USAID/ Systems For Better Health Quarterly Progress Report January–March 2018

April 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. BroadReach Institute for Training and Education Initiatives Inc. Imperial Health Sciences 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

Acronyms ...... ii Executive Summary ...... 1 1. Introduction ...... 2 2. Progress by Task ...... 3 2.1 Task One: Design, Implement and Monitor National Level Interventions to Strengthen Health Stewardship by the Ministry of Health ...... 3 2.1.1 Sub-Task 1.1: Strengthen Human Resources Planning and Management ...... 3 2.1.2 Sub-Task 1.2: Improve HCF and Public Financial Management ...... 4 2.1.3 Sub-Task 1.3: Strengthen MOH Capacity to Oversee Delivery of Key Health Programs ...... 4 2.2 Task Two: Design, Implement, and Monitor Interventions to Strengthen Program Management Capabilities of Provincial and District Teams ...... 6 2.2.1 Sub-Task 2.1: Strengthen Program Management Capacity ...... 7 2.2.2 Sub-Task 2.2: Improve Technical Capacity of Provincial and District Health Teams to Deliver Quality Health Services in Facilities ...... 8 2.2.3 Sub-Task 2.3: Improve Districts’ Capacity to Manage G2G Funding for the RMNCAH Continuum of Care Program ...... 9 2.3 Task Three: Support the Government and Community-Based Organizations to Increase the Quality, Availability, and Use of Health Services ...... 10 2.3.1 Sub-Task 3.1: Improve the Capacity to Deliver Quality Health Services in the Community ...... 10 2.3.2 Sub-Task 3.2: Strengthen Linkages between the Facility and the Community ...... 11 2.4 Cross-Cutting Technical Areas ...... 12 2.4.1 Task 4: Grants under Contract ...... 12 2.4.2 Task 5: Research, Monitoring and Evaluation (RM&E) ...... 12 3. Project Management ...... 13 3.1 Finance and Administration ...... 13 3.2 Overall Budget and Expenditures ...... 13 3.3 Personnel ...... 13 4. Success Stories ...... 14 Annex 1: Performance Indicator Tracking Table ...... Error! Bookmark not defined.

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Acronyms

AMEP Activity Monitoring and Evaluation Plan ART Antiretroviral Therapy CBO Community-based Organization CBV Community-based Volunteer DHIS2 District Health Information System Version 2 DHO District Health Office FP Family Planning GST Grants Support Team HCC Health Center Committee HCF Health Care Financing HMIS Health Management Information System HP Health Promotion HRH Human Resources for Health HRHSP Human Resources for Health Strategic Plan HRIS Human Resources Information System MOH Ministry of Health MSI Management Systems Inquiry NHC Neighborhood Health Committee NHI National Health Insurance PA/e-PA Performance Assessment/electronic Performance Assessment PHO Provincial Health Office QI Quality Improvement RED/C Reach Every District/Child RMNCAH Reproductive, Maternal, Neonatal, Child and Adolescent Health SBH Systems for Better Health TSS Technical Support Supervision TWG Technical Working Group USAID United States Agency for International Development ZMLA Zambia Management and Leadership Academy

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Executive Summary

This Quarterly Progress Report for the United States Agency for International Development Systems for Better Health (SBH) activity covers the period from January 1st through March 31st, 2018. During this first quarter of Year Three, SBH continued providing health systems strengthening assistance to the Zambian Ministry of Health (MOH) at central, provincial, district, facility, and community levels to achieve the project’s goals.

At the central level, SBH continued to support the finalization and circulation of important policy documents, including the National Health Insurance Communications Strategy, the Roadmap of Scaling-Up of Injectable Contraception, the National Maternal and Newborn Referral Manual, and most importantly, the 2017-2021 Human Resources for Health Strategic Plan. The project also supported the functioning of key MOH Technical Working Groups, such as family planning, health promotion, and quality improvement. Additionally, SBH helped strengthen materials and systems for nutrition policy through attending relevant events and reviewing national dietary guidelines. Lastly, SBH supported the MOH to review and finalize various community health guidance documents and training materials.

