USAID/ Systems For Better Health Quarterly Progress Report April–June 2018

July 2018

This publication was produced for review by the United States Agency for International Development. It was prepared by Abt Associates for the USAID Systems for Better Health activity.

Contract No: AID-OAA-I-14-0003 Order No: AID-611-TO-16-00001 GUC Mechanism

Submitted to: William Kanweka Contracting Officer’s Representative USAID Zambia

Prepared by: Abt Associates Inc.

In collaboration with: American College of Nurse-Midwives Akros Inc. Initiatives Inc. Save the Children

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

Contents

Contents ...... i Acronyms ...... ii 1. Introduction ...... 4 2. Highlights ...... 6 3. Progress by Task ...... 8 3.1 Task One: Design, Implement and Monitor National Level Interventions to Strengthen Health Stewardship by the MOH ...... 8 3.1.1 Sub-Task 1.1: Strengthen Human Resources Planning and Management ...... 8 3.1.2 Sub-Task 1.2: Improve HCF and PFM ...... 10 3.1.3 Sub-Task 1.3: Strengthen MOH Capacity to Oversee Delivery of Key Health Programs ...... 11 3.2 Task 2: Design, Implement, and Monitor Interventions to Strengthen Program Management Capabilities of Provincial and District Teams ...... 17 3.2.1 Sub-Task 2.1 Strengthen Program Management Capacity ...... 17 3.2.2 Sub-Task 2.3: Improve Districts’ Capacity to Manage Government-to-Government Funding for the RMNCAH&N COC Program ...... 17 3.3 Task 3: Support the Government and CBOs to Increase the Quality, Availability, and Use of Health Services ...... 28 3.3.1 Sub-Task 3.1: Improve the Capacity to Deliver Quality Health Services in the Community ...... 28 3.3.2 Sub-Task 3.2: Strengthen Linkages between the Facility and the Community ...... 32 3.4 Cross-Cutting Technical Areas ...... 32 3.4.1 Task 4: Grants under Contract ...... 32 3.4.2 Task 5: Research, Monitoring, and Evaluation (RM&E) ...... 34 4. Project Management ...... 36 4.1 Finance and Administration ...... 36 4.2 Overall Budget and Expenditures ...... 36 4.3 Personnel ...... 36 5. Success Stories ...... 37 Annex I: COC Activity Report by Province ...... 40 Task 2: Design, Implement, and Monitor Interventions to Strengthen Program Management Capabilities of Provincial and District Teams ...... 40 Sub-Task 2.3: Improve Districts’ Capacity to Manage Direct Grants for the RMNCAH and Nutrition Continuum of Care Program ...... 40 Annex II: Performance Indicator Tracking Table ...... 65

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Acronyms

AMEP Activity Monitoring and Evaluation Plan ART Antiretroviral Therapy CBO Community-based Organization CBV Community-based Volunteer COC Continuum of Care DHIO District Health Information Officer DHIS2 District Health Information System Version 2 DHO District Health Office DQA Data Quality Assessment DUO Data Use Officer EmONC Emergency Obstetrics and Neonatal Care HCC Health Center Committee HCF Health Care Financing HEI HIV-Exposed Infant HIA Health Information Aggregation HMIS Health Management Information System HRH Human Resources for Health HRHSP Human Resources for Health Strategic Plan HRIS Human Resources Information System ICT Information and Communication Technology M&E Monitoring and Evaluation MOH Ministry of Health MSI Management Systems Inquiry MTEF Midterm Expenditure Framework NHC Neighborhood Health Committee NHI National Health Insurance PA/ePA Performance Assessment/electronic Performance Assessment PFM Public Financial Management PHO Provincial Health Office QI Quality Improvement RM&E Research, Monitoring, and Evaluation RMNCAH&N Reproductive, Maternal, Neonatal, Child and Adolescent Health and Nutrition

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SBH Systems for Better Health SHIO Senior Health Information Officer TOR Terms of Reference TWG Technical Working Group USAID United States Agency for International Development ZAMFAM Zambia Family Project ZISSP Zambia Integrated Systems Strengthening Project ZMLA Zambia Management and Leadership Academy

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1. Introduction

The five-year United States Agency for International Development (USAID) Systems for Better Health (SBH) activity in Zambia was awarded to Abt Associates, Inc. in October 2015. Abt has been implementing SBH in collaboration with partners American College of Nurse-Midwives, Akros, Inc., Broad Reach Institute for Training and Education, Initiatives, Inc., Imperial Health Sciences, and Save the Children. Until March 2018, when USAID reviewed the scope of work of SBH, the goal of the project was to improve health outcomes for Zambians by strengthening health systems that underpin the delivery of high-quality health services and increasing the utilization of high-impact health interventions at district and community levels. The following were the expected outcomes of the activity before the review:

1. More effective national-level health stewardship; 2. Improved capacities of provincial and district health teams to perform program management functions; 3. Increased quality and availability of priority health services at the community level in targeted districts; and, 4. Increased utilization of key public health interventions. Before the review, the project had the following specific objectives:

• Retention of patients on antiretroviral therapy (ART) increased to at least 85 % in targeted districts; • Couple years of protection increased by 10% in targeted districts; • The proportion of deliveries with assistance from a medically trained provider increased by 20 % in targeted districts; and • At least 80 % of children aged 12 to 23 months fully immunized in targeted districts. Following the revision of the scope of SBH in March 2018 and the resulting cuts in major activities, the main areas of focus that have remained from the original SBH scope include Human Resources for Health (HRH) and Health Care Financing (HCF) work at the central level. For HRH, the focus remains on supporting Human Resource Information Systems (HRIS), and supporting the Ministry of Health (MOH) to develop the HRH strategic Plan 2017-21, the Health Worker Deployment and Retention Strategy, and the Health Worker Induction Manual. Performance Management Package support to MOH was phased out.

Also under HRH, the component supporting midwifery training schools through SBH implementing partner American College of Nurse Midwives will be phased out once the following remaining activities are concluded in September 2018: training of tutors and clinical instructors from seven midwifery schools in midwifery skills simulations (planned for July), and printing and dissemination of the draft Midwifery Training Skills Manual and introduction of Objective Structured Clinical Examination Skills in the midwifery examination curriculum in September.

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SBH will continue to support systems development and strengthening for HCF which include National Health Insurance (NHI), National Health Accounts (NHA), and planning. However support to MOH planning will be phased out in September 2018.

System strengthening support to MOH Technical Working Groups (TWG) will continue, including support to MOH Quality Improvement (QI) at central and provincial level only. Nutrition support to five districts in Eastern province will be phased out in July 2018.

