 2019 spray campaign, which were largely associated with legacy issues on household preparation. In addition to classroom-style sessions, participants got hands-on experience with adequate house preparation for IRS during a ‘live fire’ field simulation. The daylong field simulation was designed to mimic an operational day during the campaign, and included morning mobilization, data collection, and end-of-day clean-up activities.

Table 4: Number and Type of Full-Time GRZ and Seasonal Workers Trained, by Gender Category Duration of Training Males Females Total (% Female) Supervisors 5 days 114 61 175 (35%) Mobilizers 1 day 6,232 4,513 10,745 (42%) SOPs 5 days 1,091 858 1,949 (44%) Team leaders 5 days 227 157 384 (41%) Team leader assistants 5 days 47 21 68 (31%) Data entry clerks 2 days 58 43 101 (42%) M&E assistants 1 days 56 15 71 (21%) Storekeepers 2 days 38 62 100 (62%) Sprayer technicians 2 days 70 0 70 (0%) Washers 1 day 36 66 102 (65%) TOTAL 7,969 5,796 13,765 (42%)

2.3 SPRAY OPERATIONS AND SUPERVISION 2.3.1 OPERATIONS In 2020, the PMI VectorLink-supported spray campaign started on Tuesday, September 29 and was scheduled to end on Tuesday, November 10. All districts except for Nchelenge concluded on time. Due to operational challenges largely occasioned by deviation from the spray calendar, non-tagging of structures, and delayed provision of the Nchelenge base map, the team recorded lower-than-expected daily progress in Nchelenge leading to the extension of the campaign there for five operational days and two extra days for data capture on structures that were visited but not tagged in the Reveal system due to a system malfunction. Therefore, spray operations in Nchelenge ended on November 18, and data capture on November 20, 2020. To deliver IRS, the project implemented three IRS technical approaches for spray team deployment to maximize cost savings, efficiency, and sustainability, and given the different topographies in the target districts: 1) Centralized or district-based which involved spray teams departing from a centrally located operations site

7 to spray areas in vehicles; 2) Community-based IRS which involved use of bicycles for the entire duration of the spray campaign and; 3) Quasi-community-based which involved use of bicycles within 10km radius from the operations sites during the last eight days on average. The project implemented a centralized IRS approach in seven districts (Chipata, Katete, Lufwanyama, Masaiti, Mpongwe, Nyimba, and Vubwi), quasi-community- based IRS in seven districts (Chadiza, Chiengi, Kawambwa, Lundazi, Mambwe, Nchelenge, and Sinda) and community-based IRS in Petauke (refer to Section 2.9 for details). Generally, the campaign went according to plan across all three provinces with consistent higher-than-expected spray progress and coverage. These results can largely be attributed to the changes the team made this year to the operational design, including: (1) embedding two mobilizers from Neighborhood Health Committees (NHCs) per spray team to assist with community sensitization, mobilization, and household preparation; (2) reduction of the daily SOP target from 15 to 13 structures; (3) reduction of SOP work week from six to five days and (4) intensifying supervision of IRS operations at all levels by assigning VectorLink staff and national level master trainers to challenging operations sites. Additionally, the project ended the campaign without recording any COVID-19 related incidents by ensuring strict adherence to global and PMI prevention guidelines on COVID-19. Refer to Section 4.4 for details on measures the project implemented in adherence to COVID-19 guidelines. Additional province-specific details are presented in the following sections.

RURAL COPPERBELT PROVINCE In 2020, there was tremendous improvement in the implementation of IRS at all levels across the three rural target districts, namely Lufwanyama, Masaiti, and Mpongwe. In 2019, Copperbelt Province consistently reported lower-than-expected spray progress and coverage which led to a weeklong pause of IRS operations after 19 operational days. However, in 2020, despite a slow start due to logistical challenges in the first few days, the campaign gained momentum from week two of IRS operations and ended with all districts recording spray progress and coverage of above 100% and 92%, respectively. This resulted largely from effective planning which took into consideration lessons learned from the 2019 spray campaign when the PMI VectorLink supported IRS in Copperbelt for the first time. Some of the activities the project implemented based on the lessons learned included: DHD orientation on IRS operations to secure their buy-in; capacity building workshop for Copperbelt IRS managers from both government and private sector on standard IRS protocol; establishment of more operations and/or camping sites to reduce travel time; deployment of both vehicles and bicycles to spray hard-to-reach areas; engaging two mobilizers per spray team to identify structures a day before and guide spray teams on the actual spray day; advocacy meetings with community and religious leaders as well as facilitating district malaria task force meetings two weeks before the start of the campaign.

EASTERN PROVINCE All districts in Eastern Province completed their campaign on schedule. In Lundazi and Chipata, despite being vetted prior to the campaign, some transport vendors were not able to provide the required number of vehicles. Competing government activities (voter registration activities and transport of agricultural commodities) likely limited the availability of transport. As a result, vehicles took multiple trips to ferry SOPs to the field, which limited the number of structures that the teams could spray in the first few days of the campaign. However, the spray calendar was modified so that the campaign began with communities near the operations sites for the first couple of days before reverting to the far locations/hard-to-reach areas, after the logistics issues had been sorted out. VectorLink engaged the vendors concerned to ensure vehicles were immediately replaced and the situation was resolved. Generally, the campaign in Eastern Province was on course from the second week of the campaign with spray progress and coverage consistently higher than expected due to finding and spraying more structures in targeted communities than forecasted. Finding 5-10% more structures than targeted is expected; however, in Lundazi, the variance between targeted and found structures was more, as spray teams visited urbanized communities which were not initially targeted due to an anticipated high rate of refusals.

NORTHERN LUAPULA PROVINCE In northern Luapula Province, Kawambwa and Nchelenge started the campaign on a slow note but gained momentum in the second week of the campaign with spray coverage above 85%. Chiengi residents were generally very receptive to IRS and the campaign therefore was on course from the onset. Because Chiengi and Kawambwa were not sprayed under PMI’s support in 2019, the team found more structures than forecasted but were still able to end the campaign within the prescribed spray calendar. Nchelenge excised 4,674 ineligible structures which were made of non-sprayable materials from the district-level target. To allow the district IRS team to visit all targeted communities, the campaign was extended by five days and ended on November 18. In addition, TLAs worked for an additional two days to tag structures that had not been tagged during the 35-day campaign due to software related issues (see additional details in Section 6). To successfully implement IRS on Chisenga and Kilwa islands, the project took into consideration foreseeable challenges associated with deployment of IRS on the islands. To mitigate the challenges, the following measures were introduced in adherence to PMI BMP: • Recruited spray personnel (SOPs and team leaders) from the islands to avoid multiple water crossings. However, to ensure proper supervision, experienced IRS supervisors were recruited from Nchelenge mainland. • Reduced the campaign duration from 30 to 10 operational days to enable the supervisors to maintain maximum attention over a much-reduced period away from home. • Reduced transit time of IRS commodities over water by using a 900-horsepower engine boat from the Marine Military Police which accomplished the trip in less than one hour as compared to three hours by the conventional boats available. • Deployed mobile soak pits for end of day clean-up to prevent environmental pollution and safeguard the health of the communities. • Deployed community-based IRS with the use of bicycles and motorbikes in farther settlements for efficiency given vehicles were not available on the islands. • Engaged NMEP to deploy other interventions (e.g., MDA and/or ITNs) apart from IRS in the structures that fall within the 60 m buffer zone from the shoreline. • Collaborated with ZEMA on pre-spray inspections to confirm compliance with all ZEMA prescribed mitigation measures.

2.3.2 SUPERVISION Monitoring and supervision of IRS operations were conducted throughout the campaign. At the core of the supervisory structure were the team leaders, who supervised five SOPs each. The IRS supervisor managed two team leaders and their spray teams, and reported to the IRS manager. The IRS manager oversaw IRS supervision activities at the district level and was complemented by the PMI VectorLink District Coordinator. Since 2018, VectorLink Zambia has recruited and hired 50% seasonal supervisors to enhance IRS supervision and complement the GRZ supervisors, who occasionally are diverted by other activities during the campaign. VectorLink made provisions for NMEP, ZEMA, as well as provincial- and district-level staff to conduct monitoring and supervision of IRS activities. Additionally, VectorLink Lusaka and field-based staff were deployed to challenging locations and supervised all aspects of the campaign. One problem encountered was inadequate household preparation in Chipata district in the first few operational days. In response, VectorLink conducted a half-day refresher training of spray teams at all four sites. SOPs, team leaders, and supervisors alike participated in “live fire” simulations focused on household preparation, including explaining the importance of this step to household members. The campaign experienced a few, minor lapses by some SOPs in spray technique, operator conduct, and community mobilization. The project continued to emphasize supervision of SOPs during all phases of daily operations, including demonstrating insecticide mixing, structure marking, and end of day clean up during daily morning mobilization. VectorLink Zambia, in collaboration with DHOs, recruited spray personnel as shown in Table 5.

9 Table 5: Number of Seasonal Workers Hired to Support IRS Disaggregated by Gender Category Number of Staff Hired to Support IRS Total (% Spray Ops Data Capture Other Female) M F M F M F Supervisors 114 61 175 (35%) Mobilizers 6,232 4,513 10,745 (42%) SOPs 992 780 1,772 (44%) Team leaders 206 143 349 (41%) TLAs 39 18 57 (32%) Data entry clerks 48 35 83 (42%) M&E assistants 47 12 59 (21%) Storekeepers 58 35 93 (62%) Sprayer Technicians 70 0 70 (0%) Washers 36 66 102 (65%) TOTAL M/F 1,312 984 134 65 6,396 4,614 13,505 (42%) TOTAL 2,296 199

2.3.3 OPERATIONS SITES The project utilized a total of 70 IRS operations sites. Prior to the campaign, the team established 20 new operations sites in Eastern (14 sites), Copperbelt (2 sites), and Luapula Provinces (4 sites) to avoid congestion and maintain a maximum of 35 SOPs per site, reduce spray teams’ travel time in the field, and minimize camping by spray teams in remote sites. Furthermore, for sites that serviced more than 25 SOPs, the project maintained and constructed larger wash bays (8×4 meters) that could accommodate two sets of rinse barrels to alleviate crowding and excessive wait times at the end of the day, in addition to maintaining adequate physical space for COVID-19 mitigation measures. Given the geographical vastness of Lufwanyama and Mpongwe districts in which settlements are scattered and difficult to access in many areas, VectorLink established an additional site in each district. The community-based IRS technical approach utilized in Petauke necessitated the establishment of an additional operations site (one site to cover communities within a 10km radius) to make a total of 16 operations sites. In addition to the new sites established in Eastern Province (Chipata - 4, Petauke - 1, Lundazi - 4, Nyimba - 1, Sinda - 2, Chadiza - 2, and Katete - 1), the project rehabilitated the insecticide storage facility in Mambwe and conducted minor works in Vubwi. The other eight pre-existing sites in Masaiti, Mpongwe, and Lufwanyama also received maintenance to ensure adherence to PMI BMP requirements.

2.3.4 COMMUNITY-BASED IRS In 2018, the project piloted a quasi-community-based (QCBIRS) approach that involved switching from using trucks to the use of bicycles to deploy spray teams when the campaign progressed within 10km of the operations base to reduce transportation cost. In 2019, VectorLink implemented this approach in one district (Lundazi) and, based on the findings, scaled it up to six additional districts in 2020 (Kawambwa, Nchelenge, Chiengi, Mambwe, Sinda, and Chadiza). In 2019, VectorLink piloted a full community-based IRS (CBIRS) in Petauke district which utilized bicycles through the entire duration of the campaign. This necessitated the establishment of additional sites to make a total of 15 sites to reduce distances from sites to the target communities, allowing SOPs to use bicycles for the duration of the campaign. In this regard, the project set up five main sites that were each supported by two sub-sites, and spray teams from each site were dispatched to cover areas within 10km radius. Based on the lesson learnt from the pilot, in 2020 VectorLink established an additional site to address the challenges observed at one site where spray personnel cycled for more than the required 10 km. The project had selected Petauke as the district to participate in CBIRS delivery model because the terrain is mostly flat and thus suitable for bicycle use. The project notified all prospective spray personnel (SOPs and

team leaders) in the districts during recruitment that ability to provide and ride a bicycle was a prerequisite for their recruitment. VectorLink paid SOPs and team leaders a daily bicycle maintenance allowance of 20 kwacha per person for the period they used bicycles.

KEY FINDINGS The key findings from implementation in 2020 were quite similar to 2018 and 2019 when QCBIRS and CBIRS was first piloted in Zambia and include the following: • Deployment of bicycles in both QCBIRS and CBIRS districts led to the use of 1,023 bicycles for an average of 8 and 30 operational days, respectively. • Use of bicycles simplified the daily deployment of SOPs. • Use of bicycles expedited movements between structures in widely dispersed communities. • Use of bicycles simplified accessibility in areas which are hard to reach by vehicles. • Establishing one additional IRS operations site in Petauke in 2020 helped ensure that no SOPs would need to travel more than 10km. • The bicycle allowance of K20 (effectively a rental charge for project use of the SOPs’ personally owned bicycles) motivated and encouraged spray personnel to work harder. • Being the second round of deploying CBIRS, most spray teams were familiar with the requirement and appropriate methods for carrying sprayers and insecticide bags. • Net cost savings from reduced transportation costs were realized from the use of bicycles under the QCBIRS approach. However, under CBIRS, savings in transportation costs were offset by the start-up costs of installing 14 new operations sites. Table 6 shows the summary of the cost analysis on use of vehicles versus use of bicycles to ferry spray personnel during the two community-based approaches used in the eight districts. Refer to the conclusion section for details.

Table 6: Cost Analysis of Community-Based and Quasi-Community Based IRS District Use of Vehicle Community-Based IRS/ Cost Savings Quasi-Community-Based IRS

Days Days (ZMW) (ZMW) (ZMW) (ZMW) Cost of Vehicle of Vehicle Cost Total Cost of of Cost Total No. of Bicycles of No. No. of Vehicles Fuel /L (ZMW) Total Cost Saved Cost Total Vehicle Hire/day Hire/day Vehicle Fuel/Day (ZMW) Hire/Day (ZMW) Total Cost (ZMW) Bicycle Allow./Day Total Total Total Cost for Period Fuel/Vehicle/Day (L) Fuel/Vehicle/Day Petauke 30 13 750 9,750 20 15.59 4,053 414,102 30 220 20 132,000 282,102 Lundazi 12 4 750 3,000 20 15.59 1,247 50,966 12 83 20 19,920 31,046 Chadiza 6 6 700 4,200 20 15.59 1,871 36,425 6 73 20 8,760 27,665 Sinda 4 9 750 6,750 20 15.59 2,806 38,225 4 164 20 13,120 25,105 Mambwe 2 5 730 3,650 20 15.59 1,559 10,418 2 74 20 2,960 7,458 Kawambwa 5 5 850 4,250 20 15.59 1,559 29,045 5 82 20 8,200 20,845 Nchelenge 17 11 920 10,120 20 15.59 3,430 230,347 17 181 20 61,540 168,807 Chiengi 14 8 750 6,000 20 15.59 2,494 118,922 14 146 20 40,880 78,042 Total 90 61 775 47,720 20 15.59 19,020 928,449 90 1023 20 287,380 641,069 Total Cost Saved (Vehicles vs. Bicycles) 641,069 ZMW (about 35,615 USD)

CHALLENGES • In a few instances, bicycle breakdowns led to reduced daily spray coverage by SOPs. • Some SOPs could not maintain the physical demand of riding a bicycle continuously therefore reducing on the number of structures sprayed in a day.

