1 THE CLOVER PROJECT HEALTH SYSTEMS STRENGTHENING ROUNDTABLE CLOVER COUNTRY REPORT: ZAMBIA Improving health systems: working together, with malaria as an entry point Malaria Consortium Irish Aid Development House Department of Foreign Affairs 56-64 Leonard Street Riverstone House London, EC2A 4LT 23-27 Henry Street +44 20 7549 0210 Limerick +353 1 408 2000 Malaria Consortium disease control, better health www.malariaconsortium.org www.irishaid.gov.ie Introduction 2 Malaria Consortium Zambia began its work on health systems strengthening in 2005, under the second phase, Irish Aid-funded Clover II project. Malaria Consortium Zambia began its work malaria will focus primarily on IEC/BCC and 5km from the nearest health center. There on health systems strengthening in 2005, research. Clover III, however, is the only is approximately one health center per under the second phase, Irish Aid-funded programme in Zambia at present that uses 6,780 people. Only 43% of trained health Clover II project. At that time, Clover was malaria technical interventions as a means workers in Zambia reach the WHO-recom- implemented only in Southern Province. of building capacity across systems at the mended level of 2.4 workers per 1,000 pop- Clover II’s most important achievements district-level. ulation and less than 50% of frontline health were 1) the establishment and support for workers are available relative to the need district-level Malaria Task Forces, the first Background for primary health care services. Turnover sub-national, public-private partnerships of staff at all levels of the health system is for malaria prevention and control in South- Zambia is a land-locked, Central African high and the Ministry of Health (MoH) is re- ern Africa and b) the creation of innovative country sharing boarders with Democratic stricted from hiring new staff due to highly rapid diagnostic test (RDT) training modules Republic of Conga, Tanzania, Malawi, Mo- indebted poor countries (HIPC) completion targeted to both rural health facility work- zambique, Zimbabwe, Botswana, Namibia conditionality. The National Decentraliza- ers (HFWs) and community health workers and Angola. Zambia is made up of nine tion Policy, launched in 2003, has meant 14 (CHWs), the IEC/BCC materials for which Provinces and 72 Districts. The estimated that districts have a degree of autonomy in Figurewere 1: Map adopted of Projects Areas and scaled up by the World current population is 12 million based on planning and budgeting health activities at Health Organization (WHO). the sub-national level. a population growth rate of 2.4 percent per annum. Zambia is making moderate progress meet- Zambia has a high disease burden and faces ing a number of its health-related MDGs a number of challenges common to devel- and its progress is immediately noticeable oping countries [Table 1]. Immunization in Zambia’s malaria prevention and con- trol efforts [Table 2]. Zambia is the sixth coverage rates, while high at the national level, vary considerably from province to largest recipient of malaria funding in Af- province, with some regions falling signifi- rica, with most of its funding coming from cantly below the national average. Diar- Global Fund and USAID. Bed net coverage rhea and acute respiratory illness (ARI) still is much higher than many of its neighbors. account for 35% of deaths among children 4.8 million LLINs were distributed between 2006 and 2008. 3.1 million courses of ACT <5 years of age. Neonatal factors account for another 20%, while malaria accounts for were distributed in 2008, reaching close to Following the extension of funding via the 17%. Under-5 mortality rate (170 per 1,000) 1/3 of patients diagnosed with malaria in third phase Clover III project in 2008, Ma- and infant mortality rates (103 per 1,000) public sector health facilities. It is one of laria Consortium expanded its activities into remain much higher than the regional av- only nine countries in Africa with evidence Eastern Province. Presently, Malaria Consor- of a greater than 50% decrease in malaria erages (145 and 88 respectively). The HIV tium Zambia works in all 19 districts across incidence cases in between 2000 and 2008, prevalence rate is estimated to be as high as Southern and Eastern Province, reaching 17% and, largely due to the ravages of the along with a 35% decrease in under-5 all a population of approximately 3.2 million epidemic, the average Zambian has a life cause child mortality rates. Malaria preven- Tablepeople 1: Key Health [Figure Statistics 1]. Its relationship with sub- expectancy at birth of only 46 years. tion and control is coordinated centrally by national stakeholders is its greatest strength the National Malaria Control Centre (NMCC), and Malaria Consortium Zambia is