Quarterly Progress Report (July – September, 2018)

Approval Date: September 30, 2015

QPR Number: [002]

Contract/Agreement Number: [AID-611-C-15-00002]

Activity Start Date and End Date: [October 1, 2015 to September 30, 2020]

Total Award Amount: [$24,389,716.00]

Submitted by: [PATH Zambia Office, Stand 11059 Mikwala House, Brentwood Lane, Lusaka] [Tel: +260211378950]

DISCLAIMER: The author’s views expressed in this report do not necessarily reflect the views of the United States Agency for International Development (USAID), United States President’s Malaria Initiative (PMI) or the United States Government CONTENTS

1. LIST OF ABBREVIATIONS & ACRONYMS ...... 3

2. INTRODUCTION ...... 4

3. BENCHMARKS AND ACHIEVEMENTS ...... 6

4. KEY ISSUES ENCOUNTERED DURING THIS QUARTER ...... 19

5. KEY ACTIVITIES PLANNED FOR THE NEXT QUARTER ...... 19

6. SUCCESS STORIES ...... 20

1. LIST OF ABBREVIATIONS & ACRONYMS

ACT Artemisinin-based Combination Therapy ANC Antenatal Care BRITE Broad Reach Institute for Training & Education CBO Community-Based Organization CCP Johns Hopkins University Center for Communication Programs CHAZ Churches Health Association of Zambia CHW Community Health Worker CSO Civil Society Organization DHIO District Health Information Officer DHIS2 District Health Information System 2 DHO District Health Office DQA Data Quality Audits EDS Electronic Data System ETR End Term Review GRZ Government of the Republic of Zambia GUC Grants under Contract HMIS Health Management Information System iCCM Integrated Community Case Management IPTp Intermittent Preventive Treatment in Pregnancy IRS Indoor Residual Spraying LLIN Long-lasting Insecticide-Treated Net M&E Monitoring and Evaluation MACEPA Malaria Control and Elimination Partnership in Africa MIP Malaria in Pregnancy MIS Malaria Indicator Survey MOH Ministry of Health MRR Malaria Rapid Reporting NMEC National Malaria Elimination Center NMEP National Malaria Elimination Program NMESP National Malaria Elimination Strategic Plan NMSP National Malaria Strategic Plan OR Operations Research OTSS Outreach Training and Supportive Supervision PA Performance Assessment PAMO Program for the Advancement of Malaria Outcomes PHD Provincial Health Director PHO Provincial Health Office PMI President’s Malaria Initiative RDT Rapid Diagnostic Test SBC Social and Behavior Change SHIO Senior Health Information Officer SMEOR Surveillance, Monitoring, Evaluation and Operations Research SP Sulfadoxine-Pyrimethamine TWG Technical Working Group USAID United States Agency for International Development USG United States Government WHO World Health Organization ZMLA Zambia Management and Leadership Academy ZCAHRD Zambia Center for Applied Health Research and Development

2. INTRODUCTION

The Program for the Advancement of Malaria Outcomes (PAMO) is a malaria activity program for the United States President’s Malaria Initiative (PMI) in Zambia. The PMI Strategy for 2015–2020 states that “the U.S. Government's goal is to work with PMI-supported countries and partners to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.” In line with this strategy, PAMO was designed to assist the Government of the Republic of Zambia (GRZ) to reach its goal of eliminating local malaria infection and disease in Zambia by increasing access to and uptake of quality malaria control interventions. In 2018, PAMO’s support to the Ministry of Health (MOH) was aligned strategically with the new Zambia’s National Malaria Elimination Strategic Plan (NMESP) 2017–2021 and the PMI FY2017 Zambia Malaria Operational Plan (MOP).

PAMO’s geographic focus is on Eastern, Luapula, Muchinga, and Northern provinces, as depicted in Figure 1 below. These provinces were selected due to the high malaria disease burden at the beginning of the project (in 2015). The rural nature of the PAMO supported provinces, with an estimated population of 5,455,218 (Source: CSO 2017), makes PAMO project efforts particularly challenging.

Figure 1: Map of Zambia depicting Malaria Parasite Prevalence (Microscopy)

Source: MIS 2015

PAMO has three objectives: (1) to support proven malaria interventions in alignment with the National Malaria Strategic Plan (NMSP) 2011–2016 and the follow-on plan of the MOH; (2) to strengthen management capacity of provincial and district MOH personnel to provide supervision and mentoring to improve delivery of proven interventions; and (3) to strengthen provincial and district health management information systems (HMIS) to improve data reporting, analysis, and use for decision-making.

PAMO’s programmatic focus is on increasing coverage of long-lasting insecticide-treated nets (LLINs); improving malaria in pregnancy (MIP) services; improving access and quality of case management; introducing and scaling up social and behavior change (SBC) activities in support of malaria prevention and control activities; improving and scaling up of surveillance, monitoring and evaluation (M&E) related to PAMO’s interventions.