System strengthening support to central, provincial and district level MOH on HIV, Reproductive, Maternal, Neonatal, Child, Adolescent Health and Nutrition (RMNCAH&N), Zambian Management and Leadership Academy (ZMLA), supply chain management, and community health were all phased out in April 2018. This included the phasing out of the grants to community-based organizations (CBOs) and faith-based organizations, as their agreements expires for each of the two cohorts in May and September 2018. The review of SBH scope also led to the termination of 42 personnel at the end of previous quarter.

However, SBH’s systems strengthening technical assistance role on the RMNCAH&N Continuum of Care program, (COC) in public financial management (PFM), enhancing use of HMIS data for decision making and RMNCH&N program performance in 72 districts started peaking in the quarter under review.

This quarterly report summarizes the progress and achievements for the second quarter of Year Three, April to June 2018, based on the revised SBH scope of work. It includes only those sub-tasks and activities where significant progress was made during the reporting period. This report follows the structure of the revised Annual Work Plan for 2018 approved in April 2018.

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2. Highlights

This section highlights the most notable achievements of SBH during the reporting quarter:

• Project management: During this period, SBH successfully faced the major management challenge of operationalizing both a contraction (significant cuts in budget, scope, staff) and an expansion (roll out of COC activities in the provinces) simultaneously. These changes required significant time and effort from the project’s senior management. Against this backdrop, SBH continued implementing its “classic” activities and launched the new COC activities in full steam, achieving important results at all levels. • Improving HRIS monitoring: SBH developed and helped the MOH apply an assessment tool to collect data on HRIS utilization at district level. Based on the results, the MOH will provide mentorship and on-the-spot support to districts on HRIS. This tool will allow the MOH to monitor and support HRIS use, ensuring that previous investments in HRIS roll out, including training, yield results. • Finalization of HRHSP: in June 2018 the MOH finalized the 2017-2021 HRHSP, with significant technical support from SBH in every step. The HRHSP will serve as a roadmap for the MOH to ensure proper HRH management at all levels throughout the country. A notable aspect of this HRHSP is that the MOH provided true leadership in its development, while also benefiting from a lot stakeholder input. This is an important factor for the sustainability of the plan. • First ever Health Worker Induction Package approved: the Health Worker Induction Package, which SBH helped the MOH to develop, was finalized and approved this quarter. The package, the first of its kind in Zambia, will standardize the staff induction process across the MOH. • Introducing NHI in Zambia: in April 2018, the NHI Bill, which SBH helped draft and advocate for, was signed into a law by the President of Zambia. SBH has been recognized by the MOH as a “trusted partner” due to the project’s leadership in technical support for the NHI scheme. • Another step towards NHA institutionalization: this quarter the Ministry expressed its intention to build a permanent NHA team. This marks another important milestone in the sustainability and continuity of NHA in Zambia. During the quarter SBH helped the MOH finalize the 2013-2016 NHA report, which will be disseminated in July. • Institutionalizing QI within the MOH: in April 2018 the MOH created a new Department for QI, Performance Improvement and Monitoring an Evaluation (M&E). The creation of this department is in large part the result of longstanding advocacy efforts by SBH and its predecessor project, the Zambia Integrated Systems Strengthening Project (ZISSP), for a greater central MOH leadership role in QI. SBH intensified this advocacy after noticing a decline in QI activity following the closing of ZISSP. The new department will help avoid the same situation after SBH’s closing, reducing donor dependency and improving the sustainability of QI in Zambia. • Quick wins in COC districts: SBH has hit the ground running with the COC activities, quickly achieving the first set of milestones, including:

o Approximately 90% of districts are using their RMNCAH&N scorecard to conduct evidence- based planning

o 94% of districts finished entering population data into DHIS2 to generate their RMNCAH&N scorecards

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o 100% of DHOs/PHOs conducted Performance Assessment (PA) in at least 80% of their facilities/DHOs with a final report

o NAV implementation nearly complete, with 100% of districts completing six out of nine milestones • Improving pediatric HIV services in Kitwe: SBH registered an additional 209 children in the Kitwe HIV Linkages Activity, bringing the total number of enrolled children to 1,334. Using the PedTrack system and the activity caseworkers, the participating facilities achieved 100% success rate in bringing clients who missed their appointments back into care and treatment services. To date, the 12-month retention rate for clients enrolled in the activity is 76% (March 2017-March 2018).

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3. Progress by Task

3.1 Task One: Design, Implement and Monitor National Level Interventions to Strengthen Health Stewardship by the MOH During Quarter Two of Year Three, SBH has continued to provide essential support to strengthen health stewardship at the central MOH to support HRH and HCF and the nutrition component of health program management, which will be phased out in July 2018. Task 1 focuses on supporting the development, review, implementation, and monitoring of key MOH strategies and plans, and strengthening the implementation of existing systems and processes.

3.1.1 Sub-Task 1.1: Strengthen Human Resources Planning and Management Sub-Task 1.1.1 Strengthen Routine HRH Planning and Management Fora

Activity 1.1.1.2 Support annual HRH review meeting

In the quarter under review, SBH provided technical and financial support for the seven-day HRH review meeting which included 71 participants from the central MOH HR Departments, as well as provincial Senior HR Officers, Provincial Health Directors and Senior Medical Superintendents.

During the meeting, participants assessed performance during the first quarter of 2018 against annual HRH plans and the targets in the draft Human Resources for Health Strategic Plan (HRHSP). The review revealed that the MOH only completed 60% of the planned activities for the first quarter of the year primarily due to financial constraints. However, the meeting participants also observed areas that could still improve performance without financial resources such as monitoring the performance of HRIS and the cascading of the Performance Management Package. Participants developed a performance improvement action matrix in line with the expected performance targets in for the year. SBH’s contribution to the meeting included consolidating the presentations and editing the final report. The SBH HRH Specialist also developed and delivered a presentation at the meeting on change management and the new HR competencies required by the new HRHSP, linking HRH policy and MOH objectives.

Following SBH support in 2017 to train 97 MOH HR officers in Eastern, Southern, Central, and Copperbelt provinces on HRIS in quarter one of 2018, this quarter SBH assisted the MOH to monitor progress at the district level in validating and augmenting the initial HRIS data. SBH supported the MOH to carry out assessments of the performance of the districts after the HRIS trainings in Central and Copperbelt Provinces. SBH developed the assessment tool which was used to collect data on the HRIS utilization, the first assessment of this kind to be conducted in Zambia. The assessments showed variations in systems utilization rate, and improvements in data entry varied from district to district. Based on the assessment results, the MOH provided mentorship and

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on-the-spot support, including developing timelines for the completion of HR data entry and validation in each of the districts visited.

