Quarterly Progress Report (April – June, 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 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 ...... 5

3. BENCHMARKS AND ACHIEVEMENTS ...... 7

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 AIRS Africa Indoor Residual Spraying project AMF Against Malaria Foundation ANC Antenatal Care BRITE Broad Reach Institute for Training & Education CBO Community-Based Organization CCO Clinical Care Officer CCP Johns Hopkins University Center for Communication Programs CDC U.S. Centers for Disease Control CHA Community Health Assistant CHAZ Churches Health Association of Zambia CHW Community Health Worker CMA Community Malaria Counseling Agents CSH Communication Support for Health CSO Civil Society Organization DHD District Health Director 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 EPI Expanded Program on Immunization FANC Focused Antenatal Care GHSC-PSM Global Health Supply Chain-Procurement and Supply Management GRZ Government of the Republic of Zambia GUC Grants under Contract HF Health Facility HFCA Health Facility Catchment Area HMIS Health Management Information System iCCM Integrated Community Case Management IMCI Integrated Management of Childhood Illnesses 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 MOP Malaria Operational Plan MRR Malaria Rapid Reporting NAC National Aids Council NHC Neighborhood Health Committee NMEC National Malaria Elimination Center NMEP National Malaria Elimination Program NMESP National Malaria Elimination Strategic Plan NMSP National Malaria Strategic Plan OPD Outpatient Department 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 SBH Systems for Better Health SHIO Senior Health Information Officer SMAG Safe Motherhood Action Group SMEO 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 ZISSP USAID Zambia Integrated Systems Strengthening Program

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 population in these four provinces is estimated at 5,455,218 (Source: CSO 2017).

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 (HFs), 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 second quarter of 2018 and a brief outline of activities planned for the third quarter.

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 National Malaria Elimination Centre (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 2 Planned Activities: TWG meetings are conducted quarterly; therefore, during the second 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 2 Achievements: During the reporting quarter, PAMO supported the Case Management TWG meeting. The Vector Control and SMEOR TWGs did not meet during this quarter.

The Case management TWG meeting was held on 1st June 2018, with the following key issues emerging:

Topic Discussion points Quality assurance  NMEC reported that there remains a concern about the ability of program for malaria microscopists to read results accurately. There is also inadequate diagnosis support for assessment of malaria microscopy readers, and support for their training among other things. Only PAMO was supporting this in Eastern, Luapula, Muchinga and Northern Province in 2017.

 In line with WHO recommendations that during pre-elimination, the country should have a core group of accredited microscopist, a national core group of microscopists, has been formed. They will train microscopists and provide standard operating procedures. The core group comprises of six (four level 1 and two level 2), microscopists who are accredited by WHO. Three of these microscopists (One male from Northern province and two females from ), benefitted from PMI and PAMO supported training which was held in these provinces.

 Standard training slides set are available and validated

Revised malaria  NMEC reported that the guidelines were launched in Kabwe on World treatment and diagnostic Malaria Day. NMEC has contracted Government printers to print guidelines 15,000 copies which will be distributed once ready.

iCCM  NMEC reported that no stock outs of iCCM commodities are anticipated. At the time of the TWG meeting, MSL had reported that RDTs had run out at the central level but supplies were still available in the facilities. MSL was expecting the next shipment of RDTs within the month of June 2018. Monthly meetings between CHAZ and NMEC to discuss commodity status were suggested.  iCCM + Component D national training of trainers was planned for the 4th to 9th June in Chilanga. Four participants from each province of the 9 provinces were invited. Luapula was not included because PAMO conducted a training of trainers for that province in May 2018

Mass drug administration  This will be piloted in high burden districts of Lunga and Sikongo, a baseline study will be conducted

Chemoprophylaxis  The TWG discussed the possibility of introducing chemoprophylaxis in Zambia. In countries like Senegal and Mali, chemoprophylaxis has been shown to reduce malaria mortality during peak season by as much as 80%.