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

PAMO is currently in its third year of project implementation. This quarterly report describes project achievements during the third quarter (July –September) of 2018 and a brief outline of activities planned for the fourth quarter (October - December) of 2018.

3. BENCHMARKS AND ACHIEVEMENTS

A summary of the key achievements and the activities undertaken by the consortium during this quarter is provided below.

Objective 1: Support proven malaria interventions in alignment with the National Malaria Strategic Plan (2011-2016) and the follow on plan of the Ministry of Health

Task 1.0: Strengthen national technical working groups

Overview: Technical Working Groups (TWGs) are important mechanisms designed to bring stakeholders in malaria control and elimination together to share best practices and drive targeted, harmonized programming and policy. PAMO supports the NMEC to improve the functionality of the TWGs and other stakeholder platforms. PAMO’s support includes both technical and material assistance and is limited to only three TWGs.

Quarter 3 Planned Activities: TWG meetings are conducted quarterly; therefore, during the third quarter, PAMO planned to support the NMEC to host meetings for the following three TWGs:

1. Surveillance, Monitoring, Evaluation, and Operations Research (SMEOR) 2. Vector control 3. Case management

Quarter 3 Achievements: During the reporting quarter, PAMO participated in the Case Management TWG held on the 28th of September and the Vector Control TWG which was held on the 21st September. The SMEOR TWG was held on the 8th October 2018 and will therefore be reported in the next quarterly report.

Case Management TWG Some of the key issues which emerged from the last Case Management TWG meetings are listed below:

1. Update on Outreach Training and Supportive Supervision (OTSS) The meeting learnt that in 2018, OTSS has been implemented in eight out of ten provinces. OTSS was not implemented in Lusaka and Western province because the Biomedical Scientists in these two provinces were not trained in the microscopy competence assessment. OTSS will commence in these two provinces in the fourth quarter because the biomedical scientists are now trained.

NMEC findings/concerns on OTSS in the provinces where it has been implemented: a. The coverage of microscopy facilities was very low in almost all the provinces b. There are insufficient numbers of Standard Operating Procedures (SOP), quality assurance manuals, and bench aids for malaria microscopy. c. There are inadequate microscopy reagents, equipment and other materials, this is negatively affecting the quality and availability of microscopy. d. The updated Guidelines for the Diagnosis and Treatment of Malaria in Zambia have not yet been distributed to health facilities.

NMEC Recommendations a. Partners must ensure that district OTSS teams consist of five members of trained staff who were selected by the DHO. b. Districts need to be reminded to source or identify alternative sources of funding for OTSS in order to maximize coverage. c. Partners implementing OTSS should orient at least five members of staff for provincial OTSS and five members of staff for district OTSS on the Electronic Data Systems (EDS).

2. Integrated Community Case Management (iCCM) Updates • With support from various partners, NMEC would like to train 2,500 Community Health Workers (CHWs) across the country. Since the last TWG meeting, the NMEC has learnt that only 1,500 will be trained this year through support from various partners and funding sources. • A small quantity of rectal artesunate will be provided by the NMEC, to the PAMO supported provinces. The rectal artesunate will be used CHWs as pre-referral treatment for severe malaria.

3. Update on the printing of the Guidelines for the Diagnosis and Treatment of Malaria in Zambia (5th Edition) The meeting was informed by Dr. John Banda from the Global Fund Program Management Unit of the MOH that 15,000 copies of the guidelines were now printed and ready for distribution. Dr. Mulakwa Kamuliwo (PAMO Senior Advisor) suggested that a distribution plan for these guidelines should be developed by the NMEC.

4. Malaria Case Management Policies Dr. Wajilovia Chilambo the NMEC Case Management Specialist, informed the meeting that the NMEC is developing a malaria policy document. The case management team has been requested to develop the component related to case management. Dr. Mulakwa Kamuliwo from PAMO has been included in the core team that will work on this component of the malaria policy document.

Vector Control TWG The Vector Control TWG focused mainly on the upcoming Indoor Residual Spraying campaign. However the Vector Control TWG discussed the 2020 ITN Mass Distribution Campaign. One of the key lessons learnt from the 2017 Mass Distribution Campaign is the need to conduct a household registration exercise before the quantification and procurement of ITNs is done. The NMEC would like to conduct a nationwide household registration exercise in the country in 2019.

Task 1.1: Strengthen long lasting insecticide treated net distribution in the target provinces

Overview: Long lasting insecticide treated nets (LLINs) are used by the NMEP alongside indoor residual spraying to achieve universal vector control coverage (NMESP). In order to support the NMEC, PAMO works with them to strengthen distribution of LLINs through various channels in the target provinces. In the first quarter of 2018, PAMO supported the mass distribution campaign in the four PAMO supported provinces. For the rest of the year, PAMO is supporting LLIN durability monitoring; assessment of health facility distribution channels; revision of continuous distribution guidelines; and school-based distribution.