11 CONCLUSIONS The continued deployment of community-based IRS in Petauke reduced transportation costs for spray teams, saving the project 282,102 ZMW (about 15,672 USD, 1$= 18 ZMW), whereas quasi-community-based IRS resulted in cost savings of 359,967 ZMW (about 19,998 USD). In Petauke, since the introduction of the CBIRS delivery model, the project has established 14 new IRS operations sites at the cost of 1,380,570.25 ZMW (about 76,698 USD). However, in two spray seasons of deploying this operational design (CBIRS), the project has saved 409,902 ZMW – about, 22,772 USD (127,800 ZMW in 2019 and 282,102 ZMW in 2020), from deploying bicycles as opposed to hiring vehicles to ferry spray personnel. While the additional start-up costs are substantial and must be carefully considered prior to scale-up, the cost of continuing to implement community-based IRS in Petauke will be significantly less in subsequent years given the establishment of new sites has already occurred. Assuming the status quo is maintained, it will take 6 spray season/years (2024) to recover the funds spent on establishing 14 new sites. Therefore, there are 4 more spray seasons left to reach the payback period, assuming at a minimum, the project is saving 282,102 ZMW in each spray round. The project will consider scaling up quasi-community-based IRS approach in 2021 to all districts when spraying communities surrounding the operations, except at some of the sites in Chipata and Katete where the urban areas that house the operations sites are not targeted for IRS. This will drastically reduce transport costs when more districts are involved thereby enhancing sustainability. However, the project would not recommend scaling up the full CBIRS model due to the long (six-year) period required to recoup start-up costs.

2.3.5 PAYMENT OF SPRAY PERSONNEL In 2020, VectorLink used a mobile payment system to pay seasonal workers including SOPs, team leaders, supervisors, storekeepers, M&E assistants, Data Entry Clerks (DECs), washers, and mobilizers. Prior to the start of the campaign, seasonal personnel provided personal mobile money contact numbers to use for payment. Additionally, the project engaged the mobile network provider and provided SIM cards for spray personnel who did not have one. After reviewing and confirming their daily participation using attendance registers, spray personnel were paid in two installments—one for the first 10 days and one for the last 20 days (plus extension days in Nchelenge). The project liaised with the mobile payment system provider to make agents available in all places including hard-to-reach areas, which allowed seasonal workers to access money at their convenience. The exception to mobile payments were chiefs, who due to cultural considerations received their allowances in cash during the advocacy meetings. For the next spray season, the project plans to engage the Ministry of Chiefs and Traditional Affairs to explore avenues for mobile payments for chiefs.

2.3.6 PROCUREMENT VectorLink Zambia procured IRS commodities both locally and internationally for the 2020 spray round based on the results of the logistics needs assessment which took into consideration leftover stock from the 2019 spray campaign. Whenever possible, the project procured items locally to ensure cost effectiveness and timely delivery. This was done according to USAID and Abt protocols to ensure competition, transparency, and fairness. The procurement process involved use of an open, competitive bidding process for local tenders of commodities and services, which were evaluated by the VectorLink Zambia procurement committee and MOH provincial procurement officers in Lusaka and in some stances at provincial VectorLink offices in Ndola, Nchelenge, and Chipata. Based on historical consumption of insecticide in Zambian IRS campaigns, VectorLink estimated 188,829 units of insecticide to spray 639,536 structures. Due to cost sharing with NMEP in Luapula (refer to Section 2.1), VectorLink procured 128,600 units and NMEP supplied 37,570 units from their 2019 leftover insecticides. Additionally, the project used 22,659 units of leftover insecticides from the 2019 spray season. Other major items procured included 1,030 sprayers, 2,679 overalls, 1,044 helmets, 1,074 pairs of gum boots, 81,125 nose masks, 3,165 face shields, 2,791 pairs of gloves, and 657 insecticide backpacks. The project also supported NMEP with the procurement of sprayers and PPE (see Section 2.9 for details).

2.4 INSECTICIDE STOCK MANAGEMENT The project engaged two storekeepers at the main district operational sites: the MOH district storekeeper and the VectorLink seasonal storekeeper. At all other operation sites, only the VectorLink seasonal storekeeper was engaged. The inclusion of the MOH district storekeeper was to enhance collaboration with the district and build IRS capacity for sustainability. To track insecticide usage, daily insecticide usage registers were used, along with stores ledgers, insecticide tracking logs, and stock control cards. The project continued to use a serialized insecticide tracking book to reconcile insecticide usage between storekeepers and team leaders as well as a serialized insecticide tracking form to reconcile insecticide usage between team leaders and SOPs. This helped to identify the culprit(s) in the few cases when a sachet was missing. Table 7 shows the type, amount, and utilization ratio of insecticide procured in each province. The project used 181,938 sachets of insecticide (91,426 sachets of SumiShield and 90,512 sachets of Fludora Fusion) to spray 648,952 structures, for a utilization ratio of approximately 3.6 structures per sachet. Each SOP sprayed an average of 12.2 eligible structures per day. The project reported attempted pilferage of insecticides in Mpongwe and Lufwanyama and later retrieved insecticides after rigorous investigations. However, seventeen (17) sachets are in the custody of the Zambia Police as evidence to present before court during prosecution of spray personnel involved. In Eastern, the project reported one missing empty sachet in Vubwi. The project reported the incidents to PMI and the Zambia Police for investigation (see Section 4). At the end of the campaign, the project recorded 6,891 sachets of leftover insecticide (36 sachets of SumiShield and 6,855 sachets of Fludora Fusion) with an expiration date of June 2022 for SumiShield as well as October 2021 (3,481 units) and June 2022 (3,374 units) of Fludora Fusion. The 6,874 units of leftover insecticide is safely stored in the provincial VectorLink warehouses in Chipata, Nchelenge, and Ndola until the 2021 spray campaign, where the Fludora Fusion insecticides with October 2021 expiry date will be first utilized in September/early October 2021. As earlier stated, 17 sachets are in the Zambia Police custody. The 2020 leftover IRS commodities will set a benchmark for planning the 2021 spray season. Table 7 indicates insecticide consumption during the 2020 campaign.

Table 7: Insecticide Consumption in 2020, by Province Leftover Avg # Type of insecticides structures/ Province Insecticide (2019) Qty Supplied Qty used Qty in stock sachet Eastern SumiShield 15,382 76,080 91,426 36 3.6 Fludora Fusion - 33,150 31,840 1,310 Copperbelt Fludora Fusion 7,277 21,320 26,526 2,071 3.8 Luapula Fludora Fusion - 35,620 32,146 3,474 3.3 TOTAL 22,659 166,170 181,938 6,8741 3.6 1 17 sachets of Fludora Fusion are in the custody of the Zambia Police in Mpongwe as evidence to present before the court during prosecution of the accused spray personnel who attempted to steal these sachets. 2.5 INFORMATION, EDUCATION, AND COMMUNICATION AND SOCIAL BEHAVIOR CHANGE COMMUNICATION ACTIVITIES AND RESULTS In 2020, VectorLink Zambia worked closely with the NMEP, PHOs, DHOs, and key stakeholders to conduct social and behavior change communication (SBCC) activities prior to the start of the campaign. Drawing from lessons learned from the 2019 spray campaign, specifically on the Copperbelt; where the project had experienced challenges with refusals by householders to allow proper household preparation especially of their bedrooms, the project commenced early engagement of key provincial and districts stakeholders and community leadership to achieve early sensitization of the spray communities. This helped in addressing communities’ anxieties occasioned by the current COVID-19 pandemic as well as the national ‘gassing’ hysteria of December 2019 through March 2020, which led to mob violence in parts of the country and resulted in

13 some deaths. To overcome the fears caused by the ‘gassing’ incidents the community was also reassured on the safety of IRS using trusted channels such as the traditional institutions and faith-based organization leadership. Again, based on the 2019 spray campaign experience, each spray team included two NHCs who mobilized communities one day before and on the day of spray. The deployment of NHCs who carry out various community health projects throughout the year enhanced the acceptance of the intervention and further allayed the communities’ fears on issues such as ‘gassing’. The NHCs guided spray teams to structures that they mobilized the day before, while also mobilizing households who initially refused IRS. There were however instances during the campaign where NHCs did not show up as planned and in such situations the spray teams struggled to combine mobilization with their spray activities. In 2020, the project employed four major strategies for communicating IRS messages to the community which included: 1) early community sensitization, 2) community mobilization, 3) print and mass media, and 4) monitoring of communication activities. The outcomes of the SBCC intervention are highlighted in the following sections.

2.5.1 ADVOCACY MEETINGS WITH CHIEFS AND INFLUENTIAL COMMUNITY LEADERS Starting late August 2020, the project collaborated with NMEC, PHOs, and DHOs and held district level clustered advocacy meetings with chiefs and influential community leaders. The project held a total of 9 advocacy meetings with chiefs across the 3 provinces: five in Eastern Province, three in Copperbelt and one in Luapula. In addition, the project facilitated meetings of district Malaria Elimination Task Force (METFs), which are chaired by the District Commissioners, and had in attendance influential community leaders such as traditional leaders, religious leaders, district health directors and other members of the DHO. In total, 20 METF meetings were held (14 in Eastern, 3 in Copperbelt and 3 in Luapula). The advocacy and METF meetings disseminated information on the campaign start and end dates, spray calendar, and the responsibility of community leadership to ensure acceptance of the program. A total of 707 (549 male; 158 female) participants attended the METF meetings across the three provinces (134 from faith-based organizations, 66 chiefs, and 507 other key stakeholders). The advocacy meeting with Chiefs was followed up by palace meetings between the chiefs and their headmen which cascaded the messages from the district advocacy and directed them to sensitize their communities using the usual traditional channels of communication. The palace meetings were also attended by District Heath Promotion Officers and District Directors of Health who provided IRS technical information, IEC materials, and the spray calendars to chiefs and their headmen. Chiefs and religious leaders were given posters for their communities and churches, as well as IRS leaflets that guided their sensitization process.

2.5.2 COMMUNITY MOBILIZATION In 2020, VectorLink Zambia used District Health Promotion Officers, HFCA Environmental Health Technologists (EHTs) and zonal NHCs to mobilize communities for the IRS campaign. The Health Promotion Officers and Senior Health Education Officers from the Provincial Health Offices were oriented on the VectorLink Zambia 2020 IRS communication strategy. After their orientation, the Health Promotion Officers then oriented EHTs and Community Health Assistants from HFCAs on IRS mobilization and sensitization, who then in-turn oriented NHCs two weeks prior to the campaign. In total, EHTs and Community Health Assistants held 374 meetings across the three provinces. The Health Promotion Officers, IRS managers, and VectorLink district coordinators attended some of these meetings and provided additional technical support and clearly explained the roles of NHCs as mobilizers for the campaign. The spray calendars and IEC materials were shared during the orientation. A total of 10,745 NHCs participated in the campaign and conducted community mobilization and sensitization activities. During the campaign NHCs visited households a day before the arrival of the spray teams and on the spray day, they then guided the teams to the households that they mobilized the day before. Each HFCA was given a spray calendar that was placed on the notice board for referencing by mobilizers and community members. The headmen also reinforced the community mobilization using their traditional village indabas and events to deliver IRS messages.

In addition to the NHCs and headmen activities, Zambia National Information Services (ZANIS) was hired across all supported districts a week before through to the end of the campaign to make IRS public announcements and sensitize communities a day before an area was sprayed using motorized public address systems. To reinforce the public announcements by ZANIS, the project procured megaphones for each operational site which were used by a designated site supervisor who traveled ahead of spray teams reminding communities to prepare their house for spraying.

2.5.3 PRINT AND MASS MEDIA COMMUNICATION In 2020, VectorLink continued to use the two main radio programming initiatives used in the 2019 IRS campaign: radio spots (jingles) and discussions (interactive shows) about IRS and its benefits. The radio programs commenced airing one week before the start of the spray campaign and continued two times per day for three days each week throughout the campaign. The project aired a total of 733 spots/jingles, across the three provinces through local radio station, exceeding the project target of 440. The increase in the number of spots aired was a result of the community radio stations airing free complementary spots as part of their corporate social responsibility program. To address community’s concern and improve IRS acceptance, the project also supported 34 radio discussion across three provinces. The interactive nature of these discussion programs helped restore confidence in the spray communities. To monitor airing of jingles and radio discussions, the project engaged an independent media house which submitted a report at the end of the campaign confirming that this activity took place. Both radio spots and radio discussions were aired using fewer, strategically selected stations that reached the entire province. This strategy helped in reducing the cost of purchasing radio spots by 57 fewer spots. Additionally, VectorLink Zambia worked closely with the MOH and the NMEP through the IEC/SBC Technical Working Group to review and update national IRS IEC materials. Subsequently, the project produced and distributed a total of 18,357 copies of IEC materials: 16,000 “IRS Frequently Asked Questions” sheets, 1000 copies of talking points for religious and community leaders, 1,300 IRS posters, and 57 IRS radio discussion guides. The project also supported the NMEP to develop and print IRS launch guidelines and banners for each PMI- supported district, in line with the Minister of Health’s vision to ensure visibility of the start of the IRS season in the communities thereby leading to enhanced community acceptance.

2.5.4 SUCCESS STORIES VectorLink Zambia published three success stories on the VectorLink project-wide website in 2020 (refer to Annex C for details). One featured the integration of IRS and entomological data in the VectorLink Collect database, a second highlighted the adaptation of VectorLink entomological collection methods during COVID- 19, and a third showcased a range of other VectorLink Zambia COVID-19 adaptations implemented during the 2020 IRS campaign. 2.6 POST-SPRAY ACTIVITIES 2.6.1 INVENTORY ASSESSMENT AND DEMOBILIZATION At the end of the campaign, the project conducted physical counts of IRS materials and equipment at various operations sites. Three days after the campaign, the team transferred all leftover commodities and equipment from the operations sites to the provincial warehouses. The project tested equipment for proper functioning and then isolated broken equipment for repair prior to the 2021 campaign. Unserviceable equipment will be discarded in an environmentally sound manner.