Rectal artesunate  Following the successful completion of a pilot (in Serenge) on use of rectal artesunate by CHWs, and inclusion in the fifth edition of the “Guidelines for the Diagnosis and Treatment of Malaria in Zambia” (Page 10) MAMAZ’s recommendation to the NMEC is that rectal artesunate should be rolled out nationwide as soon as possible. NMEC is satisfied with the encouraging results of the pilot, but unfortunately government does not have funds to procure the drug at this time but is encouraging partner who are able to support the government with the roll out.

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 2018, PAMO is supporting mass distribution campaigns in the four PAMO supported provinces; LLIN durability monitoring; assessment of health facility distribution channels; revision of continuous distribution guidelines; and school-based distribution.

Quarter 2 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to:  Hold national level capacity building workshop for LLIN durability monitoring  Submit LLIN Durability study protocol to the research ethics board

Quarter 2 Achievements:

National level capacity building workshop for LLIN durability monitoring: A national level capacity building workshop was held at the PATH office from the 20th to 26th May 2018. The workshop was led by Albert Kilian from Vectorworks and fifteen people participated. The participants comprised of five people from the NMEC, five from PAMO, one from Eastern province health office (PHO), and one each from Lundazi and Katete district health office (DHO). PMI were represented by the Resident Advisor Dr. Chomba Sinyangwe.

The training begun with a quick overview of the four-day agenda, presentation of review of the objectives and introduction of the resources which were made available to participants.. This was followed by an introduction to the concept and general methodology of durability monitoring for LLIN and specifically the guidance from PMI and the design of the activity in Zambia which will compare two different LLIN (Olyset and Permanet 2.0) in two similar locations (see Figure 2 below).

Figure 2: Durability monitoring locations

Next, the cluster sampling design was discussed and the process for identifying the sampling frame and selecting fifteen clusters per site with probability proportionate to size with the cluster sampling tool was explained and practiced using a sampling frame from Kenya as an example. The rest of day one focused on the structure of the questionnaires at different time points and specifically the baseline questionnaire was discussed in detail and any necessary adaptation in language or options were identified.

On the second day, the approach to hole-assessment was discussed and intensive practice of determining hole-sizes using the hole template and counting holes was done using three training nets. Common mistakes in counting such as double-counting, holes around the corners of the net, ignorable holes were highlighted. Participants were introduced to the hole-counting app on the tablets and the tally sheets. Participants were divided into three groups and each team had to assess independently each of the three nets and results for each team and each net were compared using the net assessment comparison tool which will also be used during training of field teams. While the overall assessment of each net (good, damaged or torn) was always in agreement, there initially were some differences especially for one of the groups. However, the possible difference in approach and how to void this during training was discussed.

Next was a session on how to collect and manage the collection and replacement of the nets for bio-assay testing followed by a detailed presentation and discussion of the field work planning, materials needed and organization of training. The team decided that they will use three field teams of three interviewers plus one supervisor each per site so that they can complete the field work within five working days. The day ended with a presentation of the basics of GPS and mapping and how it will be used to track households in the durability monitoring.

The third day focused on the selection of the 10 households and replacements within each cluster using the household listing and then either the random number tables or the random household selection app on the tablet. Then the questionnaires were introduced and hands-on exercises carried out using the Kenya baseline questionnaire as an example. This included obtaining a global positioning system (GPS) reading and scanning barcode labels with the bar code scanner. The rest of day focused on household follow-up and how the lists for that are prepared and then introduced the tool to help visualize and interpret the survival estimates at each time point and obtaining “median survival in years” results using various methods with the tool. Intensive exercises on the tool concluded the day. On the last day, a review of the workshop was done and certain exercises were repeated to ensure that all participants had a clear understanding. The final version of the Zambian baseline questionnaire was uploaded on the tablets. The training ended in a very positive spirit and all participants felt motivated to start the durability monitoring in July.

Dr. Sinyangwe from PMI made a short presentation and had a short side meeting with the facilitator and selected participants. Vectorworks plans to hold discussions with PMI Zambia and PMI Washington DC for possible support for the baseline data analysis.

Submit LLIN Durability study protocol to the research ethics board PAMO begun the implementation of the LLIN durability study in quarter 1. The project received the durability monitoring tools from Vectorworks and submitted the protocol to the NMEC for review and input. The NMEC made some adjustments to the documents and thereafter approved them. The protocol was then submitted to ERES Converge, a privately owned research ethics board for approval.