Under Task Two, SBH provided ongoing support to provincial and district teams to strengthen their capacity to perform their functions. At the provincial level, the project assisted Provincial Health Offices (PHOs) to conduct Management Systems Inquiries, Provincial Integrated Meetings, and partner coordination meetings. Similarly, at the district level, SBH extensively supported the performance assessment process at multiple District Health Offices (DHOs). To improve service quality, SBH helped PHOs and DHOs to mentor health workers in different roles on quality improvement tools and processes. Further, the project provided training and mentorship on various clinical topics, including malnutrition, essential newborn care, emergency obstetric and neonatal care, long-lasting reversible contraceptives, etc. Lastly, SBH continued implementing the Reproductive, Maternal, Neonatal, Child, and Adolescent Health Continuum of Care program via coordinating with other donors and deploying program personnel.

Lastly, at the community level, SBH supported DHOs financially and technically to mentor community volunteers and orient neighborhood health committee (NHC) members. The orientation, along with the capacity assessment tool revised by SBH, will help strengthen NHCs activities in health promotion. Most notably, the project continued implementation of the Kitwe HIV linkages project. These efforts included mentoring on the Pedtrack system; identifying and registering new clients; assessing additional facilities for inclusion; coordinating with partners, and disseminating the results of the baseline study.

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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 is 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. The goal of SBH is to improve health outcomes for Zambians by strengthening 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 expected outcomes of the activity are: 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. During this period, 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. This quarterly report summarizes the progress and achievements for the first quarter of Year Three, January to March 2018. The narratives under each sub-task include activities where significant progress was made during the reporting period. This report is the last quarterly report which documents activities under Tasks 2.1, 2.2, and 3.1 and 3.3. This report follows the structure of the Annual Work Plan for 2018 submitted in December 2017. From January to March, USAID provided SBH with comments on the December 2017 Work Plan and new information on the expected annual funding. As a result, the project extensively revised the Work Plan and budget. USAID accepted the revised plan in April 2018, and the next quarterly report will follow the format of the final 2018 Work Plan. As a result of the extensive changes to the work plan, SBH will propose changes to the contract which will include revised project objectives.

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2. Progress by Task

2.1 Task One: Design, Implement and Monitor National Level Interventions to Strengthen Health Stewardship by the Ministry of Health During Quarter One of Year Three, SBH has continued to provide essential support to strengthen health stewardship at the central MOH to support human resources for health (HRH), health care financing (HCF), and health program management. 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.

2.1.1 Sub-Task 1.1: Strengthen Human Resources Planning and Management Sub-Task 1.1.2 Support the Development and Dissemination of Key HRH Strategies, Guides, and Policies Activity 1.1.2.3 Contribute to the development of the 2017-2021 HRH Strategic Plan (HRHSP) In February, SBH helped the MOH to convene an HRH Technical Working Group (TWG) meeting to consult stakeholders regarding the HRHSP for 2018-2021. SBH provided technical support to the HRH unit to prepare for the TWG meeting by drafting a roadmap and timeline for the HRHSP, providing technical reviews of draft sections of the plan, and developing a draft program, approach and expected outcomes for the TWG meeting. During the TWG meeting, the MOH provided updates on the country HRH pipeline, national hospital bed space, Zambia workforce stock, and the Zambia MOH human resources information system (HRIS). The participants discussed the framework for the HRHSP, the draft strategy chapter, and the monitoring and evaluation framework. In March, the MOH circulated draft 0 of the document, and the provinces submitted comments to the HRH TWG subcommittees. The MOH plans to circulate a new draft of the HRHSP for comments from stakeholders after the next provincial consultative meeting.

Sub-Task 1.1.3 Strengthen Central MOH Capacity to Support Implementation and Monitoring of HRH Systems at Sub-National Levels Activity 1.1.3.1 Support the central MOH to implement and monitor Performance Management Package/ Annual Performance Assessment System and HRIS In March, SBH assisted the MOH to monitor the progress at the district level in validating and augmenting the initial HRIS data. Once the districts complete the data validation, they will submit their monthly workforce reports from HRIS. The MOH Information Technology team created a help desk portal on the WhatsApp platform which is helping district and province HR Officers to solve user problems. In 2017, SBH assisted the MOH to train 97 HR officers in Eastern, Southern, Central, and Copperbelt provinces.

