usaid/zambia systems for better health

USAID/Zambia Systems For Better Health Quarterly Progress Report July–September 2016

October 2016 This publication was produced for review by the United States Agency for International Development. It was prepared by Abt Associates for the USAID Systems for Better Health activity.

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

Contract No: AID-OAA-I-14-0003

Order No: AID-611-TO-16-00001 GUC Mechanism

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

Prepared by: Abt Associates Inc.

In collaboration with: American College of Nurse-Midwives Akros Inc. BroadReach Institute for Training and Education Initiatives Inc. Imperial Health Sciences Save the Children

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Contents

Acronyms ..................................................................................................................................................... ii Executive Summary ................................................................................................................................... iv 1. Introduction .................................................................................................................................... 1 2. Progress by Task ............................................................................................................................ 2

2.1 Task One: Design, Implement and monitor National Level Interventions to Strengthen Health Stewardship by the Ministry of Health ................................................. 2 2.1.1 Sub-task 1.1: Strengthen Human Resources Planning and Management ............................ 2 2.1.2 Sub-task 1.2: Improve Health Care Financing and Public Financial Management ............. 3 2.1.3 Sub-task 1.3: Strengthen MOH Capacity to Oversee Delivery of Key Health

Programs ................................................................................................................................ 4 2.2 Task Two: Design, Implement, and Monitor Interventions to Strengthen Program

Management Capabilities of Provincial and District Teams .............................................. 6 2.2.1 Sub-Task 2.1: Strengthen Program Management Capacity ................................................. 7 2.2.2 Sub-Task 2.2: Improve Technical Capacity of Provincial and District Health Teams

to Deliver Quality Health Services in Facilities ................................................................... 8 2.3 Task Three: Support the Government and Community-Based Organizations to

Increase the Quality, Availability, and Use of Health Services ........................................ 10 2.3.1 Sub-Task 3.1: Improve the Capacity to Deliver Quality Health Services in the

Community .......................................................................................................................... 10 2.3.2 Sub-Task 3.2: Strengthen Linkages between the Facility and the Community ................. 11

2.4 Cross-Cutting Technical Areas ......................................................................................... 12 2.4.1 Grants under Contract ......................................................................................................... 12 2.4.2 Research, Monitoring and Evaluation ................................................................................ 12

3. Project Management .................................................................................................................... 14 3.1 Finance and Administration .............................................................................................. 14 3.2 Overall Budget and Expenditures ..................................................................................... 14 3.3 Personnel ........................................................................................................................... 14 3.4 Subcontracts ...................................................................................................................... 14

4. Success Stories .............................................................................................................................. 16 5. Challenges and Solutions ............................................................................................................. 18 Annex 1: Performance Indicator Tracking Table.................................................................................. 19 Annex 2: Quarterly Achievements Tracking Table ............................................................................... 29 Annex 3: Short-term Technical Assistance Plan for Next Quarter ...................................................... 34