Sub-Task 1.1.2 Support the Development and Dissemination of Key HRH Strategies, Guides, and Policies

Activity 1.1.2.1 Support the development of the Health Worker Deployment and Retention Strategy

To ensure that the Health Worker Deployment and Retention Policy is evidence-based, SBH provided technical support to the MOH to initiate data collection and conduct a series of consultative meetings to develop the policy. The MOH established a team in the HR Administration Department to draft an outline to identify the information required in the policy. The policy will articulate the factors the MOH considers when posting health workers and how long the health workers must stay in an assigned post before they are eligible for a transfer. The policy will also stipulate the bonding period which new graduates will be required to serve in a MOH position to reciprocate for the scholarships or financial support provided by the Zambian government for their education. SBH will work with MOH to design a tool to measure changes which result from implementation of the new policy and will report on the indicators during the HRH quarterly review meetings.

Activity 1.1.2.2 Orient MOH staff to the new Health Worker Induction Package

SBH supported the MOH to finalize and format the Health Worker Induction Package after the HR Administration Department made its final edits. The MOH approved the document and SBH will assist with printing and dissemination in July. The MOH will track the number of staff inducted with the new package and report through the HRIS monthly. The package will improve adherence to MOH systems and procedures by ensuring that newly-hired staff are properly oriented to them.

Activity 1.1.2.3 Contribute to the development of the 2017-2021 HRHSP In quarter one of 2018, SBH provided technical and financial assistance to the MOH to draft its HRHSP. In the quarter under review, SBH provided the MOH with technical and financial support to conduct a consultative workshop with the province and district representatives from the Eastern, Southern, Western and Cluster. During the workshop the MOH sought comments from the subnational level representatives to improve the draft HRHSP. SBH’s contribution included developing the workshop process and assisting in the compilation of the contributions from the workshop participants, which were then consolidated into the HRHSP. SBH also provided guidance into the overall roadmap and comments on the final draft of the HRHSP. The HRHSP was finalized in June 2018 after the consolidation of comments from the provinces and other stakeholders. SBH supported the printing of 500 copies within the same month in readiness for the launch of the strategy (launch date to be determined). The HRHSP will serve as a roadmap for the MOH to strengthen health services by ensuring proper HRH management at all levels throughout the country. A notable aspect of this HRHSP is that the MOH provided true leadership in its development, while also benefiting from a lot stakeholder input.

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3.1.2 Sub-Task 1.2: Improve HCF and PFM Sub-Task 1.2.2 Support the Development and Operationalization of Key HCF Strategies, Guides, and Policies

Activity 1.2.2.1 Support the operationalization of the HCF Strategy (HCFS) through the development of an HCFS Action Plan

The HCFS recommends the introduction of “sin taxes” on alcohol, tobacco and sugary beverages and the earmarking of the revenues from these taxes for health for the prevention and management of non-communicable diseases. SBH provided technical assistance to the Department of Health Care Finance to write a memo about the sin taxes for Cabinet’s consideration in the 2019 annual budget. The MOH discussed the memo with other ministries to build their support for a Cabinet decision to increase and earmark the taxes for health in the 2019 National Budget. If approved, this measure will significantly increase domestic funding for health in Zambia. The HCFS action plan has not yet been developed, but there are discussions for the drafting of the plan in the third quarter of 2018.

Activity 1.2.2.2 Support the development of NHI Since the beginning of the year SBH has been the lead partner in providing technical assistance to the MOH in the development of NHI, and thus has attained “trusted partner” status with the MOH for its NHI support. Following parliament approval of the NHI bill in April 2018, SBH provided technical support by helping the MOH to develop a communications strategy which will guide the MOH’s efforts to explain NHI to the public. SBH also helped to draft an NHI implementation plan for the period April to December 2018.

In the period under review SBH provided technical support to draft the NHI regulations which were later reviewed by a technical team from the MOH. SBH also supported the development of a concept note and terms of reference for the engagement of a third party private administrator to manage the NHI systems. The MOH will advertise for expressions of interest in response to these terms of reference in July 2018.

SBH assisted the MOH by developing a proposed methodology for the definition and estimation of the cost of the NHI benefits package. The benefits package will guide policy decisions on what benefits to include in the NHI package and estimate the required resources for the provision of this package. SBH also drafted an NHI position paper to assist the MOH HCF team to respond to a request from the Secretary to the Cabinet on the acceptability, viability, and sustainability of the proposed NHI scheme.

Sub-Task 1.2.3 Strengthen Evidence-based Planning and Resource Allocation

Activity 1.2.3.1 Support NHA SBH assisted MOH to collect data, analyze and finalize the NHA report for 2013-2016 with input from the World Bank. The MOH expects to share the final report during the TWG meeting in July 2018 to present the main findings from the NHA. The MOH will begin data collection for the 2017 NHA in September 2018. The MOH plans to build a permanent NHA team in the Ministry to enhance ownership and sustainability.

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Activity 1.2.3.2 Support the annual planning process at the central level During the past planning period, MOH program managers experienced challenges with the situation analysis, bottleneck analysis, and the logical framework steps of the planning process. To respond to this challenge, SBH worked with the Planning Department to remove unnecessary steps, improve the logical flow, and provide a clearer explanation of the situational analysis requirements in the planning handbooks for provinces, districts, hospitals, health centers and communities, and training institutions. This has improved consistency across the handbooks. The aim of these refinements are to simplify the planning process.

In 2018 the government instructed all ministries to shift from activity-based budgeting to output- based budgeting. This will require the MOH to adapt the handbooks and budgeting tool to align it to the output-based budgeting approach. In view of this, the launch of the 2019-21 midterm expenditure framework (MTEF) MOH planning cycle has been delayed and systems have not yet been put in place by the MOH to change the approach to output-based budgeting. As a result, the MOH will use the existing Activity Based Budgeting for 2018 to allow systems to be put in place to transition the approach in the 2020-2022 MTEF planning cycle.

Meanwhile, at the central level, program staff in the various departments continued to review the indicators and identify priorities for the technical updates to guide the implementation levels during the launch. In the 70 COC districts, SBH technical specialists initiated the planning process with the districts by reviewing the health program indicators, setting priorities, and identifying potential interventions (see Activity 2.3.4.1).

3.1.3 Sub-Task 1.3: Strengthen MOH Capacity to Oversee Delivery of Key Health Programs Sub-Task 1.3.1 Strengthen Routine Health Program Planning and Management Fora

Activity 1.3.1.1 Support review and improvement of TWG terms of reference (TOR) and procedures

SBH assisted the MOH Planning Department to organize a meeting with TWG leaders. With SBH technical support the Planning Department prepared a standard template to guide the TWG leaders on the correct format and content for the TORs and requested that all TWG leaders submit the revised TORs in June. The meeting participants recommended that all TWG TORs should have a standard format and that TWGs should establish and share a schedule of meetings with all members and the Planning Department. Participants suggested that the MOH Permanent Secretary should chair a semiannual meeting with all TWG chairpersons and secretaries to learn from one another about how TWG can improve coordination between the MOH and its partners, and learn and share best practices. These improvements to TWG operations will help make them more effective and results-oriented.