continu- The primary mission of the Zambian Na- part of the MoH. At the provincial level, the ally cited by provincial and district adminis- tional Health Strategy is to provide “cost- Provincial Medical Officer oversees disease trators as one of their most important part- effective, quality health services as close control efforts, while Malaria Focal Point ners. to the family as possible.” Public sector People coordinate efforts among District health services are structured as follows: Health Management Teams (DHMTs), which Presently, there is no national framework [Figure 2] Under this structure, most Zam- include District Environmental Health Tech- for HSS in Zambia; however, there has been bians receive their primary health care from nicians (DEHTs), District Health Information a consecutive, 5-year, USAID-funded HSS both rural and urban health centres (HCs), Officers (DHIOs) and other specialists. Be- programs since the mid-1990s. The most and their secondary care from district hos- sides Malaria Consortium, other partners recent, HSSP (Health Systems Strengthen- pitals. Health services have been free at provide financial, technical and logistical ing Program), ended in mid-2010. The new- rural health centres (RHCs) since 2006, but support for malaria including PATH’s MACE- est incarnation – the Zambia Integrated user fees are levied elsewhere. Health cen- PA program, USAID’s President’s Malaria Ini- Systems Strengthening Program (ZISSP) ters should serve a catchment population of tiative (PMI), Society for Family Health (SFH), -- is overseen by Abt Associates. HSSP had 30,000 – 50,000 people, while district hos- UNICEF, WHO and Harvard University’s Har- malaria components built into it (such as pitals 80,000-200,000 people; nevertheless, vard Business Services (HBS). bed net purchase and distribution). ZISSP’s 50% of the rural population lives more than World Health Organization. 2009. World Health Statistics 2009. Geneva: World Health Organization, p. 55. World Health Organization. 2009. World Health Statistics 2009. Geneva: World Health Organization, p. 43. World Health Organization. 2009. World Health Statistics 2009. Geneva: World Health Organization, p. 42 Government of Zambia. 2005. National Health Strategic Plan 2006-2011. Lusaka: Ministry of Health, p.1. See Annex 1 for facility coverage statistics in Eastern and Southern Province. World Bank. 2008. The International Development Association Country Assistance Strategy for the Republic of Zambia. March 28, 2008. Lusaka: World Bank. Ministry of Health, 2009, Draft concept note for the development of a community health worker national strategy, May 28, 2009, MoH: Lusaka Government of Zambia. 2005. National Health Strategic Plan 2006-2011. Lusaka: Ministry of Health, p.22. World Health Organization. 2009. World Malaria Report 2009. Geneva: World Health Organization, p.32. The Clover project 3 In Zambia, Clover is presently situated in Southern and Eastern Province. With regard to most activities, all 19 districts in these provinces have been reached, with the exception of Case Management trainings, which were implemented in five districts. Clover is managed from the county capital, Lusaka. In Zambia, Clover is presently situated in medical qualification, were trained in the ac- sors as they can carried out these supervi- Southern and Eastern Province. With regard curacy and administration of RDTs and the sory visits. They are also providing updated to most activities, all 19 districts in these appropriate diagnosis and treatment of un- training for laboratory technicians in South- provinces have been reached, with the ex- complicated malaria. They are also trained ern and Eastern Province hospitals in ma- ception of Case Management trainings, in record-keeping of ACT and RDT supplies. laria microscopy. QA targeted the following which were implemented in five districts. Case Management targeted the following components of the health system: health Clover is managed from the county capital, components of the health system: health workforce, health services delivery, health Lusaka. A Technical Officer and two Projects services delivery, health workforce, health information systems and medical product Officers implement Clover activities in both information systems and medical product supply chain. Provinces. Partnerships with the public and supply chain. private sectors, as well as the willingness of Zambulance Projects Officers to continuously travel, have HMIS Training(HMIS) In January 2010, Malaria Consortium placed played a large role in the success of Malaria Malaria Consortium sought to empower 57 bike ambulances (Zambulances) at the Consortium. Since 2008, there has been District Health Information Officers (DHIOs) community level in target districts