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 community health workers in iCCM and active surveillance.

Quarter 2 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to:  Participate in provincial level performance assessment (PA)  Support provincial and district outreach training and supportive supervision (OTSS)  Support district OTSS  Prepare for the roll out of community health workers (CHWs) in integrated community case management (iCCM) and surveillance in Nchelenge

Quarter 2 Achievements:

Participate in provincial level PA PAMO staff participated in the first round of the PA in Eastern Province, it was held from 26th March to 6th April. PAMO joined the Eastern Provincial Health Office (PHO) team and visited Chadiza, Lundazi and Chipata districts. In Northern Province, PAMO team joined the PHO team for their PA in . The facilities visited included Kapolyo and Nseluka, and Mungwi DHO. The PHOs use the PAs to monitor performance across the districts and to guide them in determining where technical supportive supervision is required to improve service provision and indicators in the health delivery system (including malaria). In , PAMO participated in the PA and a provincial technical review meeting on the progress of malaria indicators. The findings from the Muchinga provincial PA were utilized by the PHO to identify the districts which should be prioritized for OTSS.

Support provincial OTSS PAMO worked in close collaboration with the PHO to conduct the first round of provincial OTSS in all four provinces. This year, PAMO will fully support two rounds of provincial OTSS in each of the provinces. The table below provides an overview of the number of facilities covered during the first round of OTSS.

Table 1: Number of facilities visited during the first provincial OTSS round

Province Total No. of public Total No. of HFs offering Total No. of HFs offering malaria HFs in the province malaria microscopy microscopy services visited services during the first round of provincial OTSS Eastern 289 42 40 Luapula 215 23 23 Muchinga 120 17 17 Northern 196 25 25 Total 820 107 105

Some of the common issues arising from the provincial OTSS visits are:

 There is a general improvement in adherence to test results, most facilities visited did not record any clinical malaria cases.  There was poor documentation of microscopy registers in some health facilities  Health workers rarely talk to the clients about malaria prevention  There were stock outs of artesunate in some health facilities but there were adequate stocks of ACTs and RDTs  Health workers are able to use RDTs correctly in accordance with the manufactures’ guidelines  Malaria treatment guidelines are missing in most health facilities

During the OTSS visit, the mentors took immediate corrective action where possible. Action plans were developed in each of the facilities. The action plans have clear steps which need to be taken and deadlines to address the identified gaps. The action plan was discussed with the staff being observed during the debrief session. It was agreed that the gaps will be worked on within the stipulated time.

Support District OTSS PAMO supported the first round of district level OTSS in all the four provinces. District OTSS targets health facilities which offer rapid diagnostic test (RDT) and not microscopy. PAMO is aiming to cover 50% of these facilities during each round of OTSS. PAMO will support two rounds of OTSS this year. The Table 2 provides an overview of the OTSS coverage.

Table 2: Overview of first round of district OTSS Province Total No. of Total No. of HFs Total No. of Total % of HFs public HFs in the offering malaria HFs offering number of covered province microscopy only RDT HFs visited services Eastern 289 42 241 38 15.76% Luapula 215 23 192 80 41.67% Muchinga 120 17 103 73 70.87% Northern 196 25 171 117 68.42% Total 820 107 707 308 43.56%

Facility selection is based on findings from malaria data reviews, performance assessments and an analysis of HMIS data. The key issues emerging from the OTSS rounds include the following:  Stock-outs of artesunate were noted in some facilities. Where it is lacking, quinine is used to treat severe malaria.  Clinicians are not taking adequate patient history and no health education is provided to the clients.  Some facilities are routinely testing all patients (irrespective of condition) who come to the facility with an RDT. This includes all pregnant women attending ANC, all positive cases are treated. The facility staff were advised against testing all pregnant women and importance of adhering to the treatment guidelines

 Many health facilities are lacking RDT registers and job aids such as algorithms and treatment guidelines for facility staff to refer to.