2.6.2 POST-SPRAY REVIEW MEETINGS To effectively evaluate the 2020 IRS experiences, challenges, and lessons learned, as well as make recommendations for subsequent spray campaigns, VectorLink provided financial and technical support to the NMEP to hold one-day post spray review meetings in each province from November 24 to 30. Eastern

15 Province held its meeting on November 24 in Chipata; Copperbelt Province on November 27 in Ndola; and Luapula Province on December 30 in Nchelenge. To ensure that recommendations were made on key areas of challenges, participants broke into groups to discuss: 1) recruitment and training; 2) community sensitization and mobilization; 3) environmental compliance and IRS supervision and 4) data management and sustainability. Key recommendations from these meetings, whose details are captured in Section 6, will also serve to inform the 2021 work plan. 2.7 CAPACITY-BUILDING EFFORTS A key component of the VectorLink project is to continue improving competencies of the relevant local institutions and personnel so that, in future, the GRZ will be able to carry out IRS with minimal external support. Given the challenges experienced in previous spray campaigns, in 2020 VectorLink focused its capacity-building efforts on: (1) adherence to spray preparation protocols, (2) timely start of spraying, and (3) ensuring good IRS data quality for decision making. To achieve the aforementioned objectives, VectorLink implemented the following activities in line with the capacity assessment document developed in 2018 and based on the discussions held with NMEP in January/February 2020. • Provided technical assistance to GRZ-supported DDT-spraying IRS districts in Muchinga, Northern, and Luapula Provinces. This included facilitating sessions during their training of trainers’ activity, in September 2020 and support to the NMEP to undertake monitoring and supervision during the spray campaign in December 2020 accompanied by the VectorLink ECO. • Helped the NMEP to fill gaps in the GF/GRZ program as they emerged and permit timely spraying. Based on early planning, procured 1,534 Goizper spray pumps for the NMEP on a one-off basis to fill gaps for the 2020 campaign. Based on a late-breaking request, VectorLink also assisted the NMEP to procure 1,500 pairs of overalls and 2,000 units each of clear safety googles; gloves; cartridges for respirators and 800 units of mutton cloth. These efforts addressed GF/GRZ procurement shortfalls and bottlenecks, thereby preventing further delays to the commencement of their campaign. • Provided financial support to hold the quarterly meetings of the Vector Control Technical Working Group, and the annual meeting of the TAC in January 2020. • Supported four NMEP staff to conduct IRS supervision in the VectorLink-supported districts. This served the dual objectives of enabling appropriate NMEP monitoring as well as acquisition of best practices to replicate in non-PMI supported IRS districts. • Supported the NMEP with planned IRS sensitization activities on the Copperbelt in view of the late 2019 and early 2020 ‘gassing’ phenomenon which prompted mob violence. VectorLink and NMEP representatives undertook an advocacy/fact-finding trip to the Copperbelt to better understand any relationship with IRS insecticides, and determine how best to allay the public fears which tended to relate gassing with IRS. • As a follow up to reported pilferage of insecticides and misreporting of insecticide use for perceived gassing, in September 2020 VectorLink assessed and enhanced commodity security in Copperbelt through sharing of warehouse best management practices and documentation used to track the issuance and usage of insecticides. • Supported NMEP in the development of M&E tools in two aspects: (1) The microplanning template developed by PMI VectorLink was used during the planning of IRS for NMEP target districts (2) The data collection tools developed by the project were adopted by NMEP for use in the 2020 spray IRS campaign. • Supported the NMEP with customization and operationalization of GRID3 maps and data, as tools for microplanning in July 2020 in collaboration with PATH/MACEPA and Akros. The maps were obtained from the national enumeration and mapping project (GRID3) and incorporated into district-level joint planning exercises for the IRS and ITN campaigns.

• Conducted a capacity building workshop of Copperbelt IRS managers and national level master trainers for both public and private sector on IRS planning and implementation in July 2020. A total of 35 participants were in attendance. • Provided support for IRS campaign monitoring and supervision in the seven urban Copperbelt districts (use of M&E tools, environmental compliance best management practices) by sending VectorLink District Coordinators to participate in their program as supervisors. • Provided capacity building and technical assistance to strengthen the NMEP Vector Control Unit’s ability to collect and manage IRS and ITN data, through the integrated data analytics activity. To lead this activity, VectorLink hired and seconded a full-time Vector Control M&E Officer to strengthen the NMEP’s IRS and ITN data collection and management. • Built capacity of the national and provincial teams on basic principles of entomological surveillance and monitoring. In addition, VectorLink Zambia supported the NMEP to conduct quality of spray assessment and insecticide susceptibility tests in three selected GRZ DDT districts, Mwansabombwe, Chibombo, and Chongwe. 2.8 GENDER MAINSTREAMING To ensure that all program activities aligned with USAID’s policy on gender equality, VectorLink Zambia included modules on gender in all trainings (TOTs, team leader, SOP, storekeeper, and M&E). As such, participants understood the importance of integrating more females into spray teams to ensure equal participation in all aspects of IRS. The project’s goal in 2020 was to attain 40% female inclusion to support IRS operations. The project achieved 42%, an increase from the 2019 spray season where female inclusion reached 33%. The ability of the project to attain higher-than expected target could be attributed to (1) development of 40% female inclusion protocol (2) dissemination of the 40% female inclusion protocol to community leaders to encourage more females to apply for seasonal spray positions; and (3) allowing intra-gender competition among participants who attempted the standardized test – females were marked separately from men. To ensure that female personnel were comfortable and felt safe to participate in the program, the project continued to make the following provisions, as in the 2019 campaign: • Continued use of IEC posters with pictures of female SOPs to motivate women to join the IRS program. • Continued to post sexual harassment posters at all operations sites and DHOs to encourage personnel to report all forms of harassment they observe. • Continued providing wash facilities with adequate privacy for both genders. • Continued upholding the Zambian labor law that allows for female personnel to take one day off each month. • Enhanced provision of sanitary pads and sanitary bins at every operation site for hygienic disposal of pads. • Continued providing suitably sized personal protective equipment (PPE). VectorLink Zambia has continued to experience an increase in female inclusion in the program since 2018. The team will continue to dialogue with the NMEP and other stakeholders to work towards maintaining equitable engagement of women and men in future IRS campaigns.

17 3. ENTOMOLOGY

VectorLink Zambia supports the NMEP to generate data on key entomological indicators through routine entomological surveillance, insecticide resistance monitoring, and the assessment of residual efficacy of insecticide on the walls after IRS. These data guide the NMEP and other stakeholders on vector control decision-making, such as insecticide selection for IRS and insecticide resistance management. VectorLink currently conducts entomological surveillance and insecticide resistance monitoring activities in four PMI- supported districts (Nchelenge, Mambwe, Katete and Lufwanyama) and three districts supported by the Global Fund and GRZ (Milenge, Serenje and Chililabombwe). The assessment of spray quality was conducted in six PMI supported districts (Nchelenge, Mambwe, Chipata, Katete, Masaiti and Lufwanyama) and one Global Fund/GRZ supported districts (Kawambwa), while the longitudinal assessment of residual efficacy is taking place in five of the PMI supported districts (Nchelenge, Mambwe, Chipata, Katete, and Lufwanyama). The entomology section in this report focuses on the susceptibility of local vectors to the IRS insecticides and the insecticide residual efficacy activities conducted during the 2020 spray campaign. The Entomology progress and annual reports will include a comprehensive report on this and other entomologic indicators. 3.1 INSECTICIDE SUSCEPTIBILITY TESTS The Insecticide Resistance Monitoring and Management/Technical Advisory Committee of the National Malaria Elimination Program recommended two insecticides for the 2020 IRS campaign: DDT and the neonicotinoid clothianidin. Two types of clothianidin products; SumiShield containing only clothianidin and Fludora Fusion containing clothianidin and deltamethrin were deployed. Susceptibility of the local malaria vectors to DDT (4%), clothianidin (2.0%), deltamethrin (0.25%) and chlorfenapyr were tested at some sites in three provinces where PMI VectorLink supports entomological monitoring. Susceptibility tests using adult mosquitoes collected from inside houses were suspended in March 2020 due to the COVID-19 pandemic. This restriction resulted in less tests performed, especially for An. funestus s.l. (mainly indoor resting adults used for susceptibility testing). The susceptibility tests were conducted using standard WHO tube assays (Standard Operating Procedure 06/01)4 and CDC bottle assays Standard Operating Procedure 04/01)5; mortality was determined 24 hours after exposure for DDT and deltamethrin, and up to seven days after exposure to the slow acting clothianidin and chlorfenapyr insecticides. Vectors are considered susceptible when post exposure mortality is ≥98%, have probable resistance when mortality is between 90-97% and resistant when mortality is <90%. The test results are presented for the two main local vectors An. funestus s.l. and An. gambiae s.l. in Figure 2. An. funestus s.l. and An. gambiae s.l. were fully susceptible to clothianidin and chlorfenapyr in all three provinces tested: Luapula, Eastern, and Copperbelt. DDT resistance was confirmed among An. gambiae s.l. and An. funestus s.l. populations in Copperbelt province, while local vectors in Luapula and Eastern provinces were either susceptible or exhibited probable resistance. Deltamethrin resistance was observed among An. funestus s.l. in Luapula Province, while An. gambiae s.l. populations in Eastern Province were fully susceptible (data for Copperbelt Province not currently available). No or negligible mortality (<5%) was observed in controls negating the need to do Abbott’s correction analysis. These test results including the results obtained for other insecticides—pirimiphos methyl and bendiocarb—and results from additional tests currently underway will be submitted to the 2021 Insecticide Resistance Monitoring and Management/Technical Advisory Committee’s technical working group for decisions on insecticides to be used in the 2021 IRS campaign.

4 SOP 06/01. Insecticide susceptibility test, intensity, and synergist assay using WHO test kits, January 2020. 5 SOP 04/01 Susceptibility testing, resistance intensity and synergist assays using the CDC bottle bioassay

Figure 2: Susceptibility Status of An. funestus s.l. and An. gambiae s.l. to Clothianidin, Chlorfenapyr, DDT, and Deltamethrin at PMI VectorLink Entomological Monitoring Sites, 2020

3.2 IRS SPRAY QUALITY ASSESSMENT VectorLink Zambia conducted cone bioassays to assess the quality of spray during the 2020 IRS campaign in six PMI-supported districts: Nchelenge, Mambwe, Chipata, Katete, Lufwanyama, and Kawambwa in October 2020. Two clothianidin insecticide products were sprayed at different sites; Fludora Fusion (in Nchelenge, Kawambwa, Katete and Lufwanyama districts), and SumiShield (in Mambwe and Chipata districts). Cone bioassays were conducted using the WHO test procedures in three randomly-selected mud houses and three randomly-selected cement houses in each site (Standard Operating Procedure 09/01)6. In addition, cone bioassays were conducted in one unsprayed mud house and one unsprayed cement house in each site as controls. A total of 48 sprayed houses (24 mud and 24 cement) and 16 unsprayed houses or surfaces (8 mud and 8 cement) were assayed during the campaign 24-48 hours after each selected house was sprayed (T0). In each house, a total of 30 mosquitoes were exposed in groups of 10 in cones placed at 0.5m, 1.0m, and 1.5m above the floor. All mosquitoes exposed to walls sprayed with Fludora Fusion were dead after 48-hours post exposure (Nchelenge, Kawambwa, Katete, Masaiti and Lufwanyama districts) indicating a high quality of spray. For the sites sprayed with SumiShield (Mambwe and Chipata districts), 80% mortality was achieved 72 hours post-exposure, indicating a good quality of spray. There was a high variation in mortality at the household level at the site in Mambwe and one site in Chipata district (Mtubbaya) with a range of 33-97% (data not shown). Due to this observed variation, all affected SOP teams were immediately retrained, and all SOPs at the respective operation sites were sensitized on spray techniques and homeowner preparation to ensure high quality IRS during the remainder of the campaign. The percent mortality by wall type and district at T0 (quality

6 Standard Operating PROCEDURE 009. Wall Cone Bioassay of Sprayed Surfaces for Quality Assurance and Residual Efficacy Monitoring of IRS, January 2020.

19 of spray cone assays) are shown in Figures 3 and 4 provide a summary of the T0 bioassay results for the Fludora Fusion and SumiShield sprayed sites, respectively. Corrected mortality was calculated using Abbott’s formula for all exposed mortality figures where control mortality was greater than 5%. Overall, control mortality was less than 20% in all cases which obviated the need to repeat any of the assays. 3.3 RESIDUAL EFFICACY VectorLink Zambia conducts monthly cone bioassays to monitor the duration of residual efficacy of the insecticides in five districts: Nchelenge, Mambwe, Chipata, Katete, and Lufwanyama. T1 (one month after spray) cone bioassays were conducted in November 2020. Thirty sprayed houses (15 mud and 15 cement) and 10 control (unsprayed) houses (five mud and five cement) were assayed. The 80% mortality threshold was achieved after 24 hours for all wall surface types for both Fludora Fusion (Figure 3) and SumiShield (Figure 4) sites. This indicates that both insecticides last for at least one month. Residual efficacy monitoring will continue in each district until mortality falls below the 80% threshold for two consecutive months which will indicate a loss of residual efficacy. The results will be presented in the entomological monitoring progress report and the annual report. Results from residual efficacy monitoring are also submitted to the NMEP for use in the decision-making process of the NMEP Insecticide Resistance Monitoring and Management/Technical Advisory Committee’s technical working group. Figure 3: Mortality of An. gambiae s.s. Kisumu Susceptible Strain after Exposure to Fludora Fusion in Select Districts in the 2020 Campaign

Note: The red line indicates the 80% minimum mortality threshold for insecticide efficacy; the rate of insecticide decay is measured according to when the mosquito mortality falls below 80% for two consecutive occurrences. Bars with asterisk indicate the assays where control mortality was between 5-20% and therefore mortality was calculated using Abbott’s correction formula.

Figure 4: Mortality of An. gambiae s.s. Kisumu Susceptible Strain after Exposure to SumiShield in Select Districts in the 2020 campaign

21 4. ENVIRONMENTAL AND SAFETY COMPLIANCE

4.1 IRS CAMPAIGN ASSESSMENTS AND PREPARATIONS The project implemented the 2020 IRS campaign under a new SEA approved in September 2020. The SEA is valid for the period 2020‒2025 and authorizes the use of five WHO-recommended classes of insecticides: pyrethroids, carbamates, organophosphates, neonicotinoids, and pyrroles. The project ECO worked with the district coordinators, provincial and district health officers and ZEMA to oversee all environmental compliance activities before, during, and after the campaign. The home office Environmental Compliance Manager provided technical assistance for the process. VectorLink Zambia continued to use the Environmental Mitigation and Monitoring Plan as the guide for corrective actions to mitigate potential environmental impacts. The Environmental Mitigation and Monitoring Report in Annex B describes mitigation actions the project has taken to achieve safe and efficient spraying. As part of the initial pre-spray Environmental Compliance Assessment, VectorLink Zambia assessed all IRS facilities (storerooms, wash areas, soak pits) four months ahead of spray activities. Upon completion of the assessments, the ECO shared a worklist of required upgrades and improvements with the operations team to ensure that renovations were completed on schedule. For the 2020 campaign, the project prepared 68 operations sites with fixed soak pits and two sites with mobile soak pits (MSPs). Twenty new operations sites with fixed soak pits and two mobile soak pit sites were established. The new fixed soak pits used the improved design, with plastic sheets lining the walls, a metal cover over the bio-beds, and a topmost layer of large stones, as prescribed in the revised 2020 PMI BMP Manual. The new wash areas were also covered with roofs. VectorLink Zambia continued to use mobile soak pits to supplement the fixed soak pits. The project deployed a total of 57 MSPs, comprising 48 original (mobile soak pit I) and three of large capacity (45‒50 L capacity, 9 MSP were dismantled to construct the MSP-II) in the 15 districts. The three 40-50-liter MSPs were installed at Kilwa and Chisenga islands in Nchelenge District where fixed soak pits could not ideally be constructed due to high water levels to avoid possible environmental pollution due to flooding. During the final assessment, the project ECO together with ZEMA and DHOs identified suitable locations for installation of the remaining mobile soak pits in the communities. The project team also used the final assessment to verify completion of all refurbishments and authorize the distribution of insecticides to the operations sites. To ensure a healthy workforce throughout the campaign, the project conducted pre-campaign medical screenings for all candidates for field positions as well as pregnancy tests for the female candidates. The pregnancy tests were repeated after 30 days, during the spray campaign. Team leaders conducted daily health checks using a special questionnaire to ensure that all SOPs were fit before heading to the field. Completed health checklists were filed at operations site level. The USAID-funded Environmental Compliance Operations Support (ECOS) project conducted an IRS Environmental Compliance Field Evaluation as mandated by PMI. The ECOS environmental consultant accompanied by the project ECO visited six districts (Chipata, Chipangali, Kasenengwa, Mambwe, Katete, and Petauke) to assess and audit environmental compliance at operations sites. VectorLink Zambia supported the assessment, and areas for improvement observed by the auditor were immediately communicated to the spray teams for correction. The consultant advised that SOPs must state the exact time for reentry into the house rather than mentioning two hours as some householders may not know when exactly to open the structure to allow for 30 minutes of ventilation. The VectorLink Zambia team together with government partners carried out inspections throughout the campaign at the operations sites and in the field. The ultimate goal was to ensure ongoing compliance with

prescribed safety and environmental requirements, and to build in-country capacity to sustain IRS implementation. Site managers, after receiving feedback from inspections, addressed all “red flags” and solutions during morning assemblies. 4.2 INCIDENT REPORTS

VectorLink Zambia recorded ten incidents during the 2020 spray campaign, as described in Table 9. This was a marked reduction from the 18 incidents recorded during the 2019 spray campaign.