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Sub-Task 1.3.2 Strengthen Central MOH Capacity to Develop and Implement Health Program Management Systems

Activity 1.3.2.1 Strengthen structures, systems, and tools for PA at the central level The MOH Department of Clinical Care and Diagnostics shared PA guidelines drafted in 2017 with SBH technical support with the Permanent Secretary for Administration and other senior managers who provided comments on the guidelines. The Clinical Care Department worked with the QI, Performance Improvement, and M&E Department to incorporate all contributions and addressed comments. Central MOH personnel joined the PA in the Western and Northwestern provinces and field-tested the draft PA guidelines. During PA, the central MOH team shared the draft guidelines with Provincial and District Health Offices (PHOs and DHOs) and health facility participants to gather their input. The MOH Planning and Policy unit currently has the draft. SBH will follow up to ensure the inputs from the implementation level are incorporated, printed and disseminated.

Activity 1.3.2.2 Strengthen the structures, systems, and tools for performance review meetings. SBH began a discussion about developing guidelines and presentation templates for Provincial and District Integrated Meetings (PIMs and DIMs) with the newly formed Department of QI, Performance Improvement, and M&E.

SBH’s Health Management Information System (HMIS) Specialists assisted the MOH to update the automated RMNCAH&N scorecard in DHIS2 based on the M&E framework for the COC program developed in April in consultation with MOH program officers and other stakeholders. The revised scorecard is live on the DHIS2 instance, and the SBH provincial HMIS and Performance Management Specialists are explaining the scorecard to the DHO teams in the six COC provinces. The DHO teams will use the scorecard during DIMs to display the performance of their facilities over time to identify areas of poor performance and seek solutions.

Activity 1.3.2.3 Strengthen structures, systems, and tools for QI In April, the MOH formed a new Department for QI, Performance Improvement and M&E which is led by three directors. The department aims to improve the quality of service delivery to improve health outcomes in maternal and child health, nutrition, HIV/AIDS, malaria, and tuberculosis. The MOH will select key indicators that will be monitored and evaluated periodically through DIM/PIMs and promote use of QI approaches for problems solving. The creation of this department is in large part a result of longstanding advocacy by SBH and its predecessor project, ZISSP, for broadening the QI unit and appointing MOH staff to manage QI activities. It marks an important milestone in the sustainability of QI efforts beyond donor support.

SBH’s QI Specialist and Director of Technical Support met the MOH Director of Performance Improvement to discuss interventions for the new MOH department. The team discussed criteria for priority HMIS indicators which the MOH could track at all health system levels to focus the QI program, which should align with the National Health Strategic Plan 2017-2021.

The new department intends to engage the central MOH National Coordinators (specialist doctors) in technical and mentoring activities and to participate in developing templates for the PIMs and DIMs, which will improve the quality of discussions and productivity of these meetings.

SBH provided technical assistance to the new department to organize a QI TWG meeting in May chaired by the Permanent Secretary, during which he introduced the new department, its role, the

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structure at all levels of the health care system and emphasized the MOH’s commitment to improving quality of service delivery and performance at all levels. The MOH will appoint QI and Infection Prevention Coordinators at all levels of the health care system to ensure that all facilities plan and implement QI activities. Two presentations from both the MOH and partners highlighted poor data management in facilities as a major challenge, and the group discussed strategies to improve data quality.

In June, the newly formed department also disseminated the MOH QI and Clinical Mentoring Guidelines which were reviewed, printed and launched in December 2017 with support from SBH. SBH’s QI Specialist also supported the provincial dissemination of the guidelines in Eastern, Luapula, and Muchinga Provinces. During the dissemination the central MOH facilitators explained the key changes in the guidelines, how to use the Service Quality Assessment tool and demonstrated its use at a nearby hospital. The hospital and PHO personnel participated in the assessment and the detailed review of findings which followed.

Figure 1 shows an example of the Service Quality Assessment findings from Mansa General Hospital. The most common areas of weakness in the hospitals visited included data management, M&E, practice and use of guidelines, and infection prevention practices.

Figure 1. Service Quality Assessment findings – Mansa General Hospital

Finally, during the reporting period, SBH also supported a number of meetings related to QI:

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• The SBH QI Specialist supported a meeting for social workers from three tertiary hospitals in Lusaka (University Teaching Hospital, Chainama, and Levy Mwanawasa). During the meeting, participants learned that lack of standardized guidelines was making it difficult for social workers to meet client expectations of quality service. This issue was relayed to the Ministry of Community Development and Social Welfare. • SBH QI Specialist supported an HIV Differentiated Service Delivery meeting which involved representatives from the central MOH, University Teaching Hospital, the DHOs, and implementing partners. Participants focused on the quality challenges related to Differentiated Service Delivery implementation and ways to use QI to improve its delivery, coverage and impact. • The SBH QI Specialist supported the Lusaka PHO QI Forum where all districts presented their QI projects which were addressing antenatal or postnatal care coverage, improving early infant diagnosis of HIV, and HIV or adolescent health services. The forum participants pointed out problems with the current QI program and made recommendations which included: dissemination of QI tools to facilities and districts, standardization of the use of scorecards to track performance, increase in community involvement in QI activities, and increase the use of data to document QI projects for decision making. Sub-Task 1.3.3 Improve HMIS Implementation

Activity 1.3.3.1 Support the MOH on DHIS2 and HMIS SBH provides technical support to the central MOH M&E Unit to improve the use of DHIS2 and HMIS data. In the quarter under review, SBH helped the MOH M&E unit to update DHIS2 with revised Central Statistics Office population projections and to create data entry templates in DHIS2 to enable districts to enter data from the recently revised HMIS Health Information Aggregation (HIA) forms. SBH Specialists also updated DHIS2 visualizations including dashboards and the RMNCAH&N scorecard. SBH helped the MOH finish the prototype for the HMIS portal and is helping to finalize the content of the portal. The portal will enable anyone to view HMIS data online. SBH specialists helped the M&E team to upload and update missing GIS files for and in DHIS2. This DHIS2 update will enable all provinces to analyze their data more accurately by region, by utilizing the GIS Module in DHIS2.

Following the training of the MOH Information and Communication Technology (ICT) team on DHIS2 customization in 2017, SBH Specialists continued to provide mentorship support to the MOH Senior ICT Officer to use the programs and module within DHIS2 to develop the electronic PA (ePA) site. The SBH Specialists helped the MOH ICT team to migrate the ePA database to the DHIS2 platform. SBH specialist contributed to the design and development of the DHIS2 platform for ePA reports. SBH helped MOH program officers define the visual display for priority ePA findings. SBH plans to conduct a second round of training for the ICT Officers to enable them complete the migration of the PA data to the DHIS2 platform.