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2.1.2 Sub-Task 1.2: Improve HCF and Public Financial Management Sub-Task 1.2.1 Strengthen Routine HCF Planning and Management Fora Activity 1.2.1.1 Support effective HCF TWG meetings In January, SBH assisted the MOH to hold the first HCF TWG meeting for 2018. The group evaluated the inception report submitted by the contractor engaged by the MOH to develop systems for the proposed National Health Insurance (NHI). SBH provided the venue for the TWG meeting, which included partners such as USAID, the International Labor Organization, the United Nations Development Programme, the European Union, and the Clinton Health Access Initiative. The SBH Health Care Finance and Planning Specialist reviewed the inception report and provided the MOH with comments. The MOH used these comments to initiate the discussions in the TWG meeting. SBH assisted the MOH to integrate all stakeholder comments in a single document for the consultants. The TWG’s comments will guide the MOH response to the systems development consultants as well as the next steps in the developing NHI systems.

Sub-Task 1.2.2 Support the Development and Operationalization of Key HCF Strategies, Guides, and Policies Activity 1.2.2.3 Support the development of Social Health Insurance In addition to the NHI support described under Activity 1.2.1.1 above, SBH helped the MOH to draft the NHI Communications Strategy which will guide the MOH’s information dissemination plan on the NHI Bill. SBH provided the initial draft reference note for the communications strategy, and also participated in the actual drafting of the document (strategy). As of March, the NHI Bill is still in Parliament and has advanced to the second stage of approval.

Sub-Task 1.2.3 Strengthen Evidence-based Planning and Resource Allocation Activity 1.2.3.3 Support the annual planning process at the central level SBH helped the MOH to revise the District Planning Handbooks during a consultative meeting. MOH tasked SBH with editing the final version after it completes all inputs to the revised documents. The handbooks will help the MOH to plan and prioritize health services in Zambia and improve service delivery.

2.1.3 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 TOR and procedures Throughout this quarter, SBH continued its efforts to support relevant TWGs, including the family planning (FP) TWG and the health promotion (HP) TWG. In January, SBH attended and provided technical support to the FP TWG meeting, during which participants highlighted the need to conduct training on long-acting FP for health providers. SBH proposed a quick survey to determine why uptake of long-acting FP services does not increase after training. SBH also noted commodity stock-

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outs in Monze to the Medical Stores Limited representative who agreed to arrange re-distribution of commodities.

Then, in February and March, SBH assisted the MOH with technical and logistical support to restore the first quarterly Health Promotion (HP) TWG. The MOH Directorate of HP, Environment, and Social Determinants (DHPESD) shared its 2018 action plan with the partners. The TWG members set dates to start developing the various MOH standardized guidance documents which include: the district HP guidelines, the HP strategic framework, and to complete the RMNCAH Communication Strategy, and several other documents. These documents will help to support the implementation of the MOH transformation agenda with a focus on primary health care and HP at the community level. In addition to drafting these materials, the next steps are to create the district coordinating committee and coordinators to lead the activities.

Sub-Task 1.3.2 Strengthen Central MOH Capacity to Develop and Implement Health Program Management Systems Activity 1.3.2.3 Strengthen structures, systems, and tools for quality improvement (QI) This quarter, SBH funded and played a central role in assisting the MOH to organize the QI TWG meeting. During the meeting, the SBH QI Specialist helped the TWG chairperson to facilitate the discussions. The QI Specialist updated the TWG members on the first combined MOH HIV/QI Annual Conference which SBH and other partners supported financially. The TWG members discussed the harmonization of mentoring and assessment tools used by program teams in the field. The MOH emphasized the use of standard tools by all and requested that the meeting attendees share their field projects. The members also discussed the dissemination plan for the QI and mentorship guidelines which SBH printed at the beginning of the first quarter.

Activity 1.3.2.4 Strengthen MOH use of DHIS2 and HMIS at the central level SBH assisted the central and second level hospitals in Lusaka during a review meeting to harmonize reports generated by the various university hospitals and to agree on the indicators to report in 2018, the timelines, and medium of transmission. The hospitals include Adult, Children’s, Women and Newborn, Eye, Cancer Diseases, Levy Mwanawasa General Hospital, and Chainama Hills Hospital.

Sub-Task 1.3.3 Strengthen Central MOH Strategies, Guidelines, Tools, and Materials for Health Programs Activity 1.3.3.2 Support central MOH HP efforts In support of MOH HP efforts, SBH actively participated in the MOH Evidence for Impact Symposium. The event held under the theme ‘Translating Research into Gains for Primary and Community Health in Zambia’ was supported by USAID and the UK Department for International Aid. SBH showcased various project activities and achievements to support the MOH at the symposium exhibition. These included the work on Saving Mothers Giving Life, QI activities to improve implementation of health policies at health facility level; strengthening of Community-Based Organizations (CBOs); and awarding of grants to the CBOs to improve community participation in health. During the symposium, SBH distributed various guidance materials and guidelines that it helped the MOH to print. These materials included nutrition, National Health Accounts 2011-2012 report, Health Care Financing Strategy 2017-2027 towards Universal Health Coverage for Zambia,

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mentorship guidelines for health workers, QI and assurance guidelines for health workers in Zambia, and the Zambia Consolidated Guidelines for Prevention and Treatment of HIV Infection 2018.