Table 8: 2020 PMI VectorLink Zambia Incident Report Summary

Incident ID Description of Incident Location ZAM-051920-001 Natural accident: a tree fell onto the IRS storeroom at the Masaiti DHO Masaiti district operations site causing damage to the structure. ZAM-091020-002 Health: An SOP complained of chest pains and was treated at the hospital. Petauke district ZAM-121020-003 Insecticide exposure: an SOP accidently sprayed their face with Fludora Masaiti district Fusion insectide from the sprayer. ZAM-131020-004 Other Health: One empty sachet of SumiShield insecticide missing— Vubwi district insecticide usage of the SOP coincided with the number of structures sprayed. ZAM-101520-005 Other health and safety: Five sachets of Fludora Fusion insecticide missing Mpongwe district from Kalweo operations site storeroom. ZAM 102020-006 Theft: A team leader working with four other team SOPs misappropriated 17 Mpongwe district sachets of Fludora Fusion insecticide. ZAM-102420-007 Insecticid theft: a sachet of Fludora Fusion insecticide (inner sachet only) Lufwanyama wrapped in cloth material was picked around the wash area at Mibenge district operations site. ZAM-102720-008 Other Health: An SOP was bitten by a dog when entering a compound for Katete district spraying. ZAM-110420-009 Insecticide theft: An inner sachet of Fludora Fusion insecticide fell out of one Nchelenge district of the personal SOP bags during cleaning. All empty and full sachets in the storeroom were accounted for. ZAM-111020-010 Falsified data/insecticide pilferage: An SOP at Kawambwa Boma reported Kawambwa spraying structures that did not exist and attempted to steal insecticide. district

To mitigate the risk of insecticide pilferage and data falsification, the project implemented the following measures:

• Supervisors conducted spot checks of Daily SOP forms to verify whether the number of structures recorded as sprayed tallied with the expected number of insecticide bottles/sachets used. • The project serialized each insecticide sachet with a unique number and required that SOPs record it on their SOP form against the number of the structure for which it was opened. Each team leader had to sign against the serialized insecticide units during issuance in the morning and reconciliation at the end of the day; team leaders tracked distribution of insecticide against each SOP in the team. • VectorLink Zambia posted “Insecticide Theft and Data Falsifications Warning” posters at all sites. • Any seasonal worker implicated in data falsification and/or insecticide theft or misuse faced immediate dismissal and loss of wages. The respective districts reported the cases to the police for further action. Seasonal workers involved in such incidents are ineligible for rehire in future IRS campaigns.

23 4.3 DEMOBILIZATION AND WASTE MANAGEMENT VectorLink Zambia decommissioned all 70 sites and moved all spray equipment and materials from the operations sites to the respective regional stores within two weeks after the end of 2020 campaign. The ECO with three selected District Coordinators led the post-IRS EC inspections at all operations sites from November 23-30, 2020 to ensure that storage facilities had been cleaned; soak pits properly closed, cleared of vegetation, and covered; and no IRS-related hazardous material remained at the sites. The project moved all solid waste and contaminated waste materials (batteries, damaged hand gloves, and torn plastic sheets) to Lusaka City Council Cleansing depot. Empty cardboard boxes will be recycled through an approved procurement process. The project will use ZAMRA in Lusaka and Mopani Copper Mines (MCM) on the Copperbelt for incineration of contaminated waste (insecticide sachets, nose masks, handkerchiefs/mutton cloth). Incineration will be completed by December 30, 2020. Boxes will be sold to a vendor who deals in non-consumable recycling of paper using the Procurement process. Upon completion of their task, contracted waste management companies will issue certificates of completion to document incineration, and all other waste disposal methods. 4.4 COVID-19 MITIGATION EFFORTS To ensure the protection of the target population against malaria, IRS implementation continued during the COVID-19 pandemic with strong adherence to risk-mitigating measures. VectorLink Zambia increased the number of training venues during TOTs to ensure adequate social distancing. The project held multiple TOTs in Eastern Province with reduced number of participants per venue and held all trainings outdoors to allow ample air circulation. Furthermore, the project reinforced the standard IRS practice of spray personnel wearing N95 nose masks immediately upon arrival at the site and increased the number of hand-washing stations at each site. The project increased the number of SOP vehicles significantly (to convey 13 team members per vehicle as opposed to 25 pre-COVID-19); where additional vehicles were not available, drivers made multiple trips to the field. The project provided bleach for disinfecting vehicles’ doorknobs, storerooms, and other equipment, and procured sanitizing wipes (one pack per vehicle, and for team leaders and SOPs) to clean their gloves before and after household preparation. Daily temperature checks using handheld thermal thermometers were conducted and recorded every morning before teams entered the site. Mobilizers, drivers, and storekeepers maintained proper social distancing and protective guidance issued by the MOH including the use of face masks provided by the project. Reminders on COVD-19 prevention were reinforced to all seasonal workers daily during morning mobilization and posters were displayed at all sites. All 10 data centers were set up under tents that the project hired for the duration of the campaign. All Data DECs wore masks at all times and each data center was equipped with washing basins as well as wet wipes that DECs used to wipe their computers on a frequent basis. Additionally, all DECs sat at least 2 meters apart from each other and they were not allowed to share laptops or daily SOP forms. Additionally, the physical data entry forms were held for at least 24 hours from the time of field data collection until the commencement of data entry by the DECs to decrease the possibility of COVID-19 transmission. The M&E Assistants conducted an abridged 5-day field data monitoring activity rather than the usual 30-day field data collection and verification (DCV) to mitigate the spread of COVID-19. Both the DECs and M&E Assistants were supplied with the Zambian standard triple layered cloth N95 equivalent masks that they were required to wear at all times while at the data centers and IRS operational sites. All entomological monitoring activities were conducted under strict COVID-19 prevention measures to minimize the risk of contamination of households by staff or of contamination of our staff in the context of COVID-19. These measures in addition to the standard COVID-19 guidelines, included: using handheld battery-operated aspirators instead of standard mouth aspirators, cleaning and disinfecting surfaces and equipment, allowing only one person at a time inside the house, non-sharing of equipment among individuals and conducting conversation with the community outdoors.

5. MONITORING AND EVALUATION

5.1 DATA COLLECTION, ENTRY, AND QUALITY ASSURANCE VectorLink Zambia considered and adopted the successful aspects of the M&E system from the 2019 IRS campaign to ensure high-quality data collection, management, and reporting. During the TOT for IRS managers and supervisors, the M&E team reviewed and trained IRS managers and supervisors on the paper-based Daily SOP form, Team Leader form, and Directly Observed Supervision form. IRS managers and supervisors explained the forms during the cascade training for SOPs and team leaders. The SOP form served as the primary data collection tool. In addition to the SOP forms, the Team Leader forms were used to supervise and improve data collection. As part of the measures to mitigate the threat of spreading COVID-19, the Data Collection and Verification tool was not widely used to collect data in the field during the 2020 IRS campaign but was used in select instances to follow up on data falsification incidents. Prior to the 2020 IRS spray campaign, the project established 10 data centers across the three target provinces: five in Eastern (Chipata (2), Petauke, Katete, and Lundazi), two in Copperbelt (Ndola and Kalulushi) and three in Luapula (Chiengi (2) and Kawambwa). Data centers were established in strategic locations where connectivity was sufficiently strong to support the data entry and cleaning across 13 districts. Data from Chadiza and Nchelenge districts was entered into the Reveal tool with the support of PMI VectorLink sub contractor Akros (see Section 5.1.1). To support data collection and entry and the supervision of both activities, VectorLink Zambia hired an M&E assistant at each operations site. The project also engaged data transporters who transported data collection forms from some remote IRS sites to respective data centers, which greatly improved the timeliness of data entry and availability compared to previous years. DECs were required to enter data into a central database within 48 hours after structures were sprayed. The data collection forms were kept for a period of 24 hours after data collection to mitigate the possible spread of COVID-19. Thereafter, the spray “Totals” (summary of each Daily SOP Form) were entered within 24 hours to produce “real-time” reporting of spray progress. Later, the spray “Details” (household-level data) were entered within 48 hours for a more accurate picture of spray progress and coverage. By using the cleaning tool, DECs investigated and reconciled discrepancies between spray “Totals” and “Details” data for a final data set with the campaign results. DECs entered data into VectorLink Collect, the project’s DHIS2-based data platform. The M&E Team and Abt’s Data Science and Enabling Technologies team worked together to update VectorLink Collect for the 2020 IRS campaign. DECs primarily used a desktop application to enter spray data since it functions offline, which was important given the occasionally unstable internet connectivity experienced at the designated data centers. All electronic data are securely stored and backed up on VectorLink servers which are hosted by BAO Systems team. VectorLink Zambia technical staff also used the database to generate near “real-time” reports for quick feedback and to reconcile and prevent additional errors in data collection and entry. Based on the team’s experience in 2018 and 2019 the M&E team reviewed the data from the VectorLink Zambia database on a weekly basis and provided feedback to provinces and districts on performance and coverage, highlighting areas that had not achieved 90% coverage. The report also indicated the number of structures to be revisited through a mop-up campaign to attain a minimum of 90% coverage. The M&E team sent the weekly report to PMI VectorLink technical staff, NMEC staff, district coordinators, chief environmental health officers, IRS managers, and district/provincial health directors. After successfully updating data from the Daily SOP forms onto the VectorLink Collect database, DECs filed the SOP forms at the district data centers according to spray date and team number, on a daily basis.

5.1.1 DATA COLLECTION USING REVEAL The Reveal platform, which is managed by Akros, was built using the lessons learned from the mSpray tool and was deployed for the first time in 2019 and deployed again in the 2020 campaign. During the 2019 IRS campaign, the tool was used for data collection in four PMI VectorLink target districts, while in 2020, the tool’s

25 scope was reduced to two districts. Collection of data using the GPS-enabled mobile tool has been used in Zambia since 2014 by both PMI AIRS Zambia and the PMI VectorLink Zambia projects. Using satellite mapping technology, Akros also enumerated structures in each geographical area. Data were uploaded to ONA database, at the end of each day for spray campaign progress and imported into VectorLink Collect on a weekly basis. The following are key features of the Reveal tool for data collection and management: • Data was captured directly on mobile forms using a smartphone or tablet. • Pre-programmed data entry controls on mobile devices reduced illogical data errors. • Near real-time data was available via the Reveal dashboard to immediately address campaign challenges and improved spray progress. • Mobile data were compared with SOP forms daily to enhance data quality. During the 2020 IRS campaign, VectorLink Zambia used the Reveal tool in two PMI-supported districts; Chadiza in Eastern Province and Nchelenge in Luapula Province—for mobile spray data collection and reporting. As in non-Reveal districts, SOPs collected spray data on paper SOP forms. In both the Reveal implementing districts one TLA was assigned three SOPs, and one team comprised one Team Leader, two TLAs, and six SOPs.

5.1.2 DATA COLLECTION VERIFICATION PMI VectorLink technical staff and MOH supervisors conducted field spot checks to validate data authenticity. This enabled the project to validate spray data and, in some instances, identify SOPs who may have falsified data. There were three recorded instances of data falsification during the 2020 IRS campaign; one instance involved one SOP in Kawambwa district while the other two instances involved one Team Leader and four SOPs in Mpongwe district. A thorough review and investigation revealed that all SOPs involved in the data falsification incidences recorded non-existent structures as sprayed. The SOPs were ultimately dismissed. As part of project’s standard COVID-19 mitigation measures, M&E Assistants were not widely deployed in the field to conduct the Data Collection Verification (DCV) exercise. Data collection and verification, using the DCV tool, was only implemented in the two districts (Mpongwe and Kawambwa) following data falsification incidences. 5.2 MHEALTH IMPLEMENTATION VectorLink Zambia collaborated with Dimagi to ensure quality reporting and supervision in all target districts. In 2020, the Dimagi platform included daily SMS reminder messages to spray teams, PMT messaging and supervisory checklists. The Dimagi SMS messaging platform was further used to communicate and enhance the COVID-19 prevention measures developed by the project, during the 30-day IRS campaign period. 5.3 IRS CAMPAIGN RESULTS Out of the 672,581 structures found in the targeted districts, VectorLink sprayed 648,914, resulting in a spray coverage of 97%. The campaign protected 2,776,336 people including 73,959 pregnant women and 391,438 children under 5. Table 9 provides additional summary statistics, Table 10 shows provincial-level coverage, and Table 11 details district-level coverage.