SBH Specialists also joined the MOH M&E team to train provincial MOH staff on the new HIA tools. The Specialists provided continued support through a WhatsApp group which links MOH personnel from the lower levels to central MOH M&E team. While the SBH Specialists initially provided most of the responses to the WhatsApp user group question, the M&E team has begun to provide user support more regularly. See sample screenshots below in Figure 2.

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Figure 2. Sample screenshots from MOH data quality and use Whatsapp group

SBH also provided technical assistance through a consultant to the MOH M&E team to hold a workshop to clean and maintain the DHIS2 database. The team mapped old data elements on the 2016 HIA2 form to the new data elements on the 2017 HIA2 which will enable users to see performance trends. Once complete, the team will delete the old data elements to improve system speed. During the mapping, the team extracted monthly data from 2013 to 2017 and imported it into the format. The team also created groups of related data elements groups. The workshop will continue during the first week of July, where participants will:

1. Map all data elements from the old MOH HIA2 form to the new data elements in the revised HIA2 to ensure accurate reporting 2. Assign all data elements to the correct data sets and remove redundant data elements from the system 3. Ensure that all DHIS2 labels for data element match the labels printed on the paper based forms 4. Update population figures in DHIS2 based on revised projections from the Central Statistics Office With SBH technical support, the MOH will make the DHIS2 database better organized, more reliable, and easier for users to understand. During this quarter the proportion of health facilities submitting HMIS reports monthly was 82%, up from 78% in the previous quarter; however only 42% of the facilities submitted their reports on time (though this represents a marked improvement from 21% in the previous quarter).

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Sub-Task 1.3.4 Strengthen Central MOH Strategies, Guidelines, Tools, and Materials for Health Programs

Activity 1.3.4.1 Strengthen materials and systems to support the implementation of nutrition policies The SBH Nutrition Specialist worked with the National Food and Nutrition Commission (NFNC) to ensure that Chipata, Petauke, Lundazi, Katete and Nyimba districts received the nutrition materials which SBH assisted the MOH and the NFNC to develop and print. The PHO distributed the following materials to the districts: trainers guide, participants manual, counseling cards, the operational framework, the guidelines, and the Zambia Complementary Feeding Book. The districts will distribute the materials to the facilities through DIMs or planning meetings. SBH will also assist the MOH to distribute the remaining materials to the other provinces.

The SBH Nutrition Specialist also helped to develop the Food-Based Dietary Guidelines during an NFNC and Ministry of Agriculture-led workshop. A consultant from the Food and Agriculture Organization helped participants to identify nutritional problems, develop dietary recommendations, and identify evidence to support the recommendations. The problems identified included: non-communicable diseases related to diet, micronutrient deficiencies, His Excellency, the President of the Republic of Zambia, Mr. undernutrition in children, under nutrition in Edgar Chagwa Lungu listens to Mrs. Dorothy Sikazwe, Chief women, and over-nutrition. The consultant will Nutrition Officer as she explains the important role of local consolidate the work done by each group so Zambia Foods in the promotion of health. The President visited the MOH nutrition booth during National Health that the participants can reconvene and review Week. The Minister of Health, Honorable Chitalu Chilufya, all the suggested recommendations. M.P, MCC, stands to the right of the President.

SBH supported the MOH Nutrition Unit to design and display a nutrition booth during the 2018 National Health Week. Zambia’s President supported National Health Week for the second consecutive year. The nutrition booth provided participants with nutrition services and information related to undernutrition especially among children and the rising problem of over-nutrition which contributes to increased risk of non- communicable diseases.

SBH helped the MOH Nutrition Unit set up a booth with nutrition educational materials, a display of local foods, and prepared complementary foods for babies. Booth personnel showed parents how to enrich maize meal porridge with protein-rich foods like pounded groundnuts, caterpillars, kapenta, soya flour, beans, pumpkin spinach, pumpkin, and cowpea leaves. The entire exhibit used local products which are abundantly available.

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3.2 Task 2: Design, Implement, and Monitor Interventions to Strengthen Program Management Capabilities of Provincial and District Teams 3.2.1 Sub-Task 2.1 Strengthen Program Management Capacity Sub-Task 2.1.1 Strengthen Leadership, Management, and Governance

Activity 2.1.1.1 Support ZMLA training Management and leadership has continued to be a challenge in the health sector affecting the quality of health service delivery. In 2017, SBH continued to assist the MOH to build capacity of health care providers from four target provinces (Southern, Copperbelt) covering six districts (Livingstone, Monze, Kitwe, Mufulira, Chingola, Chililabombwe) in the ZMLA program.

In September 2017, 62 SBH-supported health managers from the 2016 cohort from Lusaka and Central Province districts and health facilities graduated from ZMLA. The SBH Year Two Annual Report included success stories highlighting the service delivery results achieved by ZMLA graduates’ QI projects in their health facilities. In the 2017 cohort, by December 2017, 202 trainees had completed their classroom training sessions and were working on their individual and group QI projects, which are a pre-requisite to academic qualification and graduation. However, due to SBH project re-focusing, which included the phasing out of the ZMLA program, mentorship activities could not continue to facilitate graduation of this cohort.

In June, SBH mobilized some resources to work with National Institute of Public Administration trainers to provide mentorship to the 202 trainees under training to prepare them for graduation in September 2018. These measures will enable at least 75% of trainees to successfully complete their course and graduate. As illustrated by SBH’s Year Two success stories, improved leadership and management skills is key to enhancing efficient and effective administrative and technical oversight at all levels of the health care system and improving service delivery and health outcomes.

3.2.2 Sub-Task 2.3: Improve Districts’ Capacity to Manage Government-to-Government Funding for the RMNCAH&N COC Program Sub-Task 2.3.4 Specific Areas of SBH Technical Support for the COC Program

Activity 2.3.4.1 Support development and quarterly review of annual Action Plans for MOH and COC resources During the reporting quarter, SBH visited 51 of the 70 COC districts (73%) to provide technical support to the 2019-2021 MTEF planning process. The project is tracking seven milestones in Year Three to monitor district progress in improving their planning process. Table 1 below summarizes visited district and PHO progress on the milestones by province (see Annex 1 for summaries by province and district). Overall, 92% of all DHOs/PHOs reviewed and analyzed their RMNCAH&N scorecards, identified priority program areas based on indicator performance, and suspected causes for poor performance, while 88% of DHOs/PHOs identified and selected interventions to address these causes.