Quarter 3 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to: − Commence LLIN Durability Monitoring study

Quarter 3 Achievements:

LLIN Durability monitoring study Following the national level capacity building workshop for LLIN durability monitoring conducted in May 2018, PAMO worked closely with a team from the NMEC to train the data collectors and to kick start data collection for the baseline. The NMEC team comprised of the Insecticide Treated Net (ITN) Principal Officer, the Principal Biostatistician and Entomologist. PAMO was represented by the ITN advisor and the senior monitoring and evaluation manager. The training was held in Chipata, six teams of four were trained to collect data from two sites: Lundazi and Katete districts. Baseline data and ITNs for bioassay have been collected and will be undergoing data analysis. A report will be written once the data is cleaned and analyzed. The picture on the right shows data collectors examining holes in an LLIN collected in the field.

PAMO planned to commence the data processing, analysis and report writing for the durability monitoring study in September. However after consulting Dr. Killian from Tropical Health, he suggested that it would be best if he travelled to Zambia to work on these activities with PAMO and the NMEC. PAMO is working to finalize the logistics for his travel and for an in-country workshop to complete this process. This workshop has been tentatively set for the 12th to 16th November 2018.

Task 1.2: Improve access to and quality of malaria case management in public health facilities and communities to ensure prompt, accurate diagnosis and appropriate treatment

Overview: The NMESP 2017 – 2021 states that universal coverage with early diagnosis and effective treatment is a key strategy in reducing morbidity and mortality due to malaria. In 2018, PAMO is utilizing three main approaches to support the MOH to improve access to and quality of malaria case management at public health facilities and at the community level to ensure prompt and accurate diagnosis of malaria, and effective treatment of the disease. At health facility level, the strategies involve improving parasitological diagnosis and strengthening quality of care. At community level, it involves strengthening quality of and access to care and treatment through training of CHWs in iCCM and enhanced surveillance.

Quarter 3 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to: − Train 333 CHWs in iCCM and surveillance − Conduct a mentorship visit for trained CHWs in Muchinga province

Quarter 3 Achievements:

Training of 133 CHWS in iCCM and enhanced surveillance in Nchelenge (PAMO focus district). In 2018, PAMO introduced the “focus district” concept. This concept allows for a concentration of interventions and enhanced monitoring in a geographically limited area. The focus district concept was introduced because, it is challenging for the project to show year-to-year local impact when limited resources are spread across a vast geographic area in a high burden zone. In the focus district, PAMO can concentrate resources in order to maximise impact. Nchelenge has been selected as the focus district. In the last quarter, PAMO hosted a planning meeting in the district in order to elaborate on the focus district concept and to develop a harmonized work plan for PAMO and Nchelenge DHO. PAMO also worked in close collaboration with Luapula PHO and Nchelenge DHO to conduct a training of trainers (TOT) workshop for 28 healthcare workers (19 male, 9 female) in order to have sufficient trainers to roll out iCCM and enhanced surveillance in the district.

During this quarter, PAMO supported Nchelenge DHO to train 206 (80F, 126M) CHWS in iCCM and enhanced surveillance. PAMO worked with the NMEC, Luapula PHO, and Malaria Control and Elimination Partnership in Africa (MACEPA) to oversee the training of these CHWs. The CHWs were trained in groups of 40, each training session lasted six days. At the end of the training, the CHWs had a clear understanding of how to implement iCCM and enhanced surveillance and to report correctly. Overall, the 206 CHWs came from 15 health facilities. It is also worth mentioning that four (1F, 3M) additional CHWs from Mantapala refugee resettlement scheme also joined the PAMO led training. UNICEF provided funding for these 4 CHWs, who joined the PAMO led training sessions. The four CHWs will use the skills they learnt to provide iCCM services at the refugee camp. As stated earlier, the total number of CHWs trained by PAMO is 206 (80F, 126M) this represents an achievement of 154.9% of the PAMO target. This was possible because PAMO was able to make some savings as the trainings were implemented in a very cost effective way.

Training of 160 CHWS in iCCM and enhanced surveillance in Eastern, Muchinga and Northern Province.

Apart from the CHW training in the focus district, PAMO also planned to train another 200 CHWS in iCCM and enhanced surveillance in the other three PAMO supported provinces - Eastern, Muchinga and Northern Province.

Mambwe, Eastern province 41 CHWs (14 female and 27 male) from 12 health facilities were trained in Mambwe from the 6th to 11th August. Participants were drawn mainly from newly opened health facilities and facilities which had a low number of CHWs. The training included practical field work in Masumba rural health facility catchment area. The PAMO target in Eastern province is currently 40, therefore in this province, the project achieved 102.5% of the target. The district still requires more support to saturate the need for CHWs.