Table 9: Summary of 2020 PMI VectorLink IRS Campaign Dates of PMI-supported IRS campaign September 29 – November 18, 2020 Total operational days 35 SumiShield 50 WG (clothianidin) and Fludora Fusion (clothianidin and Insecticides used deltamethrin) Number of provinces 3 (Copperbelt, Eastern, and Luapula) Number of districts 15 Number of structures found by SOPs 672,581 Number of structures sprayed by SOPs 648,914 2019 spray coverage 97% Population protected 2,776,336 (73,959 pregnant women; 391,438 children under 5 years old) Number of people trained with U.S. 2,5767 Government funds to deliver IRS

Table 10: Provincial Spray Progress and Coverage Province Targeted Found Sprayed Spray Progress Spray Coverage Eastern 427,661 456,903 443,039 104% 97% Copperbelt 93,935 106,120 100,651 107% 95% Luapula 107,659 109,558 105,224 98% 96% Total 629,255 672,581 648,914 103% 97%

Table 11: District-level Spray Progress and Coverage

Children Pregnant Spray Population Province District Targeted Found Sprayed Coverage <5 Women Progress Protected Protected Protected

Total 104% 427,661 456,903 443,039 97% 1,738,660 251,756 40,422 Chadiza 98% 22,800 23,651 22,262 94% 84,662 12,339 1,886 Katete 115% 32,392 38,348 37,141 97% 137,691 19,878 2,828 Sinda 104% 50,332 53,330 52,311 98% 181,285 27,542 3,812 Chipata 101% 122,297 127,027 123,168 97% 514,527 73,065 12,028 Eastern Lundazi 104% 78,344 84,362 81,709 97% 343,499 48,902 8,566 Mambwe 101% 22,215 22,894 22,479 98% 91,267 13,238 2,145 Nyimba 106% 21,545 23,604 22,752 96% 89,011 12,552 2,775 Petauke 103% 67,042 71,254 68,977 97% 248,372 37,253 5,447 Vubwi 114% 10,694 12,433 12,240 98% 48,346 6,987 935 Total 107% 93,935 106,120 100,651 95% 426,627 57,243 14,629 Lufwanyama 108% 22,952 26,676 24,850 93% 102,918 13,040 3177 Copperbelt Masaiti 97% 32,305 32,844 31,347 95% 129,164 18,671 3839 Mpongwe 115% 38,678 46,600 44,454 95% 194,545 25,532 7613 Total 98% 107,659 109,558 105,224 96% 611,049 82,439 18,908 Nchelenge 91% 38,664 37,598 35,061 93% 215,351 32,211 5,684 Luapula Chiengi 105% 44,063 46,781 46,049 98% 263,077 33,212 9335 Kawambwa 97% 24,932 25,179 24,114 96% 132,621 17,016 3889 Total 103% 629,255 672,581 648,914 97% 2,776,336 391,433 73,959

7 This included: 1,949 SOPs, 384 Team Leaders, 175 supervisors, and 68 Team Leader Assistants.

27 VectorLink Zambia monitored the structures that were found and sprayed and compared this to the target structures on a weekly basis. Table 12 summarizes reasons that structures were not sprayed by province.

Table 12: Reasons for Not Spraying Targeted Structures Reasons for Not Spraying Structures Structures Structures Not Locked/Adult Province Found Sprayed Sprayed Sick Refused Not Present Funeral Other Eastern 456,903 443,039 13,864 11% 32% 40% 3% 13% Copperbelt 106,120 100,651 5,469 7% 28% 52% 2% 11% Luapula 109,558 105,224 4,334 12% 31% 41% 2% 14%

The three most common reasons documented as to why structures were not sprayed were: (1) locked structures or structures where no adult was present; 43%, (2) refusals (e.g., anecdotal reasons include local myths, negative influence by some local leaders, outright refusal for no reason); 31%, and (3) other reasons (e.g., houses used as food stores, etc.); 13%.

6. CHALLENGES, LESSONS LEARNED, AND KEY RECOMMENDATIONS

6.1 CHALLENGES • Lower-than-expected spray progress and coverage in the first three weeks of the campaign was largely due to: ˗ Logistical challenges particularly in Masaiti, Lufwanyama, Mpongwe, Lundazi, and Chipata. Despite being vetted prior to the campaign, some transport vendors were not able to provide the required number of vehicles. Competing government activities (voter registration activities and transport of agricultural commodities) likely limited the availability of transport. As a result, vehicles took multiple trips to ferry SOPs to the field, which limited the number of structures that the teams could spray. ˗ Inadequate community sensitization and mobilization because of low turnout of mobilizers in some instances led to inadequate household preparation, refusals, and many locked structures. ˗ Commencement of the rains in Masaiti, Mpongwe, Lufwanyama, Chadiza, and Vubwi during the third week of the campaign led to interruption of spray operations, delayed departure of spray teams in the morning, many locked structures as householders went to till the fields, long travel hours to spray areas due to road inaccessibility, and high rate of refusals as householders were reluctant to take their belongings outside. • Despite engaging NHCs, the team experienced high rate of refusals during the initial visits to households in some parts of Lufwanyama, Masaiti, Mpongwe, and Nchelenge, particularly in more urban communities. • Lack of adherence to household preparation protocol, particularly in Chipata, necessitated a half-day refresher training of spray teams at Chikando, Msekera, Katandala, and Boma operations sites. • Long distances between spray areas, as well as between structures in the rural communities, remained a challenge (particularly in Lufwanyama, Mpongwe, and Masaiti districts). • Higher numbers of structures were found than targeted in some parts of Mpongwe and Lundazi. In Mpongwe, this was because, during the 2019 campaign, some SOPs recorded households instead of structures; this was how data was recorded in previous GRZ-supported IRS campaigns. In Lundazi, the district did not spray urbanized communities in 2019 due to a high refusal rate, but in 2020 these communities were visited due to improved community acceptance. • The project reported 10 incidents – 5 in Copperbelt, 3 in Eastern, and 2 in Luapula (Table 8). Some of the incidents recorded involved spray personnel attempting to pilfer insecticides. Major incidents included: ˗ Attempted pilferage by four SOPs and one team leader of 17 sachets of Fludora Fusion in Mpongwe district. ˗ Two data falsification incidents – Kawambwa and Mpongwe. • Data capture using the Reveal tool in real time in some instances proved to be a challenge due to system malfunctions, lack of optimal technical support and supervision of TLAs, and poor coordination among some teams in the Reveal districts (Chadiza and Nchelenge districts only.) For Chadiza, these challenges were resolved as the campaign was progressing. In Nchelenge, these challenges persisted, and several issues did not come to light until the end of the campaign when investigations were undertaken to better understand the reason for the poor spray progress. This was one reason for the extension of the campaign by five operational days and additional two days for tagging structures that could have been missed during the first visit due to the system malfunctioning, data loss due to partial syncing, and unavailability of the

29 Nchelenge base map for a significant part of the campaign. Additional details on the challenges with the Reveal system that were experienced in Chadiza and Nchelenge are as follows: ˗ Inability to enter data on a pre-enumerated structure. TLAs were forced to create new structure points and the Akros team manually matched these new points against pre-enumerated points during data cleaning. ˗ The system was occasionally slow and at times experienced incomplete syncing in low-connectivity environment (particularly Kabuta operations site in Nchelenge). This led to delayed departure for the field as teams needed to wait for data to fully sync before assigning/loading new spray areas. Assigning spray areas on the actual spray day also contributed to delayed departure to the field. ˗ Non-adherence to data syncing protocol by TLAs led to lost data during assigning of new spray areas. TLAs were required to clear the previous day’s data before loading new spray areas and this caused problems (data loss) if the data did not fully sync. ˗ Assigning three SOPs to one TLA without the option for the TLA to capture data for any other additional SOPs slowed down the rate of data capture, especially during mop-up spraying. ˗ Delayed deployment of the Nchelenge base map led to lower-than-expected coverage and progress as the team missed structures that needed to be sprayed in the first few days since they could not be visualized on the operations site maps on the tablets. ˗ Boundary mismatch of mapping data on tablets compared to what was found on the ground slowed down progress. ˗ Instances of mismatched spray profiles loaded on tablets led to delays in the start of field data capture. • Delayed start of IRS operations due to logistical challenges (procurement of IRS commodities) in non- PMI supported IRS districts led to: ˗ Interruption of spray operations by the rains ˗ Locked structures due to competing socio-economic activities associated with the rainy season. ˗ Lower than expected daily spray and coverages due to reluctance by householders to remove household items. • Non-compliance to environmental and safety guidelines in non-PMI supported IRS districts due to inadequate and old PPE and equipment. 6.2 LESSONS LEARNED • Collaborative efforts among community, civic, and religious leaders to encourage communities to accept IRS helped increase acceptance in more urban areas when the team conducted mop ups. • Collaborative partnership between VectorLink, PHOs, and the NMEP in monitoring and supervision of IRS operations helped resolve the challenges encountered without delays, leading to the success recorded across all provinces (especially in Copperbelt where the project encountered significant challenges in 2019). • Collaboration between different government and government departments simplified the transportation of IRS commodities to Chisenga and Kilwa islands in one trip using a bigger capacity Marine Military boat – something which initially proved to be a great challenge regarding water crossing of insecticides since the boat owned by MOH has a smaller capacity and would entail multiple trips.

• Strict adherence to COVID-19 guidelines opened opportunities for innovation, including outdoor recruitment, training, and data entry; use of multiple trips to ensure social distancing in SOP vehicles; daily temperature checks and recording; as well as provision of wipes to SOPs to clean gloves before and after house preparation. • Capacity-building workshop for Copperbelt IRS managers and national level master trainers on IRS planning, household preparation, insecticide management, environmental compliance, monitoring and supervision as well as use of data for decision making helped to lessen the legacy challenges the project faced in the 2019 campaign.

• ‘Live-fire’ field simulation during training of spray personnel at all levels mimicking a full operational day helped participants to practically understand the standard IRS protocol on household preparation and identify which household items constitute moveable and immovable items. However, the householders whose houses were used for demonstrations felt inconvenienced and wished their houses were sprayed with actual insecticides since the interval from the training to the commencement of the campaign was short (about one week in some instances). • Embedding of two NHC members per spray team across all districts led to: ˗ Improved community acceptance of IRS ˗ Easy navigation to all villages within the target community. ˗ Improved daily SOP performance as mobilizers also assisted in house preparation which expedited operations • Development and presentation of standard protocol and plans in some aspects of IRS operation during planning meetings and trainings based on the lessons learned from the previous campaigns led to: ˗ Achieving more-than-expected female inclusion target (40%) regarding personnel hired to deliver IRS due to adherence to the female inclusion protocol ˗ Improved management of mop up spraying including the quality of mop up data due to adherence to a mop up protocol ˗ Drastic reduction in data entry delays due to adherence to the data transportation plan unlike the late delivery of spray data forms to the data center experienced in 2019. • Changes to the operational design such as introduction of a 5-day work week and reduced daily SOP target from 15 to 13 structures improved daily SOP performance as they did not spend long hours in the field to meet their target and rested over the weekend to regain their strength for the following week. • In the hinterlands of Nchelenge, it was found that not all targeted communities/structures were eligible for IRS as they were made of wooden poles, grass, and/or sacs; such communities are better suited for other malaria interventions such as deployment of insecticide-treated nets (ITNs). • Establishment of additional IRS operations site in large districts – 14 sites in Eastern province, two sites in Copperbelt, and four sites in Luapula – enhanced operational efficiency and adherence to environmental compliance guidelines. Additionally, establishment of camping sites in hard-to-reach areas of Lufwanyama, Masaiti, Kawambwa, and Lundazi reduced travel time to spray areas and increased the time teams spent in the field. • Use of bicycles throughout the campaign in Petauke and towards the end of the campaign in Chiengi, Kawambwa, Nchelenge, Chadiza, Sinda, Lundazi, and Mambwe reduced the cost of transporting spray teams. • Daily demonstration of insecticide mixing as well as the proper documentation on daily SOP forms by supervisors during morning mobilization continued to prove very useful in mitigating SOPs’ errors normally associated with mixing of insecticides and documentation. • Engagement of pump technicians at every site drastically reduced the challenges of pumps malfunctioning in the field as these were serviced or repaired in a timely manner. • Combination of different modes of transport (vehicles and bicycles) assisted in accessing hard-to-reach areas and tackling widely dispersed structure formations in Lufwanyama and Nchelenge (hinterland). • Involvement of district HPOs across all districts assisted in coordinating mobilizers. • Engaging community-based volunteers as SOPs has continued to improve community acceptance of the program and simplified locating of structures within target communities. • Assigning of a data supervisor at each operations site improved data quality and drastically reduced the traditional discrepancies between PMT and VectorLink Collect datasets.

31 • The successful implementation of a “live fire test” of the Reveal tool in Nchelenge prior to the start of the campaign increased confidence in the ability of the tool to be effectively used for mobile data collect in the two Reveal districts. It also helped identify/troubleshoot issues prior to implementation. In addition, participation of supervisors in Reveal trainings improved understanding of the tool among more members of the team and led to quicker escalation of issues faced in the field. • The engagement of seasonal provincial-level storekeepers who oversaw the project provincial stores led to improved commodity logistics at the provincial level and enabled the district coordinators to concentrate on their supervision roles during the campaign. • The use of the Reveal tool significantly helped with satellite-based enumeration and mapping in all PMI target districts. The satellite-based structure enumeration estimates were a great resource for districts during the IRS/ITN microplanning phase; the districts were able to triangulate the Reveal enumeration data with other data sources (CSO and headcount data) and were able to determine the populations to protect with each specific intervention with a greater degree of certainty. Additionally, districts were able to use Reveal maps to determine the appropriate intervention to deliver to specific geographic locations. In Chadiza and Nchelenge, more detailed maps were available down to the location/zone level. • Use of maps provided by Gates-funded GRID3 project at no cost to the NMEP and VectorLink simplified joint planning for IRS and ITN campaigns as the maps included fine scale population estimates in addition to structure estimates which previous Reveal maps never had. Additionally, for the first time in many years, GRZ supported IRS districts used updated maps to finalize district spray targets during microplanning. • Conducting GRZ-supported IRS during the rainy season posed a lot of operational challenges due to competing social economic activities (caterpillar harvesting and farming) as well householders’ reluctance to remove household items. 6.3 RECOMMENDATIONS • Maintain the timing of the spray campaign (commencing in late September) before the onset of rainy season. This presumes continued ability to deploy insecticides with longer residual efficacy. • Maintain the five-day work week which allows a longer resting period for the spray teams and keeps them better refreshed to start the new week. • Continue to strengthen the partnership between the project and PHOs across the three provinces to enhance supervision at all levels of IRS operations (including community mobilization) and maintain good performance. • Enhance trainings at all levels with primary focus on practical trainings such as household preparation (live fire field simulation in full PPEs); and strict observance of spray technique to ensure that SOPs do not leave any inches on the bottom part of the wall untreated. Other trainings to strengthen include best warehouse management practices, environmental compliance guidelines for insecticide transportation, and supervision of spray teams to reduce potential incidents. • Re-introduce the daily DCV during the next round of IRS implementation. • Build capacity of the NMEP in IRS monitoring and supervision by supporting district representatives from non-PMI supported provinces to learn from the Eastern Province IRS campaign, which runs smoothly from the onset while adhering to all standard IRS protocols. This would be especially valuable in Petauke district which is piloting the CBIRS approach. • Continue to incorporate a session during trainings starting with TOTs to SOP training for the police (focusing on the implication of insecticide theft) and ZEMA (on the implication of the loss of insecticides). Additionally, continue to display posters depicting the penalty for insecticide theft and data falsification at all operation sites.