 There is need to re- orient district teams in electronic data system (EDS), some of the supervisors are not yet fully conversant with EDS. Preparations for the roll out of integrated community case management (iCCM) training in Nchelenge (focus district). In 2018, PAMO introduced the concept of “focus district” which 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. 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. This was intended to promote effective use of resources (in line with the approved PAMO budget) and smooth implementation of the focus district activities. The meeting was attended by 4 Nchelenge DHO staff, 4 PHO staff, 6 PAMO staff and representatives from two CSOs from Nchelenge.

An important activity which will be supported in Nchelenge, is the establishment of a community-level case management and surveillance. In order to achieve this, PAMO aims to train 133 community health workers (CHWs) to provide these services. The CHW trainings are planned forthe third quarter. PAMO also worked in close collaboration with Luapula PHO and Nchelenge DHO to conduct a training of trainers (TOT) for 28 healthcare workers (19 male, 9 female) in order to have sufficient trainers to train 133 CHWs in iCCM and surveillance. The objectives of the training were to build capacity of MOH trainers on the current malaria elimination strategy, community case management and active and passive surveillance The participants also learnt about mapping of CHWs in their respective catchment areas. The participants comprised of staff from Nchelenge DHO, environmental health technicians, nurses, clinical officers, laboratory personnel and PHO staff. The training took place from 21st to 26th May, 2018 at Uphill lodge in Kawambwa. The trainers were from the NMEC, PAMO and MACEPA.

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 2 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to  Advocate for IPTp administration at community level through the national safe motherhood TWG

Quarter 2 Achievements: The Safe Motherhood TWG meeting was held on the 18th April 2018. At the meeting PAMO made a short presentation to advocate for the use of Safe Motherhood Action Groups (SMAGs) to distribute sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp). This presentation was made to advocate for policy change toward enabling the SMAGs to access SP from the health facilities and dispense this to the pregnant women in the community. TWG members agreed to the need for a policy change. It was agreed that PAMO will work with the chief safe motherhood officer in the MOH to develop the concept note and road map on how this will be implemented and present this at the next safe motherhood TWG. On 14th May 2018 PAMO malaria in pregnancy and case management specialist met with the chief safe motherhood officer in the MOH and the Deputy Director (MOH) to discuss the development of the concept note and road map on how SMAGs could be used administer SP at community level in order to further improve uptake of IPTp. It was agreed that a proposal should be developed to conduct a small study to contribute towards implementing decision. It was also agreed that Northern Province will be an ideal site to pilot SMAGs SP administration. This activity is on-going.

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 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 2 Planned Activities: During the reporting quarter, the focus of PAMO’s work was to:  To support World Malaria Day commemoration

Quarter 2 Achievements: PAMO joined the MOH and other partners to commemorate World Malaria Day under the theme “Are you Ready to Beat Malaria?” PAMO participated in a number of WMD events in the target provinces. PAMO staff also attended the national event in Kabwe which was graced by the Minister of Health. At the

event, the Minister launched the business plan and revised case management and diagnostic guidelines, both developed with technical assistance from PAMO. Other documents launched were the SBC communication strategy and the ITN and IRS guidelines. In Mansa (Luapula) and Chinsali (Muchinga), PAMO worked with the MATFs and joined preparatory meetings for WMD, then attended the provincial launches.

Task 1.5: Strengthen malaria policies and guidelines

Overview: Under this task, PAMO support to the NMEC will include: 1. Dissemination meetings of the national malaria elimination strategic plan 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

Quarter 2 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 2 Achievements:

Support the NMEC to roll out of the work plan harmonization tool for provinces and districts Following the national level meeting held in Ndola from the 5th to 9th February, PAMO supported the four provincial health offices to disseminate the NMESP 2017 - 2021, to introduce the template for harmonizing work plans at all levels (work plan harmonization tool) and to develop draft provincial malaria work plans using the tool. In the first quarter, the provincial meetings for Luapula, Muchinga and Northern Province were held. PAMO therefore only supported Eastern Province to hold their meeting in April 2018.

Develop and implement a malaria business plan PAMO working though the senior policy and management advisor based at the NMEC, provided technical support to the NMEC to develop a “National Malaria Elimination Business Plan 2018-2020” The business plan is designed to provide guidance to partners who wish to work with the NMEC to provide scaled and sustainable financing to achieve malaria elimination. In order for Zambia to achieve malaria elimination, it will be imperative for the country to mobilize the requisite resources in a coordinated and collaborative approach. The business plan was successfully completed during this quarter and it was launched by the Honorable Minister of Health Dr. Chitalu Chilufya during World Malaria Day (25th April) commemoration in Kabwe.