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Acronyms

ALMA African Leaders Malaria Alliance

AMEP Activity Monitoring and Evaluation Plan

ART Antiretroviral Therapy

ART Antiretroviral Therapy

BRITE BroadReach Institute for Training and Education

CBO Community-based Organization

CHA Community Health Assistant

CHAI Clinton Health Access Initiative

DHIS2 District Health Information System Version 2

DHO District Health Office

DMO District Medical Officer

EmONC Emergency Obstetric and Neonatal Care

GFP Gender Focal Point

HCF Health Care Financing

HCFP Health Care Finance and Planning

HMIS Health Management Information System

HRH Human Resources for Health

HRHSP Human Resources for Health Strategic Plan

HRIS Human Resources Information System

HSS Health Systems Strengthening

M&E Monitoring and Evaluation

MCH Maternal and Child Health

MOH Ministry of Health

NCHW National Community Health Worker

NFNC National Food and Nutrition Commission

NGO Non-governmental Organizations

NHA National Health Accounts

NIPA National Institute for Public Administration

NTOP National Training Operational Plan

PA/e-PA Performance Assessment/electronic Performance Assessment

PEPFAR President’s Emergency Plan for AIDS Relief

PHO Provincial Health Office

PMO Provincial Medical Officer

PMP Performance Management Plan

QI Quality Improvement

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RBF Results-based Financing

RMNCH Reproductive, Maternal, Neonatal, and Child Health

SBH Systems for Better Health

SCM Supply Chain Management

SHI Social Health Insurance

SMAG Safe Motherhood Action Groups

SMGL Saving Mothers Giving Life

TWG Technical Working Group

ZMLA Zambia Management and Leadership Academy

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Executive Summary

This Quarterly Progress Report for the USAID Systems for Better Health (SBH) activity covers the period of July 1st through September 30th, 2016. During the reporting period, SBH conducted a number of activities in support of the project’s Year One milestones and hired thirteen new project staff. The project held several consultative meetings with the Ministry of Health (MOH) and project partners, supported the management team at Levy Mwanawasa General Hospital to conduct refresher training for thirty-three department heads in the Annual Performance Appraisal System (APAS), and supported the MOH’s recruitment of 1,894 new health workers following a treasury directive.

In this quarter, SBH successfully conducted the Community Capacity Assessment in six districts covering thirty health facilities to pave the way for capacity building interventions informed by data. The SBH Supply Chain Specialist worked together with MOH supply chain management (SCM) personnel to conduct SCM assessments in eight target districts and forty health centers. This assessment revealed key challenges in inventory management, over-stocking of drugs, and stock-outs of essential drugs.

The project completed the revision of the Activity Monitoring and Evaluation Plan, which includes the outcome and output indicators with proposed new targets for each interim result by program task. The baseline report, which provides a set of process, output, outcome, and impact level indicators that collectively demonstrate the project’s performance and contributions to improved health indicators, also was completed this quarter. Both documents have been submitted to USAID.

SBH partner BroadReach Institute for Training and Education, in collaboration with the Zambia Management Leadership Academy, conducted the second training phase of thirty MOH medical staff in management and leadership skills. One hundred and fifty health professionals have been targeted for training in Year One. This quarterly report will highlight these and other activities undertaken in support of the project’s goals.

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1. Introduction

The five-year USAID SBH activity in Zambia was awarded to Abt Associates, Inc. in October 2015. Abt is implementing SBH in collaboration with partners American College of Nurse-Midwives (ACNM), Akros, Inc., BroadReach Institute for Training and Education (BRITE), Initiatives, Inc., Imperial Health Sciences (IHS), and Save the Children. The goal of SBH is to improve health outcomes for Zambians by strengthening systems that underpin the delivery of high quality health services, and increasing the utilization of high impact health interventions at district and community levels. The expected outcomes of the activity are:

1. More effective national level health stewardship;

2. Improved capacities of provincial and district health teams to perform program management functions;

3. Increased quality and availability of priority health services at the community level in targeted districts; and

4. Increased utilization of key public health interventions.

The project has the following specific objectives:

Retention of patients on antiretroviral therapy (ART) increased to at least 85 percent in targeted districts;

Couple years of protection increased by 10 percent in targeted districts;

Proportion of deliveries with assistance from a medically trained provider increased by 20 percent in targeted districts; and

At least 80 percent of children aged 12 to 23 months fully immunized in targeted districts.

This quarterly progress report summarizes the progress and achievements during the project’s third full quarterly reporting period, July to September 2016. The narratives under each sub-task include only activities where significant progress was made during the reporting period. The summary tables for each sub-task include a brief description of the status of all activities.

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2. Progress by Task

2.1 Task One: Design, Implement and monitor National Level Interventions to Strengthen Health Stewardship by the Ministry of Health

During Year One, SBH aims to lay the foundation for evidence-based interventions to strengthen health stewardship at the central MOH. Interventions will be based on existing MOH policy documents, systems and processes to support Human Resources for Health (HRH), Health Care Financing (HCF), and health program management by the MOH. SBH has a three-pronged approach for Task One activities:

1. Support the development, review, implementation, and monitoring of key MOH strategies and plans;

2. Strengthen the implementation of existing systems and processes; and

3. Conduct baseline assessments to identify key gaps in service delivery and management capacity that can be addressed through project technical and material assistance.

2.1.1 Sub-task 1.1: Strengthen Human Resources Planning and Management

The goal for Year One is to strengthen MOH capacity at central level to plan for and manage HRH by supporting the development and implementation of key strategic plans, strengthening midwifery education, providing technical assistance to the MOH HRH Technical Working Group (TWG), and supporting HRH information and performance monitoring systems.