Mbala, Northern province 80 (28F, 52M) CHWS from 5 out of 18 health facilities in Mbala were trained in iCCM and enhanced surveillance. In addition, 22 supervisors (4F, 18M) comprising of eight from the health facilities, nine from the DHO and five from the PHO were also trained. The training was conducted from the 17th to 22nd September for the first group and from the 24th to 29th September for the second group. The PAMO CHW training target in Northern province was 80. The project has there achieved 100% of the target. However, it should be noted that only five health facilities were targeted, therefore to saturate this district, PAMO will need to train CHWs from the remaining 13 health facilities.

Muchinga province PAMO planned to train 80 CHWS in Muchinga province. The training kicked off in September and will end in October 2018. In September, 39 CHWs (13F, 26M) from Mpika were trained. An extra 41 CHWs will be trained during the first week of October in order to complete the training target. CHWs from Mpika were selected for training by the PHO because Mpika had the lowest number of CHWs trained as iCCM providers when it was compared to other districts. Mpika needs 200 CHWs to saturate all health facility catchment areas. In December 2017, PAMO trained 62 CHWs and this quarter, PAMO trained 39 more CHWs. This therefore brings the total to 101 trained CHWs. PAMO will support the district by training 41 more CHWs in October 2018, meaning the district will have 142 CHWs. A gap of 58 CHWS will remain in this district.

If PAMO is able to secure more resources, the project plans to saturate the need for CHWS, in all the districts mentioned above. An overview of PAMO’s performance in this quarter in provided below.

Table 1: Overview of PAMO performance for CHW training during Quarter 3

Province District Female Male Total Target Achievement Eastern Mambwe 14 27 41 40 102.5% Luapula Nchelenge 80 126 206 133 154.8% Muchinga Mpika 13 26 39 80 48.75% Northern Mbala 28 52 80 80 100% Total 135 231 366 333 109.9%

Mentorship visits to CHWs providing iCCM services in Muchinga province In 2017, PAMO trained 328 CHWs in iCCM across Muchinga province in all seven districts. (Since then, two districts have been added). The PAMO team in the province, worked with the respective DHOs and health facility staff to visit the CHWs offering iCCM services. 18 health facility catchment areas were visited. In general, the supervisory team found that most CHWs are active and are receiving commodities such as artemisinin based combination therapy (ACTs) and rapid diagnostic tests (RDTs). The table below is an illustration of the contribution that the CHWs are making in the respective health facility catchment areas.

Table 2: Number of confirmed malaria cases at Philip Health Post in Shiwan’gandu district (Jan- Jun 2018)

Confirmed malaria cases at Philip health post catchment area by month Jan Feb Mar Apr May Jun Confirmed cases tested by facility staff 183 233 237 192 228 215 Confirmed cases tested by CHWs 21 36 60 46 48 36 Total 204 269 297 238 276 251 CHW contribution (%) 10.1% 13.3% 20.2% 19.3% 17.4% 14.3%

One challenge which was noted during the visit, was that facilities were unable to maintain a steady supply of commodities for the CHWs. Only one facility was following the correct procedure and ensuring that they considered the CHW commodities when ordering. Guidance was given to the staff at all the other health facilities to ensure that they order adequate stocks including an allocation for the CHWs.

Task 1.3: Increase delivery of IPTp – SP as part of an integral package of ANC services

Overview: Nationally, rates of intermittent preventive treatment in pregnancy (IPTp) coverage are good, with 90.1% of all women reporting taking a first dose. In the PAMO-supported provinces, overall IPTp uptake levels of IPTp 3 are at 54.6% in Muchinga, 67.7% in Northern, 63.8% in Luapula and 57.8% in Eastern Province (MIS 2015). In order to improve IPTp coverage in the PAMO supported provinces, PAMO will support and advocate for the use of innovative ways to promote uptake of IPTp through interventions at the community level.

Quarter 3 Planned Activities: PAMO did not plan or implement any activities under this task during this quarter.

Quarter 3 Achievements: No activities were implemented during this quarter

Task 1.4: Strengthen SBCC implementation for malaria at health facility and community levels through community mobilization and community dialogues

Overview: PAMO has identified key social and behavior change activities to support improvements in key malaria related indicators. In 2018, PAMO plans to use various social and behavior change (SBC) intervention strategies including the roll out of the champion communities’ strategy, and community engagement and mobilization through CSOs in twenty four districts within the PAMO supported provinces. PAMO is using mass media to complement the community level interventions.

Quarter 3 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to: − Contract a firm to conduct SBC formative research − Participate in the Roll Back Malaria SBCC annual meeting − Participate in the Southern African Development Community (SADC) malaria day planning meetings

Quarter 3 Achievements:

Social & behavior change formative research PAMO has identified a firm to carry out the formative research. While awaiting the contract signing, PAMO has held a number of meetings with the firm in order to agree upon the preliminary activities. This is done to ensure a quick start up. As a result, a scope of work has already been developed. PATH expects to finalize the contract signing in October and immediately commence the formative research.