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 2 Planned Activities: PAMO will:  Orient the CSOs to manage and report on USAID funds and program activities.  Orient the CSOs in grants management and the SBC community activities which they will be expected to implement.

Quarter 2 Achievements: PAMO held the first start-up/orientation meeting for the CSOs in Luapula during the month of May. The PHO participated in the meeting which was attended by 11 district malaria focal point persons, 12 representatives from the 6 selected CSOs (Africa Action Help, Youth Development Association, Luapula Families in Distress, Vision Africa Region Network, Group Focused Consultations and Network of Zambian People Living with HIV (NZP+). The start-up meetings for Eastern, Muchinga and Northern Province did not take place during this quarter but are planned to take place in July. The CSOs are expected to work closely with the DHOs while the PHO and PAMO staff will provide overall supervision. It is expected that the CSOs will immediately begin to implement community level activities.

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), field testing of PBO (piperonyl butoxide) bed nets in Luapula, and LLIN durability monitoring in Eastern Province. Both of these are 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 2 Planned Activities: The ZMLA curriculum revision and adaptation was the only activity planned for this quarter.

Quarter 2 Achievements: During this quarter, PAMO consortium member –BRITE, begun to review and adapt the ZMLA curriculum. The PAMO provincial teams have also started the process of identifying possible candidates for the management training. This important preparatory work was done to ensure the planned activities can be completed with the remaining months of the year.

Objective 3: Strengthen provincial and district 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 support will be given through respective PHOs with technical oversight by the NMEP.

Quarter 2 Planned Activities: To roll out the DQA in each of the PAMO supported provinces.

Quarter 2 Achievements: PAMO conducted DQAs in Northern province. DQAs for four districts (Luwingu, Kasama, Mungwi and Senga) were supported. Each DHO visited selected health facilities for the DQA. A total of 26 facilities were visited. Some of the key findings were that pregnant women are routinely screened for malaria but tests are not recorded in the RDT registers or the OPD 1st attendance register thereby creating variances in figures reported and those audited. Two clinics, Chikoyi and Nsombo had the highest data disparities while Nsanja health posts exhibited the best performance improvement in terms of accuracy on selected indicators, quality was at 98%. The DHOs would like to have more frequent audits in order to improve overall performance of health facilities. The DQAs for Eastern, Luapula and Muchinga were rescheduled for third quarter.

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 2 Planned Activities: Conduct a rapid assessment in the PAMO supported provinces to establish existing HMIS training gaps in collaboration with the SHIOs. Quarter 2 Achievements: The project planned to conduct a rapid assessment to establish existing HMIS training gaps, then train health staff in HMIS based on identified gaps. The rapid assessment which will be done by PAMO staff and the respective senior health information officers (SHIOs) has been postpone to the third quarter. Due to busy schedules of the SHIOs, PAMO was unable to gather all the required information in good time. PAMO is taking necessary steps to ensure this activity is completed as soon as possible.

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 2 Planned Activities:  Participate in Q2 provincial and district data review meetings  Participate in the Malaria Indicator Survey

Quarter 2 Achievements During this quarter, PAMO participated in the following data review meetings:

District data review meetings in Eastern province PAMO participated in and provided material assistance for malaria data review meetings for Nyimba, Petauke and Katete districts. The data review meetings for the three districts were held between the 15th and 25th May 2018. The meeting were held to review malaria incidence data for the first quarter of the year. The district presentations showed that very few facilities reported clinical malaria in the first quarter on 2018 due to availability of RDTs. The DHOs will follow up on all facilities that are still recording clinical malaria. The DHO will follow up on facilities not conducting monthly malaria data review meetings as a priority. The DHO will try to mobilize resources in order to provide iCCM reporting tools and other enablers to facilities where CHWs are trained in iCCM. Approximately 20% to 35% of reported malaria cases are from CHWs in the represented districts. The DHO reminded the facility staff to not add (combine) the figures of clients tested at the health facility and the community in the reports. They need to send the reports from the health facility and the community separately to the DHO using the HIA4 form. Facilities working close to the border with Mozambique have continued to receive a lot of malaria cases from that country. Health facility staff are still treating these cases until further guidance is provided by the MOH.