• For operational efficiency, consider reducing the daily SOP target to 10 structures in the rural districts of the Copperbelt due to widely dispersed structures with long distances between them. • Address the challenges associated with Nchelenge hinterland (such as existence of largely ineligible structures in sparsely populated communities) by prioritizing one or more vector control interventions other than IRS. • Maintain the close collaboration with DHO and the Marine Military unit for smooth and compliant water crossing of insecticides and other IRS commodities to Chisenga and Kilwa Islands. Additionally, to ensure adequate supervision in this area, start the campaign two weeks earlier than the rest of the districts and maintain a shorter duration (10 days). • Engage NMEP to expedite deployment of an alternative intervention in structures that fall within the 60m buffer zone from Lake Mweru shoreline on both Chisenga and Kilwa islands to ensure universal vector control coverage. • Continue to assign a dedicated supervisor per operations site to verify that SOP forms are accurate before populating the PMT and authorizing their delivery to the data center. • Continue to engage both influential leaders and NHCs in community sensitization and mobilization to help maintain and improve community acceptance of IRS. • Continue to adhere to the recruitment and gender balance criteria/protocol to maintain above 40% female participation to deliver IRS. • Continue to engage the private sector, particularly collaboration with the mines on the Copperbelt (KCM and MCM) to foster public-private partnership through IRS planning, training, monitoring, and supervision as well as procurement of insecticides which has been problematic in their previous campaigns and has delayed the start of IRS implementation. These challenges persisted this year, in addition to financial challenges, which made it difficult for them to fund IRS operations in their catchment areas during the current spray season. However, the recent increase in copper prices may boost mining investments in malaria control in 2021 and beyond. • If the Reveal system were to be employed for real-time data collection in future, then enhance field technical support to TLAs in Reveal target districts by assigning one Akros field officer per site to immediately resolve any technical issues and to accompany spray teams to the field. • Encourage prompt escalation and resolution of issues with the Reveal tool to ensure that maps can be loaded, structures can be tagged and synced, and data can be used for real-time decision-making. Additionally, increase the number of SOPs to be assigned to each tablet and if possible, leave an option for additional entries • Continue to work with Akros to address all system malfunctions that were experienced with the Reveal tool during the 2020 IRS campaign. Furthermore, the tool will continue to be field-tested and the outcome report to be shared with VectorLink Zambia project staff before it is rolled out for use in the 2021 IRS campaign. In 2021, VectorLink should enhance technical assistance by (1) complementing GF investment where needed, e.g. through procurement of new PPE for SOPs, IRS equipment, and spray campaign supervision; (2) investing to help the GRZ/NMEP prepare for potential future withdrawal of IRS as the primary vector control strategy by 2023, e.g. strengthening routine ITN systems and entomological monitoring, and; (3) increasing technical assistance to GRZ to aid in timely implementation of IRS and completion of the spray campaign by the end of November.

33 ANNEX A: M&E PLAN

Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result Objective 1: Implementation of Malaria Vector Control (VC) Interventions 1.1 Successfully Execute IRS and Other Integrated Malaria VC Activities Number and percentage of completed annual 1.1.1 country work plans developed and submitted on-time Total (All) 630,000 630,000 617,000 597,625 639,536 629,255 Number of eligible (Subtotals

1.1.2 structures targeted for detail) spraying (Subtotals

detail) Total (All) 535,500 579,490 524,450 531,600 543,606 648,914 Number of eligible (Subtotals

1.1.3 structures sprayed with detail) IRS[1] (Subtotals

detail) Percentage of total Total % 85% 92% 85% 90% 85% 97% structures targeted for spraying that were (Subtotals 1.1.4 sprayed with a residual detail) insecticide (Spray (Subtotals

Coverage) detail) Total (All) 2,558,542 2,818,176 2,505,747 2,216,145 2,555,923 2,776,336 Subtotal: (as

necessary) Number of people Sex: Male 1,421,874 1,107,809 1,393,381 1.1.5 protected by IRS Sex: Female 1,396,302 1,108,336 1,382,955 Pregnant 89,959 48,099 73,959 women Children <5 411,416 308,689 391,438

Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result Number and percentage of vector control project country programs submitting an EOSR 1.1.6 Country within 45 days after the end of spray (including completing MEP and EMMR) Number and percentage of IRS country programs that conduct a Post-Spray 1.1.7 Country Data Quality Audit within 90 days of spray completion Number of Insecticide Number N/A N/A N/A N/A N/A N/A 1.1.8 Treated Nets (ITNs) distributed, by channel Channel Number and percentage of countries completing 1.1.9 ITN durability monitoring Country data collection as planned in a given project year Number and percentage of PMI-funded durability monitoring surveys with 1.1.10 Country reports submitted within 90 days of the end of data collection 1.2 Strengthen Capacity of NMCPs, VC Personnel, and Other Institutions to Implement and Manage IRS and Other VC Activities 40% 40% Total 2,006 40% Females 9,897 14,766 Females Females VC IRS/ITN IRS IRS IRS IRS Total number of people Intervention Distribution 1.2.1 trained to support VC in Sex: Male 1,464 7,526 8612 target areas [2] Sex: Female 542 2,371 6,154 See Table Job Function See Table 2 See Table 2 2

35 Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result 40% Total 2,089 40% Females 2,120 3,065 2,576 Females VC Total number of people IRS IRS IRS Intervention trained to support VC in 1.2.2 target areas with USG Sex: Male 1,441 1,427 1480 funds[3] Sex: Female 648 693 1096 See Table Job Function See Table 2 See Table 2 2 40% 40% Total 147 40% Females 171 175 Females Females Number of people trained during the Master Sex: Male 112 128 114 1.2.3 (National) Training and/or Sex: Female 35 43 61 IRS Training of Trainers. Type of TOT TOT TOT Training 40% Total 1,893 40% Females 9,052 8,913 13,505 Females VC IRS IRS IRS Total number of people Intervention 1.2.4 hired to support VC in Sex: Male 1,328 6,904 7842 target areas. Sex: Female 565 2,148 5663 See Table Job Function See Table 2 See Table 2 2 Total 1 4 2 2 2 4 Number of VC project VectorLink VectorLink Technical training workshops TOT Collect/Entomo Collect/Entom 1.2.5 Area targeting NMCP and other logy ology host country staff [4] See Table Job Function See Table 2 See Table 2 2 Number of NMCP and Total 2 4 5 24 20 22 other vector control host 1.2.6 country staff who have See Table Job Function See Table 2 See Table 2 logged into VectorLink 2 Collect

Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result Number and percentage of technical assistance Country requests to support ITN distribution planning Technical 1.2.7 and/or implementation Area completed on time as planned in a given project Channel year Number and percentage of technical assistance requests to support Country operational routine 1.2.8 monitoring systems for Channel continuous ITN distribution completed on time as planned in a given project year 1.3 Environmental Compliance and Safety Total 2,079 2,087 3,539 2,608 Sex: Male (#) 1,518 1,390 1,470 Number of seasonal vector control personnel Sex: Female (#) 561 697 1,138 trained in environmental 1.3.1 compliance and personal Sex: Male (%) 60% 73% 60% 67% 60% 56% Sex: Female safety standards in vector 40% 27% 40% 33% 40% 44% control implementation (%) See Table Job Function See Table 2 See Table 2 2 Total 31 0 0 0 0 Sex: Male (#) 24 0 0 0 0 Number of health workers receiving insecticide Sex: Female 1.3.2 (#) 7 0 0 0 0 poisoning case management training [5] Sex: Male (%) 60% 77% 0% 0% 0% 0% Sex: Female (%) 40% 23% 0% 0% 0% 0%

37 Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result Number of adverse Total 0 0 0 7 0 0 reactions to pesticide 1.3.3 exposure documented Type of that resulted in a referral Occupational Exposure for medical care Number of SEAs and Letter Reports submitted 1.3.4 at least 60 days prior to Country the commencement of VC campaigns Number and percentage of permanent and mobile Total Number 50 50 48 51 65 125 soak pits inspected and 1.3.5 approved prior to IRS campaigns or before first Percent 100% 100% 100% 100% 100% 100% use Total Number 44 50 48 51 65 70 Number and percentage of storehouses inspected Percent 100% 100% 100% 100% 100% 100% 1.3.6 and approved prior to IRS Type: campaigns Operation Site 50 51 70 Storehouses

1.4 Promote Gender Equality in all Facets of Planning and Implementation Number 565 2127 5,663 Number and percentage 40% 40% Percent 30% 40% Females 24% 42% Female 1.4.1 of women hired to support Females Females VC campaigns See Table Job Function See Table 2 See Table 2 2 Number 38 22 269 40% 40% Number and percentage Percent 31% 40% Females 25% 37% of women hired in Females Females 1.4.2 VC supervisory roles in target IRS IRS IRS areas for VC activities Intervention See Table Job Function See Table 2 See Table 2 2

Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result Total 100% 2,370 100% 2,360 100% 2,896 Sex: Male (#) 1,588 1578 1,665 Number and percentage Sex: Female of trainees (permanent (#) 782 782 1,231 1.4.3 and seasonal) who have Sex: Male (%) 67% 67% 57% completed gender awareness training Sex: Female (%) 33% 33% 43% See Table Job Function See Table 2 See Table 2 2 Number and percentage Country of women in senior 1.4.4 leadership roles in Sex VectorLink country offices (# and %) 1.5 Implement and Support SBCC and Mobilization Activities Total 495 553 540 440 440 733 VC IRS IRS IRS Number of radio spots Intervention 1.5.1 and talk shows aired 20 Talk Shows/ 34 Talk Talk Show or Radio 420 Radio Shows/ 699 Radio Spot Spots Spots Radio Spots Number of print materials Total 18,820 18,820 18,432 13,100 18,355 17,057 1.5.2 distributed to or targeted VC at beneficiaries [6] Intervention IRS IRS IRS Number of people Total 2,558,542 745,454 NA NA NA NA reached with vector VC Intervention IRS 1.5.3 control and/or SBCC messages via door-to- Sex: Male 353,191 door messaging Sex: Female 392263

39 Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result 2. Entomological and Epidemiological Data to Drive Decision-Making 2.1 Vector Control Activities Monitored via Entomological and Epidemiological Data Number of project- supported entomological Total 14 14 14 14 14 14 sentinel sites established to monitor vector 2.1.1 bionomics (vector VC species, distribution, IRS IRS IRS seasonality, feeding time, Intervention and location) Number and percentage of vector bionomics Total Number 14 14 14 14 14 14 monitoring sites measuring all basic entomological indicators 2.1.2 Percent 100% 100% 100% 100% (species composition, indoor and outdoor human biting rates, hourly VC human biting rates, indoor IRS IRS IRS Intervention resting densities) Number and percentage of vector bionomics Total Number 14 14 14 0 14 14 monitoring sites measuring the following Percent 100% 100% 100% 0% 100% 100% 2.1.3 all advanced entomological indicators: IRS or sporozoite rates and Entomology IRS IRS IRS entomological inoculation Only Program rates [7] Number and percentage Total Number 16 16 14 4 14 9 of insecticide resistance monitoring sites that 2.1.4 tested all priority Percent 100% 100% 100% 28% 100% 64% insecticides for the VC relevant local vector IRS IRS IRS control intervention Intervention

Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result

Number and percentage Total Number 42 42 42 42 of houses in which WHO cone bioassays were conducted within two Percent 100% 100% 100% 100% 2.1.5 weeks of spraying with greater than 98% test SumiShield SumiShield mortality recorded for IRS Insecticide Type (18) / Fludora (12) / Fludora countries Fusion (24) Fusion (30)

Number and percentage Total Number 30 30 30 30 of sites that conducted WHO cone bioassays after the completion of 2.1.6 spraying at monthly Percent 100% 100% 100% intervals until test mortality drops below SumiShield SumiShield 80% for two consecutive Insecticide Type (12) / Fludora (12) / Fludora months for IRS countries Fusion (18) Fusion (18) Number of countries with an integrated vector control analytics 2.1.7 Country dashboard created by PATH, available for decision-making Total 32 24 242 213 50 22 40% Sex: Male (#) 16 166 16 Number of people trained Females (VectorLink and non Sex: Female 2.1.8 8 47 6 VectorLink staff) in (#) entomological monitoring Sex: Male (%) 67% 78% 73% Sex: Female (%) 33% 22% 27% Number and percentage Total Number NA NA NA NA of sites in which WHO 2.1.9 cone bioassays were Percent conducted to evaluate

bio-efficacy of bed nets

41 Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result Number of nets in which Total NA NA NA NA WHO cone bioassays 2.1.10 were conducted to evaluate bio-efficacy of

bed nets 2.2 NMCPs Develop Country-Level IRS and Other Malaria VC Strategies Number and percentage of countries with an integrated malaria vector control strategy, including 2.2.1 Country a plan for monitoring and managing insecticide resistance supported by the project Number and percentage of countries with a data and visualization dashboard complete for 2.2.2 Country IRS and/or entomology data in VectorLink Collect for vector control decision making Number of countries that 2.2.3 implement sub-national Country insecticide rotation 2.3 Build capacity of NMCPs and local institutions to collect, analyze, and use data for strategic malaria control decision-making Number of individuals Total 4 9 4 5 4 4 trained from NMCPs and national institutions to See Table 2.3.1 Job Function See Table 2 review and interpret data 2 See Table 2 for integrated vector control decision making Organization NMEP NMEP NMEP

Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result

Number and percent of Total 4 4 4 24 4 4 targeted individuals that report using new analytical tools and/or Job Function See Table 2 2.3.2 See Table skills in their planning, 2 See Table 2 resourcing, Regional NMEP/MO implementation, or Organization Health Officers/ NMEP H measurement activities NMEP 3. Procurement and Logistics 3.1 Cost-Effective Procurement Mechanism Established Number and percentage Country of insecticide procurements that had a 3.1.1 pre-shipment QA/QC test, Insecticide done by a third party, at Type least 60 days prior to spray campaign Number and percentage Total Number 2 2 2 2 2 2 of insecticide procurements received Percent 100% 100% 100% 3.1.2 on-time to allow for the Actellic SumiShield/ Insecticide SumiShield/ initiation of spray 300CS/ Fludora Type Fludora Fusion operations as scheduled SumiShield Fusion Number and percentage of targeted countries with international equipment Country procurements, including 3.1.3 PPE, received on-time to VC allow for the initiation of Intervention vector control campaigns as scheduled Number of VectorLink 3.1.4 staff trained on Country procurement

43 Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result 3.2 Total Number 65 73 68 73 93 100 VC IRS IRS IRS Intervention Number and percentage Sex: Male (#) 52 46 38 of logistics and Sex: Female warehouse personnel 21 27 62 3.2.1 (#) (seasonal and full-time) Sex: Male 71% 63% 38% trained in VC supply chain (%) management Sex: Female 29% 37% 62% (%) See Table Job Function See Table 2 See Table 2 2 Number and percentage of operations site Total Number 44 50 48 48 65 70 warehouses where 3.2.2 physical inventories can be verified by daily stock Percent 100% 100% 100% records Number and percentage of IRS countries that Country 3.2.3 successfully completed spray operations without Insecticide an insecticide stock-out Type 4. Innovation 4.1 Conduct operational research or monitoring to scale up new tools, methods, and approaches Number of operational research studies on Total Number 0 0 0 0 0 0 promising new tools or 4.1.1 new methods/ approaches to existing Type of

tools that are Innovation implemented

Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result 4.2 Create and share knowledge through dissemination of best practices and lessons learned Number of innovations, best practices, and other Country data or lessons learned shared with other partners 4.2.1 or international institutions for global reporting on the Technical Vector Learning Area Exchange Number of individual members who use the 4.2.2 N/A Vector Learning Exchange Number of symposia Total 2 0 2 2 1 0 and/or presentations 4.2.3 submitted to and Monitoring & Technical accepted at global Evaluation and Area conferences Entomology Number of success stories written or videos 4.2.4 produced and shared on Total 5 1 2 3 2 4 the VectorLink project website Number of peer-reviewed Technical 4.2.5 journal articles submitted Area and accepted