PAMO participation in the RBM SBCC annual meeting During this month, PAMO’s SBC team comprising of the SBC specialist and community engagement and mobilization officers from Eastern, Luapula, and Northern province attended the 5th RBM SBCC annual meeting at the Radisson Blue Hotel in Lusaka. The meeting which aims to share information on advancements in SBC and malaria prevention and elimination was attended by 130 participants representing 22 countries globally. The meeting was officially opened by the MOH’s Permanent Secretary- Health Services, Dr. Jabin Mulwanda. In his opening remarks, Dr. Mulwanda reiterated the need to strengthen malaria SBC in order for the country to eliminate malaria. Dr. Paul Psychas, also gave opening remarks on behalf of the United States’ President Malaria Initiative (PMI) Zambia. The SBC experts agreed to focus on two malaria priority activities to support malaria SBC. One is an SBC package for CHWs and the other focus is incorporating/standardizing SBC indicators in the malaria indicator survey. In addition to the plenary session, skills building and poster presentation sessions were held during the meeting. The meeting was closed by Dr. Mutinta Mudenda Deputy Director for the NMEC.

Participation in SADC malaria day planning meetings PAMO’s SBC specialist was selected as the co-chair of the organizing committee of this year’s SADC malaria day. SADC malaria day falls on the 6th of November 2018. This year’s commemoration will take place in Western province and will include SBC activities such as drama shows, radio and television programs/adverts, and other activities like malaria community case management and surveillance. A private company which manufactures paint i.e. Plascon has expressed their interest in branding some buildings within selected communities with the “Malaria Ends with Me” logo. PAMO also plans to support printing of materials for the event.

Task 1.5: Strengthen malaria policies and guidelines

Overview: Under this task, PAMO support to the NMEC will include: 1. Dissemination meetings of the NMESP 2017-2021 in the PAMO supported provinces 2. Roll out of the work plan harmonization tool for provinces and districts 3. Develop and implement a malaria business plan 4. Develop a Malaria Elimination Policy Document

Quarter 3 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to: − Support the NMEC to roll out of the work plan harmonization tool for provinces and districts − Develop and implement a malaria business plan

Quarter 3 Achievements: In the first two quarters of the year, PAMO successfully supported the NMEC to disseminate the NMESP 2017 – 2021 in the PAMO supported provinces. The project has also successfully rolled out the work plan harmonization tool and developed the Malaria Business Plan.

Develop a Malaria Elimination Policy document During the quarter, PAMO working though the senior policy and management advisor based at the NMEC, provided technical support to the NMEC to commence work on the development of the Malaria Elimination Policy Document. This consists of a series of consultations, drafting and final publication. So far terms of reference for a consultant have been developed and the process of sensitizing all key

stakeholders has begun. In addition, a core group which will develop the document has been formed by the NMEC.

PAMO participation in the MOH 2019 -2021 Midterm Expenditure Framework (MTEF) panning process. In August, PAMO at the national level and in all four provinces participated in the MTEF planning process. PAMO worked with respective provinces and districts to support the development of their respective action plans and budgets. The purpose of PAMO’s participation is to ensure that provincial and district plans are appropriately aligned to the NMESP and that decisions on where to target malaria interventions are guided by the available data. PAMO was unable to make any firm commitments for 2019 because at the time of the meeting, the project did not have an approved 2019 work plan.

Task 1.6: Support civil society organizations and community based organizations to implement malaria control activities

Overview: In 2018, PAMO through grants under contract (GUC), will provide financial and technical support to civil society organizations (CSOs) to implement community-level malaria SBC interventions. The CSOs will directly engage communities in promoting malaria interventions to create demand for malaria health services.

Quarter 3 Planned Activities: PAMO will: − Hold start-up workshops for contracted CSOs to orient them on how to manage and report on USAID funds, program activities, grants management and the SBC community activities which they will be expected to implement. − Implement SBC activities through contracted CSOs − Monitor CSO activities

Quarter 3 Achievements: Start-up workshops for CSOs contracted to operate in Eastern, Muchinga and Northern provinces PAMO held the first start-up/orientation meeting for the CSOs in Luapula during the month of May. During this quarter, PAMO held two more start- up workshops for the CSOs contracted to operate in Eastern, Muchinga and Northern province. The workshop was held to orient them on grant management and implementation up to closeout. The PAMO Grants Manager facilitated these meetings. The first meeting was held in Chipata from the 4th to 6th July. In attendance were key staff from the 6 CSOs contracted to operate in Eastern province. The Senior Health Education Officer for Eastern PHO represented the health team in the workshop and one representative from each of the 6 DHOs, in which the respective CSOs will be operating, attended the meeting. The meeting was officially opened by the Eastern Province Provincial Health Director.