Activity 1.3.3.3 Strengthen materials and systems to support the implementation of nutrition policies In February, SBH participated in the launch of the Food and Agriculture Organization-supported project on Improving Diets and Nutrition Outcomes in Southern Africa and provided technical support during the development of the National Food Based Dietary Guidelines. SBH noted that one of the major contributing factors to malnutrition is poor feeding practices for children under the age of two and insufficient diversification of diets. The MOH stressed the importance of addressing malnutrition in a multi-sectoral approach and the need to develop dietary guidelines to inform nutrition practices.

Additionally, SBH provided technical input during the Nutrition Coordination Committee meeting by giving a presentation on strengthening the role of the individual coordination committee members and emphasizing the use of data for planning and guiding decision making.

Activity 1.3.3.6 Respond to requests for technical and material assistance which arise outside of the workplan cycle In this reporting period, SBH responded to some requests outside of its original workplan. For example, in February, SBH participated in the launch of the National Maternal and Newborn Referral Manual and contributed to the thematic teams which provided guidance on how to implement the guidelines and identified possible challenges and solutions. The guidelines standardize the management of expectant mothers and newborns to improve quality of care. Similarly, through participation in a MOH validation meeting, SBH contributed towards the technical review and editing of the Roadmap of Scaling-Up of Injectable Contraception (DMPA) by community-based distributors. This roadmap will guide the authorization of community-based distributors to provide FP services in the community, which will help to increase access and expansion of the methods used for FP.

In February, SBH helped the MOH to review and finalize various community health guidance documents and training materials. The next steps are finalizing the foreword and acknowledgment sections, and editing and formatting the document. Once the document is final, SBH will support the printing and distribution, and the MOH will train national, provincial and district trainers in community health leadership and governance. Lastly, SBH provided logistical and technical assistance to the MOH in developing and finalizing the community-based guide to increasing access to immunization services under the Reach Every District/Child (RED/C) programme. The MOH will edit and format the guide, and conduct a final review of the RED/C registers. 2.2 Task Two: Design, Implement, and Monitor Interventions to Strengthen Program Management Capabilities of Provincial and District Teams Task Two targets provincial and district level capacity to manage health programs and deliver quality health services. The effectiveness of activities under this task depends on the improvements achieved under Task One at the national level. The SBH approach to strengthening provincial and district capacities is similar to the approach at the national level, which is guided by participatory capacity assessments and focuses on strengthening existing systems and processes.

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2.2.1 Sub-Task 2.1: Strengthen Program Management Capacity Sub-Task 2.1.1 Improve Implementation of Management and Performance Monitoring Systems Activity 2.1.1.1 Conduct Management Systems Inquiry (MSI) SBH supported the Gwenbe District Health Office (DHO) to conduct MSI for QI and PA. The QI MSI established that there was weak coordination of QI activities in the district, the QI committee is not functioning, and it does not support the hospitals and health facilities in their QI activities. Also, few DHO program Officers had any knowledge of QI, and those who received prior training had not provided any training to hospital and facility personnel. The team agreed to address these weaknesses through a time-bound action plan. The PA MSI description appears in the next activity.

Sub-Task 2.1.2 Strengthen Leadership, Management, and Governance Activity 2.1.2.1 Support PAs SBH actively supported all parts of the PA process this quarter. In February, SBH helped Health Office (DHO) to conduct MSI for PA and QI. Corrective actions developed for PA included: all DHO Program Officers will now review the PA findings and post-PA follow-up reports; the DHO will provide hospitals and health facilities with written reports of post-PA technical support instead of verbal briefings. The PHO will provide the DHO Program Officers with mentoring guidelines and QI standards, the guidelines for PA and technical support, and the electronic version of the PA tool.

Similarly, SBH worked with the Kabwe DHO to plan and conduct a PA preparatory meeting. The DHO and facility personnel reviewed previous TA and technical support supervision (TSS) reports which the DHO made available for the first time. SBH used the meeting to review action points from the MSI PA, gave a presentation on how to conduct an effective PA, and distributed soft copies of the technical guidelines for PA and TSS.