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Table 1. Summary of PHO/DHO progress against planning milestones

Percent of PHOs/DHOs that have begun or completed task

PHOs Central Eastern Luapula Muchinga Southern Western Total Milestones (tasks) (n=6) (t=12, (t=9, (t=11, (t=9, (t=13, (t=16, DHO v=8) v=8) v=8) v=7) v=8) v=11) (t=70 v=51) 1.0 Planning: PHO and DHOs produce evidence-based annual action plans 1.1 PHO or DHO conducts the 17% 60% 56% 100% 71% 100% 36% 69% MSI for Planning 1.2 PHO or DHO develops and Action Plan to address issues 17% 60% 33% 100% 71% 100% 36% 67% identified in the MSI 1.3 PHO or DHO reviews the RMNCAH&N scorecard and 33% 60% 89% 88% 100% 100% 100% 92% describes its analysis 1.4 District identifies the priority program areas based on indicator 33% 60% 89% 88% 100% 100% 100% 92% performance. 1.5 PHO or DHO identifies suspected causes of poor 17% 60% 89% 88% 100% 100% 100% 92% performance for prioritized indicators. 1.6 PHO or District identifies potential interventions to address 17% 60% 89% 88% 100% 75% 100% 88% the causes of poor performance. 1.7 District selects interventions to address prioritized program 17% 60% 89% 88% 100% 75% 100% 88% indicators. t= total number of districts v= number of districts visited In terms of the Management Systems Inquiry (MSI), 69% of the visited DHOs/PHOs had completed MSI for planning and resource allocation, and 67% developed action plans to identify issues .Some districts had not completed their MSI baselines and/or their MSI action plans because the SBH technical staff prioritized their technical assistance time on the RMNCAH&N scorecard review and analysis, given its importance to the MTEF process. SBH expects that these DHOs will complete these first two milestones in their next visit.

The MSI tool developed by SBH is designed to facilitate meaningful and lasting improvement in the critical planning and resource allocation processes by enabling DHOs and PHOs to assess and reflect on how they are currently implementing these process and identify actions for improvement. The MSI planning and budgeting tool has a range of standards under three main domains:

1. Policy, guidelines and directives for planning and resource allocation 2. Tools, resources and structures tools and 3. Skill of MOH personnel to plan and provide support to health centers/posts and/or hospitals during planning activities Each of the above three domains have sub-domains which are scored from 1-5; 1-being lowest score showing poor compliance to national guidelines/standards and 5- being a maximum score which refers to performance as per the national MOH MTEF planning and budgeting handbook. Once each sub-domain is scored against the standards, the tool divides total domain score by the maximum score possible to get the percent score for each domain. The graphs in Figure 3 below displays the

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average scores for the DHOs that have completed MSI for planning and budgeting for each domain and sub-domain. The key areas of improvement in the three major domains include:

• Engagement of stakeholders in existing local structures during planning process (71% compliance with standards) • Conduction of monitoring and evaluation of facility action plans (58% compliance with standards) • Use of tools and resources by DHOs to monitor implementation of action plans (68% compliance with standards) • Knowledge of roles and responsibilities by district program officers during planning process (72% compliance with standards) • Inadequate ability to use tools, templates and methodology to develop plans (66% compliance with standards) Figure 3. MSI dashboard for planning and resource allocation with average scores for all districts who completed it System 1: Planning and Resource Allocation Standard: The DHO action and annual plan is based on health and other information, reflects the current health needs of district communities to improve individual and public health, includes cost effective interventions responsive to local health needs and is monitored over time to take corrective action.

Criteria SCORE 1.1 Operationalize policy and guidelines for % Achieved Score planning and resource allocation

80.87% 4 Operationalize the MOH planning process 81% Operationalize the MOH planning process

Engage district structuresEngage and district other structures partners and other71.30% partners 71% 4

Allocate Resources based on the MOH resource allocation formula 83% Allocate Resources based on the MOH resource 82.61% 4 allocation formula

Conduct monitoring and evaluation of facility action plans at the 58% district level Conduct monitoring and evaluation of facility 58.26% 3 action plans at the district level 0% 20% 40% 60% 80% 100%

Average Score 3.66

1.2 Tools and other resources used to facilitate the % Achieved Score planning and resource allocation process

Use the existing tools and resources 82.00% 4.1 Use the existing tools and resources 82%

Guide and support development of budgeted Guide and support development of budgeted action plans of health action plans of health centres/posts and 80% 80% 4 centres/posts and hospitals hospitals

Tools and resources used to monitor implementation of action plan 68% Tools and resources used to monitor 68.00% 3.4 implementation of action plan 0% 20% 40% 60% 80% 100%

Average Score 3.83

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1.3 Skill of MOH personnel to plan and provide support to health centres/posts and/or hospitals % Achieved Score during planning activities

Know and understand their roles and responsibilitie 72.00% 3.6 Know and understand their roles and responsibilities 72%

DHO personnel are knowledgeable and skilled DHO personnel are knowledgeable and skilled in the planning process 76.00% 76% 3.8 in the planning process

Ability to use the tools, templates and methodology to develop plans 66% Ability to use the tools, templates and 66.00% 3.3 methodology to develop plans 0% 20% 40% 60% 80% 100%

Average Score 3.57

Table 2 illustrates some action points developed by the DHOs to address the most common issues detected by the MSI. SBH will work with PHOs and DHOs to repeat the MSI assessment at least annually to track progress and help establish a continuous QI culture.

Table 2. Common planning and resource allocation issues detected by MSI in visited districts Issue identified Action plan to address issue Non-adherence to the planning guidelines by DHO Orientation of DHO program officers on the staff planning cycle, tools, and guidelines on roles and Health facilities received inadequate technical responsibilities support during planning Inadequate use of existing MTEF planning and budgeting tools due to inadequate knowledge and skills by district program officers Low stakeholder participation in planning Organizing a pre-planning meeting with all stakeholders to discuss and collaborate during the MTEF planning process Inadequate monitoring of implementation of action • Reviewing and revising the action plan on plans quarterly basis so that there is adequate M&E • Technical support by DHO program officers to health centers in the districts in the implementation of the action plans In addition to MSI, during their technical assistance visits, SBH technical staff also supported PHOs and DHOs in using their RMNCAH&N scorecards to ensure their annual planning is evidence based (milestones three-seven). In all visited districts, SBH assisted district program officers to review the 2017 RMNCAH&N program performance as part of the planning process using the scorecard. The program officers prioritized the indicators showing poor performance, applied root causes analysis, and selected potential interventions to improve the indicators. Table 3 below provides an example of the commonly prioritized indicators, identified contributing factors, and proposed interventions. Supporting DHOs and PHOs to carry out this analysis during planning is critical to ensure that their planning is evidence-based and results-focused. This should lead to the achievement of their COC RMNCAH&N goals through efficient use of resources.