From the 11th to 13th July, the PAMO Grants Manager held another start-up workshop in Mpika for the CSOs which are based in Muchinga and Northern province (joint meeting). Four CSOs which operate in Muchinga attended the meeting alongside the district health promotion officers from Mafinga, Isoka, and Mpika. The CSOs will be implementing their activities in these three districts in Muchinga Province. The Senior Health Education Officer for Muchinga PHO represented the health team at the meeting. From Northern Province, three CSOs which will operate in Senga, Kasama and Mungwi districts attended the orientation. Their respective district health promotion officers were in attendance while the acting Senior Health Education Officer for Northern PHO province represented the health team. Implementation of SBC activities through contracted CSOs Following the orientation meetings held to kick start the CSO activities, Luapula province reported on specific SBC activities conducted by the CSOs in the province. In Luapula, the CSOs held various community level activities in Mansa’s Mabumba catchment area. A roadshow was held and it attracted 689 (411F, 278M) people. Drama shows, songs, dance and health talks were conducted during the road show.

Monitor CSO activities During the month of September, PAMO Grants Manager, Grants Officer and the SBC Specialist joined the respective PAMO provincial teams and the provincial and district MOH officials to conduct a joint monitoring visit to all of the contracted CSOs. The purpose of this monitoring visit was to verify the CSO financial and technical reports, verify data submitted in the CSO reports, assess level of engagement between CSOs and DHOs, and review tools and approaches used in the implementation of SBC activities. The team also discussed challenges with the MOH and the CSOs. This monitoring visit begun on the 9th September and ended on the 4th of October 2018. Eighteen out of nineteen CSOs were visited.

During the monitoring visit, financial and programmatic checklists were used by the PAMO team. The monitoring team was able to review hardcopies of documents such as attendance registers, payment logs, field activity reports and other relevant documents availed by the CSOs. Additionally, the monitoring team visited a few CSO implementation sites including the health facilities. Interviews were held with members of the identified community structures such as the safe motherhood action groups (SMAGs) and neighborhood health committees (NHCs) as well as individual beneficiaries to establish whether or not SBC activities received support from the CSOs and if capacity building activities had taken place, the team assessed types of tools/materials used and how information was received and used by the volunteers.

The monitoring teams found that the selection of community champions had been done and all the activities indicated in the reports were conducted. The champions showed a lot of enthusiasm and eagerness to implement SBC activities in their communities. However, in most instances, the CSOs did not have the appropriate materials. For example, drama activities were conducted without the key messages written down for the drama groups and village meetings were also conducted without meeting guides for the headmen. The SBC specialist promised to work with officers of the various CSOs to ensure they had the key documents and materials required to ensure effective implementation of SBC in communities. The team also found that the CSOs had different reporting tools at community level. SBC specialist is working with MOH through the Health Promotions Unit to ensure a standardized reporting tool is shared with the CSOs.

Key recommendations made by the PAMO team include: 1. Closer collaboration and integration between MOH and the CSOs is needed. MOH needs to take a more proactive role in CSO implementation, reporting and monitoring. 2. CSOs need to ensure that they are using proven and up to date malaria messages in their community engagement activities. The MOH facilitators need to lead the technical aspects of the work. 3. CSOs must improve on the completeness and quality of supporting documentation for payments. Some CSOs were just following estimates in budgets and did not think they could deviate from the estimated budget.

Task 1.7: Conduct Operations Research

Overview: PAMO supports operations research (OR) as approved by PMI within the framework of the NMESP 2017 – 2021. In 2018, no funding for OR through PAMO has been designated. However, PAMO will support modest OR-related activities such as the finalization of the NMEC 2017 OR list and TWG meetings. The project will also support the implementation of the 2018 MIS (see Task 3.3), and LLIN durability monitoring in Eastern Province, this is described in more detail in Task 1.1

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

Task 2.1: Identify health system deficiencies at the provincial and district levels that constrain delivery of high impact malaria interventions in close collaboration with the MOH/NMEP, and other malaria actors This year, PAMO will not implement any activities under this Task, but findings from the management capacity assessment, gap analysis and end term review (ETR) of the National Malaria Strategic Plan (2011 – 2015) will be used to inform the activities in Task 2.2.

Task 2.2: Develop and implement a plan to strengthen management capacity as measured by set targets within each targeted province and district

Overview As stated above, using the findings of the ETR, malaria health systems gap analysis and the management capacity assessment, PAMO plans to develop and implement a malaria program management capacity strengthening plan in 2018. The following staged activities will be implemented in 2018: 1. Zambia Management and Leadership Academy (ZMLA) curriculum revision and adaptation 2. Management training in province and districts 3. One-on-one mentorship

Quarter 3 Planned Activities − ZMLA curriculum revision and adaptation

Quarter 3 Achievements: During this quarter, a curriculum adaptation meeting was held on the 5th and 6th September. Key MOH officials, Professor Sekalani Banda and Mr. Henry Kansembe participated in the meeting. Two representatives from the NMEC also participated in the meeting. The purpose of this meeting was to give the MOH an opportunity to make recommendations on how the core ZMLA curriculum should be adapted and tailored for malaria program managers. Following this meeting, PAMO consortium member BroadReach Institute for Training and Education (BRITE) continued to work on the curriculum adaptation. The first Malaria Management Training which will utilize this curriculum is scheduled to take place on the 29th October 2018.