Activity 2.1.2.2 Support performance review meetings SBH participated in the Provincial Integrated Meeting (PIM) for Central Province by giving a presentation on MSI. Participants responded positively to the concept, and districts beyond the four SBH target sites expressed willingness to use MSI tools for systems strengthening. During the meeting, SBH also helped Ngungu Health Centre from to present a completed QI project. The health center’s QI project was successful in improving testing of HIV-exposed infants at 18 months from 22% to 100% in one year, as reported in SBH’s annual report. SBH-supported districts reported improvements in most indicators. For example, in child health, all four target districts were above the 90% national target for fully immunized children less than one-year-old. Similarly, the SBH districts reported improved institutional deliveries above the provincial rate of 93%. The deployment of additional midwives and clinical officers contributed to the improvement in the indicator for skilled deliveries.

Activity 2.1.2.3 Support Zambian Management and Leadership Academy (ZMLA) training SBH assessed the status of the mentorship support for Livingstone DHO and health facility staff that received ZMLA training. The SBH team found that 77% of the ZMLA trained mentees in the district had submitted individual case studies to SBH for further processing, while 60% had submitted their group case studies.

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Activity 2.1.2.6 Support partner coordination In , SBH helped the PHO to organize a provincial partner’s coordination meeting. The meeting brought together all partners in the province who discussed the strategy to achieve the 90-90-90 targets for HIV treatment. Participants also discussed the resource requirements for support of the PHO’s activities such as the PIM, PA, TSS, child health week, and mentorship. To improve partner coordination, the participants agreed to hold meetings quarterly and not bi-annually. The PHO requested all partners to indicate their assistance to the PHO in their quarterly action plans and send to the PHO for consolidation.

Sub-Task 2.1.3 Improve HMIS Implementation Activity 2.1.3.1 Train and mentor PHO and DHO staff on District Health Information System 2 (DHIS2) In February, SBH helped the MOH M&E Unit to update the population data for all districts and health facilities in DHIS2. This exercise is expected to improve the accuracy of population-based indicators in the system, and which will, in turn, improve system use and data use for decisions. Further, SBH assisted the ministry to migrate the e-PA database to the DHIS2 platform. The SBH officers oriented the MOH Senior Information Communication and Technology Officer to the programs available within DHIS2.

2.2.2 Sub-Task 2.2: Improve Technical Capacity of Provincial and District Health Teams to Deliver Quality Health Services in Facilities Sub-Task 2.2.1: Strengthen Implementation of QI Efforts Activity 2.2.1.1 Support QI Committees and QI projects In Monze, SBH also worked with the DHO Program Officer for QI and provided technical support and mentored 26 health workers from eight facilities in QI. The workers included nurses, environmental health technologists, laboratory technologist, monitoring and evaluation officers, and community health volunteers. Then, during the follow-up visit in February, SBH worked with the Monze DHO to mentor nine registered midwives and one environmental health technologist from seven health facilities. The mentors focused on the use of the QI tools including the QI project decision matrix, QI template, prioritization matrix for causes of problems, and QI project work plan. The technical support revealed that most of the facilities had ongoing QI projects which ranged from improving staffing levels, addressing low first antenatal visits in the first trimester, to improving the rate of institutional delivery.

Similarly, SBH helped the Central PHO to mentor 28 health workers at Kabwe General Hospital on QI. During the mentoring visit, the participants identified five QI projects in radiology, dental, laboratory, administration, and pharmacy departments. The participants presented three of the five QI projects to the hospital management and staff members.

Additionally, in February and March, SBH continued to assist the MOH with conducting QI training for various Zambia Defense Force’s health workers. With funding from the American International Health Alliance, SBH collaborated with FHI360 to give QI training to 42 Zambia Defense Force health workers and University Teaching Hospitals Pharmacy Department personnel in quality and performance improvement.

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Activity 2.2.1.2 Support clinical mentoring SBH coordinated the training of 18 health care providers in clinical mentorship in Eastern Province. The mentees conducted practicum sessions at Hospital in various hospital departments which included outpatient, labor ward, laboratory, pharmacy, emergency care and children’s ward. A group of mentees focusing on severe acute malnutrition observed that nurses and the nutritionist at the hospital did not document feeding of malnourished children and that management of the children was inadequate. The mentors reported the matter to the Provincial Nutrition Officer who will follow-up on the issues identified. SBH recommended mentorship for the nurses and nutritionist.