Total 1 1 1 1 1 2

Number of contributions IRS to vector control global or (Launching 4.2.6 country policy and/or Guidelines), guidance documents Technical Entomology MOP MOP Area (Insecticide Resistance Management Document)

45 Annual Targets and Results Dis- # Performance Indicator Year 1 [2018] Year 2 [2019] Year 3 [2020] Year 4 Year 5 aggregation Target Result Target Result Target Result Target Result Target Result 4.3 Develop and deploy cost-savings approaches Number of innovative or novel approaches Total 1 1 1 1 1 0 implemented to achieve 4.3.1 cost savings in IRS and VC integrated malaria vector IRS IRS Intervention control programs Number of cost effectiveness Total 1 1 1 0 1 2 assessments of existing 4.3.2 approaches in the implementation of IRS VC IRS IRS and integrated malaria Intervention vector control programs 4.4 Cultivate public-private partnerships Number of private sector entities engaged with to establish public private 4.4.1 partnerships to increase Total 1 0 3 1 2 2 the quality and coverage of malaria vector control activities globally [1] Target based on 85% of estimated eligible structures in indicator 1.1.2 [2] With the revision of the PMP that took place in 2019, new cadres of workers are counted towards this indicator which is why the Y2 results have increased. [3] For IRS programs, this includes SOPs, TLs, Supervisors, and TLAs. [4] In Y1, the four Training of Trainers (TOTs) workshops were counted as part of this indicator. With the revision of the PMP that took place in Y2, TOTs no longer count towards this calculation. For Y2 results and beyond, TOTs will no longer be counted. [5] Clinicians were not trained in Y2, but training materials were shared with facilities on poison management. [6] With the revision of the PMP, this indicator was revised to count only print materials given to or targeted at beneficiaries. While many print materials were given to traditional and religious leaders, posted at Operational Sites, etc., none were given specifically to beneficiaries, which is why the result for Year 2 is 0. [7] With the new PMP revision, this indicator definition has been refined. Thus, the results from Y1 may look different than the target and results for the remainder of the project. No sporozoite rate measurements have been taken in Year 2 because of issues with the ELISA reagents.

Table 2: MEP Disaggregates

Selected Indicators Annual Targets and Results # with Job Function By Job Function Year 1 Year 2 Year 3 Year 4 Year 5 Disaggregates Target Result Target Result Target Result Target Result Target Result 1.2 Strengthen Capacity of NMCPs, VC Personnel, and Other Institutions to Implement and Manage IRS and Other VC Activities Total 2006 9897 14,766 ITN Supervisors 1001 Site Managers Supervisors 147 171 175 Spray Operators 1564 1524 1949 Team Leaders 295 319 384 Clinicians Total number of people M&E Asst, Data 123 172 1.2.1 trained to support VC in Clerks target areas Storekeepers, 73 100 Logistics Security Guards Pump Technicians 70 Washers 102 Team Leader 106 68 Assistants Mobilizers 7581 10,745 Total 2089 2120 2576 Mobilization

Supervisors Total number of people Site Managers trained to support VC in 1.2.2 Supervisors 147 171 175 target areas with USG funds[2] SOPs 1564 1524 1949 Team Leader 83 106 68 Assistants Team Leaders 295 319 384

47 Selected Indicators Annual Targets and Results # with Job Function By Job Function Year 1 Year 2 Year 3 Year 4 Year 5 Disaggregates Target Result Target Result Target Result Target Result Target Result Total 1893 9052 13505 Mobilization

Supervisors Data Clerks 62 83 M&E Assistants 41 59 Data Cleaners Storekeepers 73 93 Logistics Assistants

Total number of people Finance Assistants 1.2.4 hired to support VC in Supervisors 146 171 175 target areas. Site Managers SOPS 1500 1468 1772 Team Leaders 247 304 349 Team Leader 95 57 Assistants Mobilizers 6838 10745 Security Guards Washers 102 Pump Technicians 70 Cleaners Total 4 2 4 NMCP Staff- NMCP Staff- TOT Participants VectorLink VectorLink Number of VC project Collect Collect (3) training workshops 1.2.5 Community targeting NMCP and Community Based other host country staff Based Volunteers- Volunteers- Ento Ento Training Training (1) Total 4 24 22 Number of NMCP and Provincial Health other vector control host 3 3 3 Officer 1.2.6 country staff who have NMEP Staff 1 1 2 logged into VectorLink District Health Collect 20 17 Officers

Supervisors Site Managers Number of seasonal Supervisors 147 171 175 vector control personnel SOPs 1564 1524 1949 trained in environmental Team Leaders 295 319 384 1.3.1 compliance and M&E Asst and Data personal safety standards in vector Clerks Storekeepers, control implementation 73 73 100 Logistics Security Guards Washers Clinicians 1.4 Promote Gender Equality in all Facets of Planning and Implementation Total 565 2127 5663 Data Clerks 27 37 35 M&E Assistants 9 9 12 Storekeepers 27 35 Logistics Assistants Finance Assistants Supervisors 42 22 61 SOPs 399 517 780 Number and percentage Team Leaders 70 98 143 1.4.1 of women hired to Team Leader support VC campaigns 18 19 18 Assistants Mobilizers 1398 4513 Mobilization

Supervisors Security Guards Washers 66 Pump Technicians Cleaners

49 Selected Indicators Annual Targets and Results # with Job Function By Job Function Year 1 Year 2 Year 3 Year 4 Year 5 Disaggregates Target Result Target Result Target Result Target Result Target Result Total 38 22 269 Storekeepers 35 Warehouse/Logistic

Assistants Supervisors 38 22 61 Number and percentage Team Leaders 143 of women hired in Team Leader 18 1.4.2 supervisory roles in Assistants target areas for VC Site Supervisor/

activities Coordinator Mobilization

Supervisors Data Entry Center

Supervisors M&E Assistants 12 Total 2370 2360 2896 Storekeepers 73 73 100 Supervisors 147 171 175 SOPs 1564 1524 1949 Number and percentage Data Clerks 72 78 101 of trainees (permanent M&E Assistants 50 45 71 1.4.3 and seasonal) who have completed gender Washers 100 awareness training Clinicians 31 Team Leaders 295 319 384 Team Leader 106 68 Assistants VectorLink Staff 38 44 48 2. Entomological and Epidemiological Data to Drive Decision-Making 2.3 Build capacity of NMCPs and local institutions to collect, analyze, and use data for strategic malaria control decision-making Number of individuals Total 9 5 4 trained from NMCPs and Category/Function NMEP (9) NMEP (5) NMEP (4) national institutions to 2.3.1 review and interpret data for integrated vector control decision making

Selected Indicators Annual Targets and Results # with Job Function By Job Function Year 1 Year 2 Year 3 Year 4 Year 5 Disaggregates Target Result Target Result Target Result Target Result Target Result Total 2 24 4 Number and percent of M&E Officer; targeted individuals that District Health LLIN Lead report using new Officers (20; Implementation analytical tools and/or NMEP (3); MOH 2.3.2 Category/Function Provincial Health Officer; IRS skills in their planning, (1) Officers (3); Lead resourcing, NMEP (1) Implementation implementation, or Officer; IRS measurement activities Officer 3. Procurement and Logistics 3.2 Robust Inventory Management and Logistics Systems Established Number and percentage Total 73 73 100 of logistics and warehouse personnel 3.2.1 (seasonal and full-time) Storekeepers 73 73 100 trained in VC supply chain management

51 ANNEX B: 2020 ENVIRONMENTAL MITIGATION AND MONITORING REPORT

Outstanding Issues Relating Mitigation Measure Status of Mitigation Measures to Required Conditions Remarks 1a. Insecticide selection for any All insecticides used for the campaign met the USAID Programmatic No outstanding issues USAID-supported malaria program is Environmental Assessment selection criteria. The SEA, which was subject to the criteria listed in the approved on September 24, provides nationwide coverage for the USAID Programmatic Environmental period 2020–2025. Five classes of insecticides for IRS usage were Assessment, country SEAs, and host approved country requirements. 1b. Procurement and inventory logs 188,829 units of insecticides were available for 2020, VectorLink No outstanding issues The 6,891 units of must be maintained. Zambia procured 128,600 units, while NMEP supplied 37,570 units of insecticide (6,855 Fludora® Fusion, and 22,659 units were carried over from 2019. Fludora® Fusion and 181,955 units were used in 2020 (91,426 SumiShield® and 90,512 36 SumiShield®) are Fludora® Fusion). 6,891 units were left over from the 2020 campaign in stock for the 2021 (36 SumiShield and 6,855 Fludora® Fusion) campaign. 1c. Ensure storage facility and personal Central warehouse and site stores were equipped with thermometers, No outstanding issues protective equipment are appropriate fire extinguishers, spill response kits, wooden pallets, and Material for the active ingredient used and in Safety Data Sheets. Stores had adequate ventilation, impermeable accordance with approved SOPs. floors, secured windows, and doors with double locks. All storage facilities were guarded 24/7. Before the distribution of insecticides, all stores were supplied with adequate personal protective equipment for SOPs, field supervisors, storekeepers, and other casual workers. A dress rehearsal was conducted at each site to ensure there were no issues of mismatches with the personal protective equipment. Each SOP had at least two pairs of coveralls, rubber boots, neck cover, headlamp, (daily) nose mask, and surgical gloves. 1d. Distribute insecticides to facilities Distribution of the insecticides started at the provincial warehouse and that can manage such commodities moved to the district stores and further to the operations sites, safely in storage, use, and disposal (i.e., overseen by the District storekeeper. Distribution was guided by in a manner generally equivalent to historical records of insecticide consumption by site and followed the

Outstanding Issues Relating Mitigation Measure Status of Mitigation Measures to Required Conditions Remarks Implementing Partner’s own “First Expire First Out” rule. All operations site stores were inspected SOPs/Waste Management Plan twice before the campaign and found to be appropriate before insecticide distribution was authorized. During the campaign, each store was inspected at least once: any safety gaps were rectified at the time of the inspection. All empty insecticide units were properly packaged, stored, documented, labeled, and transported to the central warehouse at the end of the campaign for disposal. 2a. Inspect and certify vehicles used for Pre-contract inspection of vehicles used for IRS operations was No outstanding issues insecticide or team transport prior to conducted at the site level on September 7 to 11, 2020. The selected contract. vehicles were inspected again by the VectorLink DCs before certification on September 23, for compliance with PMI VectorLink project requirements. A total of 109 vehicles were rented to support the 2020 IRS operations. 2b. Train drivers All 109 drivers with inspected and certified IRS vehicles received an No outstanding issues orientation on safety issues including speed limits, a maximum carrying capacity, proper use of personal protective equipment, spill and emergency response procedures, and Abt’s policy on motor vehicle use during the IRS campaign. The project sexual harassment guidelines were also incorporated into the drivers’ training. Issues related to COVID-19 were highlighted, e.g., social distancing, use of nose masks, hand sanitizers, regular handwashing, and regular vehicle disinfection. 2c. Ensure availability of cell phone, All 109 trained drivers provided their cellphone numbers (which were No outstanding issues personal protective equipment, and spill shared with the site managers at each operations site), were cautioned kits during insecticide transportation. to maintain charge on their phones, received adequate personal protective equipment, and spill response kits. 2d. Initial and 30-day pregnancy testing All female SOPs, team leaders, supervisors, site managers, No outstanding issues for female candidates for jobs with storekeepers, and washers had pregnancy tests at selected health potential insecticide contact. centers at the district level on September 16-21. A second test was conducted 30 days after the first round of tests. No female was found pregnant during any tests that were conducted. 2e. Health test all spray team members All SOPs, washers, site managers, and storekeepers were taken through No outstanding issues for duty fitness. a medical fitness examination at selected health centers at the districts on September 16-21. They were examined for physical fitness, respiratory problems, and allergic reactions to the insecticides.

53 Outstanding Issues Relating Mitigation Measure Status of Mitigation Measures to Required Conditions Remarks 2f. Procure services of, distribute, and Local and international procurement of all required personal protective No outstanding issues train all workers with potential equipment and IRS commodities was done in good time and insecticide contact on the use of distributed to the operations sites a week before the SOPs training. All personal protective equipment. categories of workers with expected exposure to insecticide received personal protective equipment training either at the TOT or during the cascaded trainings (for SOPs, team leaders, washers, storekeepers, etc.). 2g. Train operators on mixing The TOT emphasized sprayer maintenance and correct insecticide No outstanding issues insecticides and the proper use and mixing procedures. The same session was included in the SOP/team maintenance of application equipment. leader training with specific demonstration of how to properly clean sprayers using the progressive-rinsing procedure and to ensure thorough cleaning of sprayer parts at the end-of-day clean-up. 2h. Provide adequate facilities and All 70 operations sites had storage facilities equipped with adequate No outstanding issues supplies for end-of-day cleanup. wash areas and soak pits for end-of-day clean-up. These facilities were inspected during the Pre-spray Environmental Compliance Assessments, and deficiencies were fixed before insecticide distribution to the site was authorized. The project supplied soap, water, and washing containers for all sites. 2i. Enforce application and clean-up Team leaders and site managers were responsible for enforcing end-of- No outstanding issues All incidents of non- procedures. day clean-up procedures. In all, 75 end-of-day clean-up inspections compliance were were conducted and only one incident of non-compliance reported. corrected immediately. 3a. Implement Information, Education The project trained neighborhood health committee members (NHC) No outstanding issues and Communication (IEC) campaigns as community mobilisers to conduct community meetings and door- to inform homeowners of to-door community mobilization and sensitization on IRS. As part of responsibilities and precautions, the IRS trainings, community mobilizers were trained to inform including washing itchy skin and going homeowners about their roles and responsibilities before, during, and to health clinic if symptoms develop after spray protocols for household safety. Households were sensitized and do not subside. to wash itchy skin with plenty of water and soap and, if itching persisted, to contact the nearest clinics. Out of 297 inspections of homeowner preparation, only three beneficiaries claimed that they were not informed of potential reactions to insecticide exposure. There were no reports of failure to inform a homeowner on referral to a clinic in case of exposure. All districts conducted radio programs as part of the IEC campaign