Objective 3: Strengthen provincial and district health management information system (HMIS) to improve data reporting, analysis, and use for decision making

Task 3.1: Provide technical/material assistance to district health offices (DHOs), health facilities, and communities to improve the timeliness and accuracy of HMIS reporting

Overview Good quality data is important for decision making as it helps to guide program activities which will help accelerate the reduction of malaria cases. This year, PAMO will provide technical and material support to conduct HMIS data quality audits (DQAs) in health facilities. This is done to help the districts and health facilities improve the accuracy of the HMIS data. This support will be given through respective PHOs with technical oversight by the NMEC.

Quarter 3 Planned Activities: To support DQAs in each of the PAMO supported provinces.

Quarter 3 Achievements: During the last quarter, PAMO conducted DQAs in Northern province. During this quarter, DQAs were conducted in Eastern, Luapula and Muchinga province.

DQA in Eastern province On the 4th to 11th August, PAMO in Eastern province worked with MOH to conduct a DQA in eight districts and visited 27 health facilities in total. Some of the key issues arising from the DQA in Eastern province include: 1. Under reporting in a number of indicators, this was revealed when HMIS data was compared to the data in the registers 2. Vubwi, Chadiza and Petauke have accuracy of less than 70% on monthly accuracy. 3. Over reporting in some indicators by districts namely Katete and Petauke 4. Some districts like Petauke, Chadiza and Chipata are still recording clinical malaria despite availability of RDTs

The DQA team took necessary corrective action and developed timelines with the facilities to address the concerns. Staff who were particularly poor in HMIS reporting, were included in the HMIS training which is reported on under Task 3.2

DQA in Muchinga province In Muchinga Province, PAMO worked with the NMEC to support the PHO office to conduct DQAs in Lavushimanda, Kanchibiya, Chama, and Shiwan’gandu districts. In each of the districts, DQA were conducted in two health facilities selected as follows: one health facility that reported a drastic reduction of malaria incidence rate and one health facility that reported an increase in malaria incidence rates. These were identified by comparing incidence rates for the first quarter of 2017 and 2018. The malaria incidence rates were reported by the facilities at the data review meetings held the previous month. For instance, in Kanchibiya district, the two health facilities where Kabinga which showed an increase in malaria incidence rates. The incidence was 71 per 1000 population in the first quarter of 2018 and was 35 per 1000 population in the first quarter of 2017. Mbati RHC showed the highest incidence rates in all four quarters compared to all the other facilities. The audit team wanted to establish the reasons as to why Kabinga RHC had increased incidence rates in first quarter of 2018 when incidence rates in most of the facilities in the district had reduced. Similar rationale for selection of health facilities to visit for a DQA was

used for the other three districts (Lavushimanda, Chama, and Shiwan’gandu). Before commencing the DQA, the district health information officers (DHIOs) participated in a one day orientation meeting. They were introduced to the NMEC revised DQA tools. Some of the key findings of the DQA in Muchinga are as follows: 1. Some in-patient and out-patient registers were either improvised or were an old version 2. The registers were not up to date and there were some blanks in the registers. 3. There were discrepancies in the diagnosis of malaria. Some cases of “query malaria” were recorded with no anti-malarial treatment. 4. Some records on the RDT register were missing 5. CHW data not reflecting at the facility

DQA in Luapula province In order to support DHO and health facilities to improve the accuracy of HMIS reporting, PAMO supports Data Quality Audits (DQAs) in the four provinces. Luapula was the last of the four PAMO provinces to conduct a DQA. The DQA was done in ten districts of Luapula (Lunga was not visited), a total of 66 facilities were visited.

Key Findings: 1. Only one register is used to record diagnosis and treatment. This is incorrect as separate registers (OPD register and improvised unstandardized RDT register) should be used to record diagnosis and treatment. In addition only one person collects and aggregates the malaria data and there is no one to verify the data which is recorded in HIA 1 and HIA 2. 2. Malaria in pregnancy is under reported because this information is often missed out by health facility staff. 3. The use of a pen with the same colour to record positive and negative malaria cases does contribute to errors during aggregation of the malaria data. 4. RDTs were not used by health facility staff during the weekend and at night. All fever cases seen during this time frame are recorded as confirmed cases instead of clinical cases. This was discovered because the RDT register did not tally with the OPD register.

Actions taken to rectify the problems: Staff were mentored at the health facilities and oriented on the correct way to enter and aggregate data. Examples of the specific items which were addressed are: 1. Illustrations on how to record information on diagnosis and treatment in the right columns of the OPD registers 2. Overview of the various data elements, filling out the HIA form and the need to ask another healthcare worker to verify the data.

PAMO works with the DHOs to ensure that the DQA team doesn’t just leave the facility without taking necessary corrective measures. They also develop action plans with the facility, with clear timelines for when the issues should be addressed and when a follow up will be made.