In Central Province, SBH collaborated with the Kabwe DHO and mentored 13 facility providers from seven health facilities in essential newborn care (ENC). The mentorship responded to the upward trend in neonatal deaths, and fresh and macerated stillbirths in the province. Some of the causes identified included: inadequate health provider hands-on practice in life-saving skills such as neonatal resuscitation and essential care for every baby practices, sepsis, prematurity, inadequate supply of essential equipment, and delays in referrals. The workers received mentoring on infant resuscitation, initiation of breastfeeding, management of hypothermia, newborn infections, prevention of eye infections, and recognizing danger signs. 60% of the healthcare providers illustrated good resuscitation skills and knowledge of Essential Care of Every Baby practices after mentoring.

In Lusaka, SBH worked with the mentors from the Women and Newborn Hospital at the University Teaching Hospitals and mentored health facility workers from three rural health centers in Shibuyunji district in emergency obstetric and neonatal care and long-lasting reversible contraceptives. Also, SBH visited , a new support district, and discussed with the team the priority areas for support in RMNCAH.

SBH worked with the Livingstone and Monze DHOs and conducted FP site visits and monitoring in nine selected target health facilities. The purpose of the visit was to monitor adherence to USAID requirements in implementing FP activities in MOH health facilities. This activity showed that the facilities were compliant with USAID FP policy requirements and ready for the USAID FP compliance visit.

2.2.3 Sub-Task 2.3: Improve Districts’ Capacity to Manage G2G Funding for the RMNCAH Continuum of Care Program SBH deployed all G2G program personnel to their stations in the six provinces. SBH senior managers visited Southern, Central, and Luapula provinces to formally introduce the Continuum of Care program personnel to the PHOs.

SBH coordinated a meeting with MCSP, the Swedish International Development Cooperation Agency, MOH, and the joint UN team to develop consensus on the format for a district and province quarterly Continuum of Care progress report tool. Based on comments, SBH is attempting to develop a standard template that will respond to all partner’s recommendations.

SBH developed the material on the DHIS2 scorecard to strengthen the DHIS2 data use and analysis training package for program personnel. The scorecard reports performance on 16 RMNCAH&N

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indicators and a color-coded format which allows easy comparison across provinces or district facilities and gives basic information on trends. 2.3 Task Three: Support the Government and Community- Based Organizations to Increase the Quality, Availability, and Use of Health Services Task Three targets the facility and community levels. It addresses both supply and demand for health services, including the critical link between communities and health facilities. SBH focuses on making community-level activities more resource efficient by addressing gaps where they exist in specific areas instead of providing a uniform “package” of community-level interventions.

2.3.1 Sub-Task 3.1: Improve the Capacity to Deliver Quality Health Services in the Community Sub-Task 3.1.1: Strengthen Outreach Services Activity 3.1.1.1 Support health outreach This quarter, SBH assisted Livingstone and Mkushi DHOs to mentor health facility personnel and community volunteers on the RED/C intervention. In Livingstone, SBH provided financial and technical support to mentor 114 community-based volunteers (CBVs) and 19 health workers in 14 target facilities. During the mentorship, the CBVs began to enter children below five years old in community registers. By the end of the training, the CBVs had entered 75% of eligible children within their catchment areas. All the 14 facilities updated their micro-plans and made plans to implement them to help improve immunization coverage in their facilities. In Mkushi, SBH assisted the DHO to mentor CBVs for one target facility.

Activity 3.1.1.3 Continue implementing the Kitwe HIV Linkages Activity During this reporting period, SBH made substantial progress in its implementation of the Kitwe HIV Linkages activity. In January, SBH provided technical support and mentored staff members on user management of the Pedtrack system. The SBH mentorship team introduced the staff members to the improved features of the software including the modified calendar to prevent appointment backdating. The system is now able to merge all the possible reports into a single report and to show detailed reports on patient appointment adherence patterns. By the end of March 2018, the Pedtrack system was fully operational and helped the caseworkers to remind clients of their appointments and follow-up with those who missed appointments.