District data review meetings in Muchinga province PAMO participated in and provided material assistance for malaria data review meetings in three districts in Muchinga province (Chama, Kanchibaya and Lavushimanda) held data review meetings in June. These data review meetings were held to improve data analysis, data use for decision making and to build capacity of MOH staff in malaria surveillance, monitoring, and evaluation. There has been a general decline in malaria incidence and also the number of clinical malaria cases reported through the HMIS. This can be attributed to improved malaria case diagnosis and improved supervision of facilities by the respective district health offices. During the first quarter of 2018, only one health facility in Chama - Chibale Health Centre recorded a malaria death.

Malaria Indicator Survey 2018 The national MIS has been a key instrument in understanding progress in controlling and eliminating malaria in line with the NMESP 2017-2021. The MIS 2018 will continue as a follow on from the past five MIS rounds performed, in 2006, 2008, 2010, 2012 and 2015, respectively. In support of the overall national program implementation and ongoing review, PAMO is part of the consortium of partners that came together to conduct the 2018 MIS. In coordination with these partners, PAMO facilitated PMI’s logistical support for the MIS by ensuring that the training venue for the field staff was available. The training ran from the 2nd to the 9th April. A total of 121 people (including PAMO’s Monitoring and Evaluation Specialist and LLIN Advisor) attended the MIS training which was held in Chongwe. In addition, PAMO facilitated the hiring of vehicles for the field work. PAMO arranged boat hire in the areas where needed. PAMO also arranged procurement and printing of T-shirts which had the “Malaria Ends with Me” and PAMO logos. PAMO also supported the printing of the administrative manual used during the training. In May, PAMO M&E Specialist and LLIN Advisor supported MIS data collection teams in Eastern, Luapula, Muchinga and Northern provinces. They worked with them in various districts, covering six clusters (Luapula 2, Eastern 2, Muchinga 1, and Northern 1). They participated in registration of households, sampling and conducting interviews. The two filled in the supervisor’s checklist at the close of the activity in each day. Generally, the field teams visited were meticulous in their data collection, they were well organized as a team and incorporated community volunteers to work with them in their day to day activities. Some of the major challenges noted were bad road terrains compounded by heavy rain fall, delayed re-supply of testing and treatment commodities from Lusaka and inadequate sensitization about the MIS data collection exercise. Some of the teams encountered resistance in certain villages because of misconceptions as what the team was doing in the community and one team was almost attacked by villagers. However quick intervention from the village headmen and chiefs averted any hostile reactions.

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:

o Support NMEC to hold quarterly TWG meetings o Complete ZMLA curriculum revision and adaptation o Complete orientation of CSOs in financial management and reporting o Commence CSO activities in the districts o Commence LLIN durability monitoring in Katete and Lundazi in Eastern province o Train 333 CHWs in iCCM combined with active surveillance o Conduct DQAs in Eastern, Luapula and Muchinga provinces 6. SUCCESS STORIES

Malaria Data Review Meetings and OTSS supported by PAMO in Muchinga revealed that trained iCCM providers contribute to reduction of misuse of RDTs in health facilities. (Written by Augustine Chinyama, Provincial Coordinator –Muchinga)

Before the introduction of iCCM training of CHWs, most health facilities in Muchinga Province were misusing malaria rapid diagnostic tests (RDTs). Some of the reasons for the misuse were that health facility staff were not adequately trained to use RDTs. In some health facilities, untrained community volunteers were assisting health facility staff to test suspected malaria cases. Rather than testing only suspected malaria cases, the volunteers were testing every patient that went to the health facility for malaria before they were even seen by the clinician or nurse in the out-patient department. This practice contributed to misuse of RDTs in most health facilities resulting into frequent shortages. Shortages of RDTs contribute to increased reports of clinical malaria by most health facilities. An example of this is shown in the table below:

Table 1: Lukulu Health Centre malaria cases reported during the first quarter of 2018

Lukulu Health Center Data Quarter 1 2018

No of suspected malaria cases tested at the health facility 1,857

No of positive cases at health facility 984

No of cases treated at health facility 984

Muchinga Provincial Health Office with support from PAMO had trained 328 community volunteers to be iCCM providers. This was done during the fourth quarter of 2017, the iCCM providers begun to work in the first quarter of 2018. During a data review meeting supported by PAMO in Lavushimanda district, it was revealed that the iCCM providers had a higher malaria positivity rate than the health center as they tested patients who presented with clinical malaria. The iCCM providers were testing and treating malaria case in the community and adhering to treatment guidelines more than the health facility staff. This was evident when the community data for the Lukulu health center was analyzed. This is shown in the table below:

Table 2: Lukulu Health Centre malaria cases reported during the first quarter of 2018

Lukulu community No of suspected malaria No of positive cases No of cases malaria data: Quarter 1, cases tested treated in the 2018 community Kalala health post (HP) 184 133 133 Mpofu HP 132 76 76 Kapwanya HP 204 147 147 Malama HP 163 103 103 Chito HP 98 39 39 Simon Muleba HP 243 170 170 Total 1,024 668 668

The tables show data for both Lukulu community and Lukulu health facility, it indicates that the CHWs malaria positivity rate was 65% and that of the health facility was at 53%. During data analysis and discussions in the data review meeting, it was evident that some health workers at health facilities still use RDTs to test all patients visiting the facility irrespective of the reason they are visiting the facility. This practice was discouraged by district health office officials in all health facilities during PAMO-supported OTSS visits. The training of CHWs by PAMO helped the DHO to realize that there was a need to scrutinize health facility staff practices more closely. This has had a positive impact in the district as the DHO has been able to address incorrect use of RDTs, this minimizing wastage of these commodities and thereby reducing shortages of it. In the long run this will greatly contribute to the reduction of reports of clinical malaria cases in the province because stock-outs should hopefully become less frequent.

OTSS improves malaria case management: A case of Munkanta Rural Health Centre (Written by Bright Katai, Provincial Coordinator – Luapula)

In Luapula Province of Zambia, malaria has remained one of the ten top causes of morbidity and mortality. As a result, malaria case management has been characterised by an irrational use of anti-malaria drugs in trying to curb the disease. This therefore meant that, every patient that presented with fever was being treated for malaria regardless of the RDT or malaria microscopy test result. This problem contributed to over-reporting of malaria case, irrational use of anti-malaria drugs in the health facilities of Luapula Province, a practice that was has since changed for the better because of OTSS rounds.

In 2017 PAMO conducted training for health centre staff and Munkata rural health centre staff participated in the training which aimed to strengthen provider skills in malaria case management. The staff who were targeted for the training included but were not limited to: clinicians, laboratory personnel, pharmacists and maternal and child health nurses. These trainings were followed by quarterly OTSS and mentorship rounds in the health facilities from the first quarter of 2017. These rounds involved health worker observations, and onsite mentorship was provided in order to improve the health workers ability to manage malaria case management in their respective health facilities.

The methodologies that were employed during the OTSS and Mentorship activities included:  Review of malaria records (OPD registers, RDT registers, ANC registers) at the health facility.  Observing and reviewing malaria quality assurance practices at the facility  Observing RDT procedures and provider competencies among OPD staff on the use of RDTs.  Observations and interviews-malaria case management as the suspected malaria cases came in to the facilities  Mentorship/onsite coaching on observed gaps  Mentors providing feedback on overall observation and findings at the health facility

As a result of the OTSS rounds, Munkanta RHC has made encouraging progress and now stands out as a facility that is recording positive change in . The data below illustrates this:

Table 3: Malaria cases reported at Munkanta RHC Jan – Jun 2017 (before OTSS) Data element Jan Feb Mar Apr May Jun Total < 1 yr 29 19 10 11 12 5 86 1 -5 yrs 164 91 39 91 110 79 574 > 5yrs 382 212 133 189 371 312 1599 Total 575 322 182 291 493 396 2259

Table 4: Malaria cases reported at Munkanta RHC Jan – Jun 2018 (after OTSS) Data element Jan Feb Mar Apr May Jun Total < 1 yr 5 3 1 2 7 8 26 1 -5 yrs 43 24 22 26 39 53 207 > 5yrs 144 92 48 76 160 174 694 Total 192 119 71 104 206 235 927

The center has also recorded a reduction in clinical malaria case. The photograph below of the HIA2 in January 2018 shows that no clinical cases were recorded in January 2018.