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Table 3. Examples of commonly prioritized indicators, contributing factors, and proposed interventions based on RMNCAH&N scorecard review in visited districts

Priority indicators Contributing factors Proposed interventions • First ante-natal care visit • Inability to detect pregnancy • Sensitization of communities before 14 weeks early and enroll women into on disclosing pregnancy to ante-natal care (inadequate health care providers early • Institutional maternal deaths pregnancy test kits, cultural through training and motivating • Institutional stillbirths barrier and low knowledge of Safe Motherhood Action among pregnant women to Groups • Nutritional indicators (wasting disclose pregnancy early • and stunting) enough) Promotion of provider initiated pregnancy test in the health • Shortage of trained midwives in facilities some clinics • Placement of trained midwives • Lack of knowledge and skills in selected facilities among healthcare providers to • attend to emergency cases Mentoring for health facility staff on emergency obstetric • Delayed referral (inadequate and neonatal care (EmONC) ambulances, distance from • communities to health facilities) Creating more Basic EmONC sites in the districts • Low number of active Safe Motherhood Action Groups for sensitization of pregnant mothers on ante-natal care, delivery, and post-natal care services

Activity 2.3.4.2 Strengthen Performance Review Meetings During the reporting period, half of the targeted PHOs and a third of the targeted DHOs held their quarterly performance review meetings, or PIMs/DIMs. The low number of PIMs/DIMs is because not all PHOs and DHOs have planned quarterly PIMs/DIMs meetings in their 2018 COC action plans mainly due to inadequate funding (i.e. they used all their budget to other prioritized interventions). SBH provincial teams discussed the importance of having a PIM/DIM at least once per quarter in all districts and advised to re-direct some of the COC budget towards planning such review meetings during the quarterly action plan review meetings.

SBH was not able to attend and provide technical support to all PIMs/DIMs this quarter because we prioritized our support to the planning process (previous activity), which is an annual activity that occurred this quarter. For those PIMs/DIMs that SBH did support, SBH provided technical support during both the preparatory as well as the actual PIMs/DIMs. The pre-PIM/DIM support focuses on generation and analysis of RMNCAH&N scorecards by DHO team at least a week ahead of the PIMs/DIMs. During the PIMs/DIMs SBH provided technical support on how to use (interpret and analyse) the RMNCAH&N scorecard, how to identify root causes for poor performance and guidance on action plan development to follow up and address the observed gaps in the review meetings. Table 4 below summarizes the progress that the PHOs/DHOs who held PIMs/DIMs this quarter made in their related milestones.

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Table 4. Summary of PHO/DHO progress against data review for action meetings milestones

Percent of PHOs/DHOs that have begun or completed task

Total PHOs Central Eastern Luapula Muchinga Southern Western Milestones (tasks) DHO (n=6, (t=12, (t=9, (t=11, (t=9, (t=13, (t=16, (t=70 PIM=3) DIM=12) DIM=9) DIM=10) DIM=9) DIM=13) DIM=10) DIM=65) 2.0 Data review for action meetings 2.1 PHO or DHO reviews and analyzes data using 50% 83% 0% 20% 44% 23% 50% 23% scorecard indicators on a quarterly basis (PIM/DIM) 2.2 PHO or DHO team documents key decisions 50% 92% 100% 20% 100% 23% 80% 49% and action plan from data review meetings quarterly t= total number of districts PIM/DIM= number of provinces/districts who conducted a PIM/DIM during the quarter As can be seen in the table, most PHOs and DHOs still have much room for improvement in terms of reviewing and analyzing scorecard indicators in their PIMs/DIMs, and documenting key decisions from the meetings. SBH’s work with the newly-established Department of QI, Performance Improvement, and M&E described in Activity 1.3.2.2 aims to improve this through the central level, while the SBH provincial teams will continue to provide mentoring to their PHO and DHO counterparts to improve the quality and effectiveness of the PIMs/DIMs.

Activity 2.3.4.3 Strengthen PA During the period under review nearly all districts and PHOs carried out a PA, and SBH provincial teams provided technical support during the process. SBH provincial supported nearly all districts. SBH also helped two districts in Luapula province and the Muchinga PHO to carry out MSI for PA. Table 5 below summarizes the status of the PA-related milestones.

Table 5. Summary of PHO/DHO progress against PA milestones

Percent of PHOs/DHOs that have begun or completed task

Milestones (tasks) PHOs Central Eastern Luapula Muchinga Southern Western Total (n=6) (t=12) (t=9) (t=11) (t=9) (t=13) (t=16) DHO (t=70) 3.0 PA 3.1 PHO or DHO conducts the 33% 0% 0% 18% 22% 0% 0% 8% MSI for PA 3.2 PHO or DHO develops and Action Plan to address issues 33% 0% 0% 18% 22% 0% 0% 8% identified in the MSI 3.3 PHO and/or District organizes a pre-PA meeting to 83% 100% 100% 100% 22% 100% 100% 90% review past findings and assign teams 3.4 PHO or DHO conducted PA in at least 80% of its districts 100% 100% 100% 100% 100% 100% 100% 100% (PA by PHO) or facilities (PA by DHO) 3.5 PHO or DHO finalizes a consolidated PA report for the 100% 100% 100% 100% 100% 100% 100% 100% period t= total number of districts

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Most of the PHOs and DHOs have not yet completed MSI for PA (milestones one and two), mainly due to timing. The PA module for MSI must be administered during the prePA period, yet many PHOs and DHOs are still catching up on the PAs that should have been conducted in the fourth quarter of 2017. This means that many PAs happen on short notice, without enough time for the SBH staff to prepare for the MSI (including orienting PHOs/DHOs to the MSI tool and process). SBH expects to continue to gradually roll out the MSI for PA in the remaining districts and provinces each quarter, having oriented the PHO and DHOs in Southern province during this quarter. As with the MSI process for planning and resource allocation, the MSI for PA helps provinces and districts detects weaknesses in how they are implementing the system and identify actions to improve implementation. This should help ensure that these systems will actually achieve their purpose (i.e. that PA will actually improve PHO and DHO performance). For example, during the Muchinga PHO MSI this quarter, the province found that: the DHO is not preparing their schedule for technical supportive supervision visits due to lack of prioritization; technical support schedule not shared with the facilities; and less than 50% of staff have access to the ePA tool because the DHO only had one computer.

In terms of the PA process, SBH provincial teams participated in and provided technical assistance to their PHO and DHO counterparts during the PAs that occurred this quarter. In some cases, this included conducting prePA meetings to review previous PA reports and plan for the upcoming assessment. Almost all PHOs and DHOs organized a prePA meeting, conducted PA in at least 80% of their districts/facilities, and finalized a consolidated PA report for this period. Examples of findings from PAs include:

• High proportions of fully immunized children below one year • Good adherence to pharmacy standards • Regular action plan reviews • Low proportions of skilled deliveries • Low 1st ante-natal care visits • Low proportions of functional Neighborhood Health Committees (NHCs) • Non- adherence to clinical care standards • Maternal deaths and still births • Financial management standards not fully met SBH helped PHOs and DHOs develop action plans to address the weaknesses identified in the PA, as well as to devise an action plan database that will assist in keeping and tracking action points. Annex I provides more detail on progress on PA by province.