In March, the HIV Linkages activity continued identifying and registering new clients from the facility registers, such as the Daily Activity Registers, the Dry Blood Sample registers, and through Smart Care data. Through this screening, the activity registered1,043 HIV-exposed babies and 504 HIV positive children and adolescents. The caseworkers referred the guardians of the babies, children, and adolescents to different social and helped to coordinate clinical services in consultation with health workers. Additionally, SBH helped to assess ten health facilities for suitability for inclusion in the HIV Linkages activity and will expand into nine of these facilities in the next quarter. With this expansion, the activity expects to reach a total of 2,000 beneficiaries comprising of HIV-exposed babies and HIV positive children and adolescents by the end December 2018.

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SBH disseminated the results of the HIV Linkages Activity baseline study conducted in July 2017, which provided key recommendations that can help improve HIV services to children and adolescents. The recommendations include:

• Promote collaboration between health service providers and other social services

• Create awareness of the importance of disclosing HIV status to children and adolescents and prepare child counselors

• Identify and support role models or adolescent mentors living positively with HIV to help reduce self-stigma and encourage retention in care

• Promote regular dialogue among health workers on HIV related stigma and health care seeking

• Strengthening the role of paraprofessionals and data clerks in outreach and case management because they can contribute to program sustainability. Lastly, SBH attended the Copperbelt Province partners’ coordination meeting, which was held to harmonize the roles and responsibilities of the HIV Linkages Activity and Zambia Family Project. Both entities support HIV care in . The partners reviewed the progress made by the Kitwe HIV Linkages Activity and agreed to leverage resources through stronger collaboration in activity planning and implementation. The partners also visited a health facility (Ipusikilo) in Kitwe to see the activities of the caseworkers and the functions of the Pedtrack system.

2.3.2 Sub-Task 3.2: Strengthen Linkages between the Facility and the Community Sub-Task 3.2.1: Strengthen Community-Level Structures Activity 3.2.1.1 Support the training and supervision of Community Health Workers SBH conducted TSS on RED/C activities to Maramba Clinic in . The TSS was a follow-up to previous training in RED/C provided to the district in 2017. In Petauke district, Eastern Province, SBH collaborated with the Program Officers from the DHO and oriented 120 neighborhood health committee (NHC) members and growth monitoring and promotion providers from six non-performing target facilities in RED/C and the expanded program of immunization. The purpose of the orientation was to improve the community members’ skills to conduct mapping, community mobilization, develop action plans and make entries in the registers. Next quarter, SBH will discontinue community activities based upon the revised workplan.

Activity 3.2.1.2 Support Health Center Committees (HCCs) and NHCs SBH reviewed the community capacity tool and aligned it to the MSI format. The tool is now able to assess the performance of health facilities, HCCs, and NHCs. The structures will self-assess bi- annually and identify activities for implementation to move from the current score to the next. This approach provides an objective way of measuring positive performance change. Also, the tool will help strengthen NHC activities in HP and increased utilization of health services by communities.

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2.4 Cross-Cutting Technical Areas 2.4.1 Task 4: Grants under Contract Throughout this quarter, SBH conducted monitoring, supervision and technical support activities of grant recipients in Monze, Shibuyunji, Lusaka, Chipata, Petuake, Livingstone, Mkushi, and Kabwe. During the monitoring visit in Monze, SBH noted that the grantee had conducted all training according to plan and achieved more than 50% of the milestones. However, SBH also reminded its Grants Support Team (GST) the requirement of convening monthly review meetings and monitoring visits to grant recipients.

In Chipata, Petauke, Mkushi, and Kabwe, 11 grantees had completed their capacity building training on community leadership for members of the HCCs who had also begun to roll out similar training to their NHCs. Also, the SBH Grants team observed that the grantees had documented all their technical field visits to HCCs and NHCs as well as their quarterly meeting. The SBH Grants Team found that the trained NHC members had commenced collecting community health data using MOH registers to prepare for the planning process.

In Lusaka, SBH assisted the GST to establish a better system of communication between the grantees and the GST members. This assistance included facilitating the GST monthly review meeting in February for five GST members and eight grant recipient representatives. The meeting participants observed that the cholera outbreak at the beginning of the year had impeded implementation of several activities by the grantees, and noted several bottlenecks and challenges between the grantees, the HCCs, and health facilities. For example, some facilities use the 10% GRZ allocation for community-initiated activities to pay the NHC and HCC members to work at the health facilities. Some of the NHC members demand some form of payment to attend the routine monthly NHC meetings, and this had negatively impacted the NHC activities due to lack of resources.