Figure 1: HIA2 Register showing no clinical malaria case for January 2018

Testimony: “Munkanta Rural Health Centre has benefited a lot from PAMO support. Among the support that has really helped us deal with the problem of malaria in our catchment area is the quarterly OTSS/mentorship visits that PAMO support. Today we are able to competently manage Malaria cases because of the mentorship that we receive during OTSS. This has resulted into a reduction in the Malaria cases as a result of improved case management as can be evidenced from the data above.” Mr. Simpasa, Munkanta RHC In-charge

PAMO’s investment in OTSS in Luapula is already reaping rewards for the province. It was rolled out in 2017 and is already proving to be working positively and will help the province achieve its goal of reducing malaria burden with the ultimate goal of eliminating malaria. A success story such as this one shows that continued investment in OTSS is truly justified and valued, it should therefore be strengthened and continued.

Bright Katai PAMO Provincial Coordinator Interviewing Munkanta RHC in-charge in Kawambwa District

Reductions in severe malaria and improved service delivery at Ukwimi ‘A’ zonal health center in Eastern province (written by Morgan Sakala – Provincial Coordinator Eastern Province)

UKWIMI ‘A’ RHC BACKGROUND Ukwimi ‘A’ RHC is located 69 kilometers from Petauke central business district along Chilongozi road. It’s catchment area boarders with that of Riverside RHC to the north, Satellite 30 RHC to the east, Sandwe RHC to the west, Satellite 18 RHC to the south and Refugee Health Post to the north-west, all within Ukwimi resettlement scheme. The health Centre is placed at the central Civic administration point of the resettlement scheme.

Ukwimi ‘A’ RHC is a zonal RHC for the Ukwimi zone comprising of Sandwe RHC, Satellite 18 RHC, Refugee, and Chibale Health Posts. The Centre was built by Lutheran World Federation for Refugees who had been displaced by war in Mozambique, Angola and Burundi and was handed over to the Government when refugees were repatriated to their countries when war ended.

SERVICES PROVIDED The facility has a full complement of staff and provides curative services, Integrated Reproductive Health services and Preventive services such Immunizations and environmental Health services. The center caters for a population of 4,722 (head count) spread across eight neighborhoods. The center has benefited from PAMO-supported malaria case management trainings, malaria microscopy training, DQA and has been visited three times for OTSS.

Ukwimi ‘A’ is among the malaria endemic health centers of with Lusandwa neighborhood health committee being responsible for most of the Ukwimi ‘A’ malaria cases. After facility staff attended a malaria case management training, the center also organized orientation for Community Based Volunteers (CBVs) in malaria case management so that more malaria cases could be tested and treated in the community. Additionally, when PAMO supported iCCM training in December 2017, Ukwimi ‘A’ sent some volunteers from Lusandwa NHC to be trained. Among those trained was Mr. Peter Tembo who testifies that severe malaria and deaths due to malaria were common in his area. He explained that due to long distances to the health facility people would wait until they are very sick before seeking health care services at Ukwimi ‘A’. Now that he is trained, he attends to malaria cases in his community. He states that during malaria peak season, he attends to an average of 30 cases each day and says severe malaria and death associated with malaria have significantly reduced in his area.

Mrs. Esther Mwale Zulu is an enrolled midwife at the Ukwimi ‘A’. She is excited with the results of malaria case management for the center and the community; “we had problems managing severe malaria cases that were being referred to the center, we had a lot of clinical malaria cases as we did not have faith in RDTs, laboratory staff never used to do malaria microscopy, our documentation had many gaps”. The story has now changed, narrates Mrs. Zulu boasts: ‘I’m now an expert in conducting RDTs and administering injectable artesunate”