Activity 2.3.4.4 Strengthen Health Management Information Systems Under the SBH COC program, the HMIS Data Use Officers (HMIS DUOs) are providing ongoing technical support to PHO and DHO personnel to successfully navigate DHIS2, facilitate the use of RMNCAH&N scorecards for performance monitoring, and improve their data analysis and use skills. The Officers are also providing DHIS2 training to Program Officers at PHO and DHO where districts included it in their COC plans and training District Health Information Officer (DHIO) as trainers of trainers, who will train facility personnel to enter HMIS data on the DHIS2 platform.

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The Officers are providing targeted technical support for HMIS to PHO and DHO teams to ensure that HMIS data is routinely presented and reviewed at performance review meetings at provincial and district levels. They are mentoring the SHIOs, DHIOs and district and provincial program officers to use the RMNCAH&N scorecard in DHIS2 to monitor program performance, guide the development plans and make decisions. They are also working with the teams to improve the quality of HMIS data by interrogating the data, identifying data quality issues and taking corrective action.

During the reporting period, the SBH HMIS DUOs visited almost all districts to provide technical assistance on DHIS2, generating and using the RMNCAH&N scorecards, and ensuring data quality. Table 6 below summarizes the progress of the visited PHOs and DHOs on the HMIS milestones that SBH is tracking. SBH placed a heavier focus on the RMNCAH&N scorecard this quarter, as opposed to data quality. The idea is to first ensure that PHOs and DHOs can generate the scorecards, which are crucial for other activities such as planning, data review meetings (PIMs/DIMs), PA, and then work on data quality. As PHOs and DHOs improve their abilities to generate and use accurate scorecards in decision making, their planning and resource use should become more effective and efficient, leading to better RMNCAH&N outcomes.

Table 6. Summary of PHO/DHO progress against HMIS milestones1

Percent of PHOs/DHOs that have begun or completed task

PHOs Central Eastern Luapula Muchinga Southern Western Total Milestones (tasks) (n=6) (t=12 (t=9 (t=11 (t=9 (t=13 (t=16 DHO v=11) v=9) v=10) v=8) v=13) v=16) (t=70 v=67) 6. PHO or DHOs generate the RMNCAH&N Scorecards 6.1 Population data entered by SHIOs, DHIOs for each org 33% 83% 100% 82% 75% 100% 100% 94% units 6.2 SHIOs and/or DHIOs run and share RMNCAH&N Scorecards with technical 0% 0% 11% 18% 50% 31% 63% 31% officers in the PHO and DHO every month 6.3 PHO or DHO personnel mentored on DHIS2 use 17% 92% 100% 73% 88% 38% 50% 72% completed 7. PHO or DHO reviews Data quality using RMNCAH&N Scorecard indicators 7.1 SHIO or DHIO creates a database to track identified data quality issues and solutions and 0% 0% 11% 0% 0% 8% 19% 7% updates it at least once in a quarter 7.2 PHO or DHO team plan for data quality assessments (DQAs) 0% 0% 0% 0% 38% 0% 19% 9% using results from Scorecard analysis. 7.3 PHO or DHO performs 0% 0% 22% 0% 38% 0% 0% 7% DQA at least twice a year. 7.4 SHIO or DHIO follow up with health facilities and records 0% 0% 22% 0% 38% 0% 0% 7% the corrective actions taken

1 The numbering of the milestones was done according to internal SBH organization of COC activities, and therefore some appear to be in the wrong order in this report. There are seven sets of milestones in total. 24

t= total number of districts v= number of districts visited PHOs and DHOs are making good progress in RMNCAH&N scorecard generation: 94% of them have entered the population data for each organizational unit, although only 31% of them are running the scorecard and sharing them every month. The SBH HMIS DUO are mentoring the SHIOs and DHIOs on the importance of sharing the scorecard with the program officers at the DHO so they can use it to review performance and monitor trends monthly. The SBH DHIS2 mentorship includes a DHIS2 overview, introduction to data analysis and use, and RMNCAH&N scorecard generation. At the end of the mentorship, the SHIOs and DHIOs have a practice session where they are supposed to demonstrate the ability to generate scorecards, interpret performance by indicators, identify which facilities were contributing to poor performance, and relate performance to the planned activities in the COC action plans.

The SBH HMIS DUO only provided technical assistance on DQAs to eight districts during this quarter. This is the area with the greatest room for improvement. Less than 10% of districts have a database to track data quality issues, have a plan for DQAs using scorecard results, perform DQAs at least twice a year, or follow up with health facilities on corrective actions (milestones 7.1-7.4). The HMIS DUO mentored the DHIOs on how the scorecard and data quality and validation modules in DHIS2 can be used to identify data quality issues by health facility, the need to follow up with health facility staff to verify data, and following up with each health facility to correct data at both health facility and district levels.

Activity 2.3.4.5 Strengthen PFM Systems by supporting the implementation of the Microsoft NAV enterprise resource planning software The key to the COC program’s success is ensuring that districts are able to effectively manage the government-to-government funding they receive. In Year Three, SBH is focusing on ensuring that districts are using the Microsoft NAV enterprise resource planning properly. Following the training of all PHO, DHO and trained institutions officers on NAV in the previous quarters, this quarter all SBH provincial PFM Specialists in Muchinga, Luapula and Western provinces prioritized the NAV implementation. They mentored the trained officers in all trained institutions by responding to issues and troubleshooting with users in consultation with the provincial accountants and training consultants. Table 7 below summarizes the progress made by PHOs and DHOs during the reporting period in the three provinces. Currently 100% of PHOs and DHOs generate quarterly electronic financial reports using NAV.

Table 7. Summary of PHO/DHO progress against NAV milestones

Percent of PHOs/DHOs that have begun or completed task

Milestones (tasks) PHOs Luapula Muchinga Western Total DHO (t=36) (n=6) (t=11) (t=9) (t=16) 4.0 Microsoft Dynamics NAV Implementation

4.1 DHO, Training Institution, and 2nd and 3rd Level Hospital 100% 100% 100% 100% 100% personnel trained to use NAV 4.2 MOH provides User-Rights 100% 100% 100% 100% 100% for trained officers 4.3 NAV software installed on 100% 100% 100% 100% 100% PHO or DHO computers

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4.4 PHO or DHO computers configured to link to the NAV 100% 100% 100% 100% 100% database on the central server 4.5 All PHO or DHO official bank 100% 100% 100% 100% 100% accounts set up in NAV 4.6 PHO established profiles for 67% 100% 11% 100% 78% all imprest holders 4.7 PHO established the full list of 67% 100% 11% 100% 78% list of official vendors 4.8 PHO or DHO completes posting of backlog of 2018 33% 100% 11% 31% 47% transactions 4.9 DHO detailed activity budgets for MOH and COC funds 100% 100% 100% 100% 100% uploaded to NAV t= total number of districts

SBH is making good progress on NAV implementation. All three provinces and their districts completed the six preparatory milestones and Luapula and Western province completed th