In Shibuyunji district, SBH provided technical support during the training of 117 HCC members from seven health centers. Similarly, the SBH headquarters grants team conducted quarterly TSS to five grantees in Livingstone and Monze. The TSS visit revealed that the grantees had trained 434 community members in leadership and governance, 234 in community health planning, 302 in facility QI, and 39 in SBCC. The grantees conducted the training using the community planning training material and focused on relevant health issues.

Following the revision of the project scope for 2018 activities, SBH prepared and submitted grant amendments letters to all the 25 grantees in March. SBH instructed the grantees to amend their fixed award amount agreement by discontinuing activity milestones for Social and Behavior Change Communication, QI, and other project activities.

2.4.2 Task 5: Research, Monitoring, and Evaluation (RM&E) The M&E team focused on gathering data and preparing the annual report, preparing data for the PEPFAR semi-annual performance report, and on validating and cleaning data from the HIV Linkages activity in Kitwe during this quarter.

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3. Project Management

3.1 Finance and Administration The Finance and Administration team conducted market surveys and found office accommodation for the Continuum of Care program personnel in Chipata, Mansa, Chinsali, Choma, Kabwe, and Mongu. The Administration team made arrangements to relocate the Continuum of Care personnel to these districts. They also conducted physical inventory verification in preparation for the Abt year-end processes. The Finance team prepared the severance payments for 41 members of staff that were laid off as a result of project restructuring. 3.2 Overall Budget and Expenditures As of March 31, 2018, SBH spent a cumulative total of $28,984,728 against the total obligations of $35,182,718.30. Cumulatively, SBH spent 82.3% of the obligated funding and 44.65% of the total project estimated amount of $64,921,096. 3.3 Personnel By 31 March 2018, SBH 90 staff out of a revised establishment of 90.

• Nine new hires joined the project during the quarter: five Public Finance Management Specialists, four Performance Management Specialists, and two drivers

• Two employees resigned during the quarter: the Public Finance Management Specialist for and the driver for and these were replaced within the quarter.

• Following the change of scope and focus of the project with subsequent reduction in the budget, the project anticipates a major reduction of staffing levels in the next quarter. The Abt Associates International HR Department issued letters to 41 members of staff to communicate that a reduction in funding and a change in the project’s scope of work would lead to the elimination of their positions in April. Two additional members of staff are scheduled to receiving their redundancy letters in April to bring the total reduction in personnel to 43 positions.

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4. Success Stories

MSI empowers the DHO staff to act on their known weakness The role of the District Health Office in the QI process is to coordinate the implementation of all QI activities in the health facilities and enable the implementation of quality health services. But for Livingstone DHO, even with the support of various partners through training and mentorship activities of its health staff in QI, the DHO QI committee remained weak and non-functional in 2016 and 2017. As a result, QI implementation was far from optimal. Some health facilities formed QI committees, but not according to the MOH standard guidelines. Some facilities operated without any QI committee. The DHO did not provide oversight and supervision for ongoing QI projects. Some QI committees were operating as individuals and not as a team in the QI process. Most QI teams did a poor job of documenting their completed projects. An opportunity arose in January 2018 with the change in leadership at the DHO and a chance to share with the new District Health Director the USAID SBH Management Systems Inquiry (MSI) concept. The new Director gladly embraced MSI and ordered that all program officers be in attendance for the MSI QI exercise the following day, facilitated by SBH. MSI is a methodology for assessing the degree to which certain MOH systems, including QI, are implemented according to standards, identifying gaps, and developing action plans for improvement. The results of the exercise were astounding. All the QI action points developed through MSI were implemented by middle February 2018, such as sourcing the latest Ministry of Health QI guidelines and distributing it to all program officers and facility In-Charges, forming a new QI committee at the DHO, and strictly following the composition outlined in the QI guidelines. A partner, Family Health International was contacted and has pledged to fund the one-day QI meeting which the Clinical Team of DHO will chair during the first week of April 2018. The use of MSI empowered personnel at Livingstone DHO to identify their gaps and immediately act to address them. This change is also happening in the other USAID SBH targeted districts. SBH developed MSI tools for QI, Performance Assessment, planning and resource allocation, and health information systems.

“It is helpful…we were in the past looking at systems generally, but now, MSI helps us look and discuss each system in depth…” Nursing Officer_Mrs E. Jere “It’s a good tool, to begin with, it provides guidance on how to organize your work, identify the gaps and address them. It’s also an induction tool for old and new staff to know the expected standards for each system. This was not the case before.” Thindo Malambo _ Planner DHO

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