Task 3.2: Assist with training for the roll out of District Health Information System (DHIS2) in the targeted provinces and districts

Overview PAMO support is aimed to strengthen HMIS in the four targeted provinces primarily at health facility level, with modest support for district and provincial levels. Activities include support for training staff at health facilities in data collection and reporting. The emphasis for PAMO is to ensure that each health facility has at least one member of staff trained to correctly complete health information aggregation forms.

Quarter 3 Planned Activities: − Conduct HMIS training in PAMO supported provinces Quarter 3 Achievements: On the 27th to 31st August, PAMO supported Eastern PHO to train 50 (16F, 35M) health facility staff in HMIS reporting. The staff were drawn from Chipata, Lundazi, Mambwe and Vubwi. The staff who were selected include new staff, and facilities which performed poorly during the DQA were also selected for the HMIS training because they need to be re-trained. The senior health information officer (SHIO) was the facilitator. In Luapula province, PAMO supported the training of 22 (10F, 12M) health workers and in Muchinga province, PAMO trained 28 (13F, 15M) health facility staff. This brings the total number of health facility staff trained to 101 (54F, 62M). The last HMIS training will be held in Northern Province in October 2018. The project target for HMIS training is 102 therefore PAMO has achieved 99% of the annual target so far.

Task 3.3: Provide technical/material assistance to district health offices (DHOs), health facilities, and communities to strengthen malaria data analysis and use for decision making

Overview: At provincial and district level, PAMO will provide technical and materials assistance to 10 districts to conduct malaria data review meetings. PAMO will also participate in other provincial and district data review meetings even though they are not directly funded by PAMO in order to identify districts and facilities that require technical assistance.

Quarter 3 Planned Activities: − Participate in provincial and district data review meetings − Participate in the Malaria Indicator Survey Report writing retreat

Quarter 3 Achievements During this quarter, PAMO participated in the following data review meetings:

Malaria data review meetings in Northern province PAMO in Northern province supported data review meetings for three districts. The malaria data review meetings are carried out by the districts in the province on a quarterly basis.PAMO supported malaria data review meetings in three districts for selected few health facilities. The criteria for the selection of the facilities to be supported was guided by the SHIO and was based on the best performing health facilities and the poor performing health facilities. Mungwi, Kasama and Senga were supported to conduct malaria data review meetings. Some of the key recommendations emerging from the meetings: − The districts should ensure that health facilities compile malaria data for each zone so that they are able to identify zones that contribute more to the malaria burden in the health facility catchment areas. − The malaria data review meetings and its outcome would be more represented if most of the districts and health facilities participated in the meetings so that sharing of data and experiences is considered on a broader coverage in the province. − The District Health Information Officers should ensure that the outcome of the malaria data review meetings are shared with other health facilities that did not attend the meetings so that

they adopt common best practices findings and challenges should help them come up with solutions.

Malaria data review meeting in Luapula province In Luapula province, PAMO supported a provincial data review meeting. PAMO supported Lunga, Milenge and Samfya districts, while the Global Fund supported data review meetings for the rest of the districts. A presentation of the DQA results was made during this data review meeting. Participants discussed how to support/re-orient health facility staff in malaria data recording and reporting. The participants also discussed ways to strengthen DQAs and data checks during performance assessments in order to improve data recording and reporting in the province.

Malaria indicator survey (MIS) report writing retreat held in August The following were the key highlights of the workshop: - − Revision of preliminary MIS results and further analysis of some of the created report tables and charts − Revision of the proposed report outline to enhance the flow of the document. The report was re- structured to follow the thematic areas: Vector Control, Case Management and Social and Behavior Change Communication (SBCC) and each thematic area to include general findings, trends and recommendations

4. KEY ISSUES ENCOUNTERED DURING THIS QUARTER This section looks at the key problems or issues encountered, how they were resolved, and mission level recommendations to facilitate their timely resolution.

− No significant issues were encountered during this quarter.

5. KEY ACTIVITIES PLANNED FOR THE NEXT QUARTER

The following key activities have been planned by PAMO for the next quarter:

− Support fourth quarter TWGs − Conduct LLIN durability monitoring study data cleaning, analysis and submission − Conduct ANC/EPI Health facility assessments − Hold national level meeting to develop LLIN disposal guidelines − Complete OTSS supervisors evaluation − Distribute Guidelines for the Diagnosis and Treatment of Malaria in Zambia (Fifth Edition) − Commence formative research to inform the national malaria communication strategy − Implement Champion Communities through contracted CSOs − Support NMEC to hold national level meeting to resolve HMIS functionality − Support NMEC to print final 2018 Malaria Indicator Survey report − Complete second round of provincial and district OTSS − Complete ANC orientation for health workers − Support HMIS training in Northern province − Support fourth quarter malaria data review meetings − Conduct management training workshop for participants from the four provinces 6. SUCCESS STORIES

PAMO has not included any success stories in this quarterly report.