Outstanding Issues Relating Mitigation Measure Status of Mitigation Measures to Required Conditions Remarks 3b. Ensure health facility staff are aware Staff from partnering health facilities across all 70 operations sites No outstanding issues of insecticide poisoning management. received orientation on insecticide selected for 2020 IRS. Material Safety Data Sheets were shared with the health workers after the orientation to assist with managing possible exposures. 4a. Storage facilities and transportation All storage facilities had secured doors with double locks, and windows No outstanding issues vehicles must be physically secured to with bars and screens. All vehicles (pick-ups/buses) had secured a prevent theft. trunk/boot/bucket with a tarpaulin to ensure the safety of the insecticide during transport and to prevent theft. 4b. Maintain records of all insecticide All insecticide issued was based on quantification with appropriate No outstanding issues receipts, issuance, and return of empty approvals and accompanied by delivery notes. All insecticides received containers. at operations sites were recorded in the store ledger, and on individual stock cards for each item including both full and empty sachets. Additionally, all sachets issued to the field were serialised, and recorded in the insecticide tracking sheets. Out 83 completed store inspections, there were no instances of non-compliance. 4c. Conduct analysis comparing number The project treated 644,595 structures with 181,938 units of of houses treated vs. number of insecticide. The ratio is 3.5 structures per a unit of insecticide. containers used. VectorLink Zambia monitored the usage ratio on a weekly basis to ensure the consumption was in line with the plan. 4d. Examine houses treated to confirm Wall cone bioassays conducted 2 days after spraying established that application. the walls received high-quality insecticide application based on the results of 100% mosquito mortality. 4e. Perform physical inventory counts Supervisors carried out 83 storekeeper performance inspections in all No outstanding issues during the application season. 70 stores. Of the 83 inspections, 0 reported a balance on the stock card that did not equal the result of a physical stock inventory counts. 5a. For shipments of insecticide over Insecticides for the two islands was packed in barrels with a watertight No outstanding issues water, sachets/bottles will be packed in lid and locking ring. PPE, including personal flotation devices, was 220 liter open top barrels with a water- worn at all times, the barrels were labelled with all details of the tight top and a locking ring, or in a insecticide before water crossing occurred. The water crossing was led similar durable container. Waterproof by the project ECO. labeling must be affixed to the barrel, with the identity of the pesticide, number of bottles inside, the weight, the type of hazard posed by the contents, and the personal protective

55 Outstanding Issues Relating Mitigation Measure Status of Mitigation Measures to Required Conditions Remarks equipment to be worn when handling the barrel. 5b. Train applicators on the SEA The VectorLink project team trained all cadres of IRS actors on how No outstanding issues operational requirements, SOPs, PMI to handle insecticide in storage and in the field, how each type of waste BMPs, and approved Waste is generated during the campaign, and where each is to be stored, Management Plan, developed for the managed, and disposed of in accordance with the Safer Use Action safe and effective storage, distribution, Plan and the revised PMI BMP manual. application, and disposal of insecticides. 5c. Ensure application equipment and Adequate spare parts were made available at all operations sites. No outstanding issues personal protective equipment are Sprayer servicing and calibrations were conducted weekly to ensure the appropriate for the active ingredient right dosage of the active ingredient was applied. Personal protective used and in accordance with approved equipment use was enforced throughout the campaign. Out of 297 SOPs, and maintain equipment to avoid homeowner preparation and SOP performance inspections, there was leaks. no instance where an SOP was not using personal protective equipment appropriately. Pump leakage was reported in only 3 instances. These were resolved promptly. 5d. Maintain application equipment. Sprayer technicians carried out weekly calibration and oiling of the No outstanding issues sprayers, replacing worn-out nozzles and nozzle sieves. 5e. No application of insecticides within There are no known beekeeping sites across the IRS districts in No outstanding issues 30 yards of beekeeping sites. Zambia. However, TOTs and SOP trainings emphasized keeping any beehives at least 30 meters away from spray areas. 6a. Handling, treatment, and disposal of Non-hazardous wastes were recorded and stored away from No outstanding issues nonhazardous (general waste) and contaminated wastes. Non-contaminated cardboard from the hazardous wastes must be in accordance insecticides will be sold to a vendor dealing in recying of non with the approved Waste Management consuptive materials using the project procurement process in late Plan /SOPs and the PMI BMPs. The December. All hazardous wastes were recorded, labeled, and kept in WMP, which outlines SOPs for the stores while awaiting disposal either by incineration by ZAMRA managing waste processes, must be in and MCM and Lusaka city council. Uncontaminated coverall, boots, accordance with PMI best practices and bags and helmets not appropriate for IRS will be donated to hard- host country requirements working and deserving SOPs. 6b. Choose sites for disposal of liquid Locations for all 68 fixed soak pits and 57 MSPs were selected jointly No outstanding issues wastes, including fixed and mobile soak with the PHO and DHO representatives, with consideration for liquid pit sites according to PMI BMPs waste disposal that accumulated from washing of personal protective equipment as prescribed in the revised PMI BMP guidelines.

Outstanding Issues Relating Mitigation Measure Status of Mitigation Measures to Required Conditions Remarks 6c. Construct fixed and mobile soak pits Twenty new fixed soak pits and 57 mobile soak pits were constructed No outstanding issues with charcoal according to the BMPs to in with the appropriate charcoal stacked as prescribed in the revised adsorb insecticide from rinse water. PMI BMP guidelines. 6d. Maintain soak pits as necessary All soak pits were in good shape and absorbed waste water without No outstanding issues Future soak pit during season. puddling during the campaign. Results from the End-of-Day Clean-Up rehabilitation will form on soak pit performance were reported. follow the directive that says all soak pits will be blocked from receiving water from the wash area during the off-season. 6e. Monitor waste storage and All solid wastes were recorded, properly labelled, and moved from the No outstanding issues management during campaign. site offices to district offices for final inventory and then to the central warehouse for disposal. Of 83 inspections carried out, there was no report of contaminated items not separated from non-contaminated waste. 6f. Monitor disposal procedures post- The ECO and ZEMA will monitor the disposal and ensure adherence No outstanding issues campaign of personal protective equipment usage during the disposal. 7a. Wastes will only be disposed in All solid wastes for recycling will be sent to Lusaka city council No outstanding issues incinerators that comply with PMI cleansing depot, and all for incineration will be sent to ZAMRA and BMPs Collect and maintain treatment MCM. These facilities meet specifications of the PMI BMP guidelines and disposal documents and records on and are licienced by ZEMA. file. 7b. Country-level USAID EC Both liquid and solid waste disposal procedures were aligned with the No outstanding issues documentation must contain guidance Safer Use Action Plan and in accordance with the revised PMI BMP on proper disposal of wastes guidelines.

57 ANNEX C: SUCCESS STORIES

Entomologists Take Testing Matters into Their Own Hands: PMI VectorLink Adapts Entomological Tool to Ensure Insecticide Residual Efficacy Testing Continues during COVID-19 August 5, 2020 – When COVID-19 began to ripple across the globe, the Government of Zambia quickly put in place strict lockdown measures to prevent the spread of the virus. In response, the U.S. President’s Malaria Initiative (PMI) VectorLink Project rapidly adapted core malaria vector control interventions, namely indoor residual spraying (IRS) and distribution of insecticide-treated nets (ITNs), following PMI and global guidelines, to minimize the risk of COVID-19 infection while continuing to protect communities from malaria and prevent further strain on health systems during the pandemic. Field assessments to measure the impact of these interventions, however, were interrupted due to the increased risk of transmission of the coronavirus. Impact assessments are critical to generating timely information to inform decisions on optimal vector control approaches and rational use of resources. PMI VectorLink conducts wall cone bioassays to assess how long the insecticide sprayed on walls during IRS remains effective. The longer the insecticide lasts, the longer household members are protected from potential malaria vectors. The traditional method of conducting wall cone bioassays involves the use of mouth aspirators to transfer mosquitoes from holding cups to cones attached on sprayed walls and back to holding cups after the insecticide exposure period. Because staff cannot keep their face coverings on and perform mouth aspiration at the same time, this step was temporarily suspended in Zambia and other PMI VectorLink country VL Zambia Insectary technician Justine entomology programs. Nzowa uses the handheld aspirator. To continue measuring efficacy while maintaining safety precautions, PMI Photo: Mohamed Bayoh VectorLink ordered handheld, battery-operated aspirators to conduct the cone assays, which would allow staff to keep their protective face coverings on while conducting the tests. The design of the aspirators, however, made it difficult to release mosquitoes from the collection vial inside the unit into the cone on the wall or the holding paper cups. The team responded quickly, modifying the aspirator to improve the mosquito release function, and then deploying them after training for field staff was conducted on their proper use. The field teams are now using the modified aspirators for wall cone bioassays to monitor the insecticide’s residual efficacy on walls while safely wearing their protective face coverings and maintaining social distance. This adaptation is also being replicated in other VectorLink country programs. As of June 2020, the cone bioassays have shown positive results, with residual efficacy of eight months. This means that the insecticides used during IRS (Fludora Fusion and SumiShield) last throughout the malaria transmission season, providing longer protection to the communities than the previous insecticide used. Without the aspirator innovation, testing during COVID-19 would not have been possible. Knowing that the insecticide lasts longer allows the National Malaria Elimination Program (NMEP) and PMI to begin IRS earlier next year before the rainy season begins, ensuring hard-to-reach areas are protected and that people do not have to bring their belongings out of the house and into the rain during spraying. “The VectorLink Zambia team’s coordinated effort to ensure continuity in residual efficacy monitoring by successful modification and testing of handheld aspirators for deployment in the field was much appreciated,” said Dr. Emmanuel Kooma, Head of Vector Control, at the NMEP. “I am particularly satisfied that the method can safely be used as a replacement to the conventional mouth aspirators for the wall bioassay tests, a needed intervention during this pandemic.”

58 Carrying on IRS in Zambia during COVID-19: PMI VectorLink Zambia Implements COVID-19 Mitigation Measures and Successful 2020 IRS Campaign December 18, 2020 – When cases of COVID-19 were first recorded in Zambia, the Ministry of Health quickly established strict guidance to prevent the spread of the virus. These measures were received with some apprehension about the prospect of continuing malaria prevention activities during COVID-19. The PMI VectorLink Project, funded by USAID and the US President’s Malaria Initiative (PMI), supports the implementation of both indoor residual spraying (IRS) and distribution of insecticide-treated nets (ITNs), along with entomological monitoring to guide vector control decision making. After extensive consultation and in alignment with national as well as PMI and global guidelines, VectorLink developed tailored adaptations to mitigate the risk of COVID-19 infection while protecting the communities from malaria in the three IRS target provinces, and four ITN target provinces where the project works. This guidance was shared with and validated by key stakeholders – the National Malaria Elimination Program (NMEP) and PMI – before implementation. In accordance with the guidance, recruitment and training of hundreds of seasonal workers was conducted outdoors (in some cases under open tents) to allow for proper ventilation. Hand wash stations were set up at the entrance. All participants had their temperature checked upon arrival, were required to wear facemasks and maintain social distancing throughout the duration of the training. Advocacy meetings with district and traditional leaders adhered to the same measures. During IRS implementation in 15 districts across three provinces, the same safety standards of daily temperature checks, provision of hand washing facilities, outdoor assemblies, adhering to full PPE use including N95 facemasks, were replicated. VectorLink also secured additional vehicles to ensure that spray teams maintained social distancing while being transported to and from the communities. COVID-19 posters were Temperature screening at a displayed at all 70 IRS operation bases. Spray training in Petauke. teams were also provided with hand sanitizing wipes to wipe down their gloves after spraying each house. All mobilizers who worked with spray teams in the communities were provided with facemasks. Other members of the project team also adhered to the same safety standards. Project data entry clerks waited a minimum of 24 hours to process data collection forms, entered spray data under open tents, and wiped down their dedicated laptops prior Storekeeper Training took place to and at the end of each workday. The project entomology team, whose role is to under a tent in Copperbelt assess the quality of spray using mosquitoes and follow up on how long the spray Province. insecticides lasts on the sprayed surfaces, observed the same standards. These rigorous safety measures, which cut across every aspect of implementation, ensured that the 2020 IRS campaign, which utilized more than 2,500 seasonal staff over a 30-day period, sprayed more than 640,000 structures (96% spray coverage), and protected more than 2.7 million Zambians from malaria, did not record one incident of COVID-19. The Head of Vector Control at the NMEP, Dr. Emmanuel Kooma, summed it up thus… “It was a tense situation conducting IRS under the COVID environment. However, I thank VectorLink for strictly observing the COVID prevention guidelines such that we never recorded a single case of COVID. The job is done – a huge relief on my part.”

A spray operator uses handwashing station Recruitment for seasonal staff: Lufwanyama Data Entry Clerk Trainings while morning mobilization is conducted at Chikando Site in Eastern Province.

59 PMI Pilots Integrated, Global Database with IRS and Entomological Data to Manage and Guide Timely-Vector Control Decisions Insecticide resistance is rising across the globe, threatening the massive gains made in the control of malaria over the past 15 years. These gains can be attributed to the increased use of indoor residual spraying (IRS) and insecticide-treated nets (ITNs), which use insecticides to kill or repel mosquitoes that carry the malaria parasite. Timely, evidence-based vector control decision-making is essential to ensuring the most effective insecticides are being used. The U.S. President’s Malaria Initiative (PMI) VectorLink Project conducts robust entomological monitoring efforts to understand malaria vectors – species that carry malaria – and their geographical and temporal distribution, feeding and resting behaviors, and resistance to insecticides. In 2018, PMI VectorLink developed a comprehensive District Health Information Software (DHIS2)-based data management system, VectorLink Collect, to support routine IRS data needs across project countries. Now, the project is expanding the database to manage entomological data across 17 African countries. This advancement enables PMI-funded IRS and entomological data to be managed in a single system, and supports improved data quality and integrated analytics. VectorLink Collect also allows both internal and external decision- makers, such as National Malaria Control and Elimination Programs (NMCP/NMEP), and PMI/USAID in the U.S. and in country, to access comprehensive data at multiple levels. Furthermore, building VectorLink Collect on DHIS2, a platform that is used by Ministries of Health in every PMI- focus country where VectorLink works, Several remote training sessions on the new programs in VectorLink also supports country-level priorities and Collect were cascaded to the entire VectorLink Zambia entomological systems, and aligns with PMI’s goal to team, empowering the team to begin data entry and management support sustainability and the journey to within the VectorLink Collect system. self-reliance. The project piloted the VectorLink Collect entomology instance in Zambia in February 2020. The Zambia country team had already been using VectorLink Collect for IRS data, and carries out comprehensive entomological activities. The pilot has helped the project to better understand data workflow needs, quality review processes, and general ease of use of this new system for entomological data. The VectorLink Zambia team provided comprehensive feedback and recommendations to inform critical updates to program design and minimize challenges as more countries start using the system. It became apparent that certain field work factors, such as the remoteness of collection sites, needed to be accounted for in determining realistic data entry timeframes. In addition, Zambia introduced a monthly plan to guide data review and data entry processes and expectations. The successful pilot concluded in April 2020, and the project continues to enter ongoing entomological data into VectorLink Collect. The success of this important pilot and overall positive feedback from the VectorLink Zambia field entomologists and data managers supports the use and expansion of VectorLink Collect for entomological data. It formed the basis for finalizing training approaches for the broader roll out to remaining country teams. This is especially valuable as all trainings will now be conducted remotely. The use of VectorLink Collect for entomological data will allow for an integrated, global database to manage and use timely data to guide malaria control work. Rabecca Ngwira, VectorLink Zambia entomology field coordinator, said, “We have longed for a system that allows rapid generation of entomological data summaries and graphical representations without a need for elaborate Excel worksheets and complicated use of formulae, and here we have it in the VectorLink Collect.”