Human Resources for Health In working to strengthen HRH, SBH has collaborated with the Clinton Health Access Initiative (CHAI) to assist the MOH to recruit and hire 1,894 new health workers. The MOH Human Resources and Administration (HRA) Directorate led the recruitment process in collaboration with the Public Service Management Division, the Public Service Commission, and the Examination Council of Zambia. The team completed the paperwork to recruit 1,894 applicants in the following categories: Zambia Enrolled Midwives (200), Zambia Enrolled Nurses (250), Registered Nurses (135), Registered Midwives (35), Registered Mental Health Nurses (11), Nurse/Midwifery Tutors (6), Clinical Officers (15), Pharmacy Technologists (8), Physiotherapy Technologists (8), Environmental Health Technologists (200), Radiography Technologists (8), Principal State Advocate (1), Community Health Assistants (261), and Classified Daily Employees (756). The MOH is preparing a report with details on the hiring process and the final figures by cadre and province.

Table 1. Summary of Year One Benchmarks for Sub-task 1.1 Expected Year One Benchmarks Achievements this Quarter

Second Program Specialist to support the Ministry Technical Working Groups to develop, disseminate and foster implementation of guidance documents

Seconded a Community Health Specialist to MOHSeconded the HRH Specialist to MOH.

Develop Human Resources for Health Strategic Plan (HRHSP) Awaiting finalization of the main National Health Strategic Plan.

Develop NTOP New NTOP reviewed and finalized with MOH leadership. NTOP is clear, realistic, and responsive to Zambia’s most critical health worker training gaps affecting service delivery.

MOH planned to develop a new NTOP for 2017-2021.

Strengthen Midwifery education to support implementation of the NTOP

Procured skills lab equipment and distributed to four midwifery schools - Monze, University Teaching Hospital, Kabwe and Mufulira.

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Improve NCHW Strategy and CHA Program implementation SBH through ACNM carried out an assessment of the two CHA training schools to identify areas needing support to enhance the quality of training.

Assist monitoring of implementation of Human Resources Information System (HRIS) and Performance Management Plan (PMP)

HRIS not yet operational in most institutions.

33 program officers from Levy Mwanawasa General Hospital received training in APAS with SBH support. All participants developed individual work plans and are ready for this year’s appraisal exercise.

2.1.2 Sub-task 1.2: Improve Health Care Financing and Public Financial Management

In Year One, SBH’s system strengthening support to MOH aims to promote improved financing for health through development and implementation of key health financing strategies and initiatives. SBH also will help the MOH to improve systems for financial management, and to produce and use financing data to inform planning and decision making.

Build Public Financial Management Capacity In the reporting period, the MOH piloted Results Based Financing (RBF) in selected districts with World Bank support and will continue to expand the program to Western, Northwestern, Luapula, Northern, and Muchinga provinces this year. The SBH Health Care Finance and Planning Specialist participated in the Results Based Financing (RBF) capacity building program as a facilitator to help prepare policy makers and implementers in target provinces to manage the RBF program. Participants received an in-depth orientation to RBF and developed the competencies required for effective RBF implementation. The SBH Specialist participated in the training in order to assess how SBH can use RBF strategies in its target districts when the project begins to make grants to the government. The SBH Specialist recommended that SBH conduct the RBF capacity building program in its target districts and health facilities, and introduce some elements of the RBF program as the basis for grants to districts.

Table 2. Summary of Year One Benchmarks for Subtask 1.2 Expected Year One Benchmarks Achievements this Quarter

Second Program Specialist to support the Ministry of Health to develop, disseminate and foster implementation of guidance documents

Secondment of the M&E Data Use Officer to Central MOH Directorate of Policy and Planning, M&E unit.

Finalize the HCF Strategy Drafting of the HCF Strategy initiated; work expected to be complete by December 2016.

Finalize HIV and health resource mobilization strategies This strategy will be part of HCF strategy, the development of which begins in October.

Support development of Social Health Insurance Completed in the second quarter. Awaiting Cabinet instruction on the way forward.

Build MOH capacity to produce and use data Training in Systems for Health Accounts as a mechanismfor institutionalization of NHA is scheduled for Nov 2016.

Build public financial management capacity Capacity building activities are scheduled for Year One, Quarter 4 as MOH prepares for next round of the NHA survey exercise.

Assess potential for project support of Results-Based Financing (RBF) SBH has consulted with stakeholders on the status of RBF and opportunities for expansion. SBH is providing technical assistance to the Government of Zambia and World Bank on the expansion of RBF as appropriate.

SBH HCF/Planning Specialist participated in the MOH-led RBF trainings and will lead discussions with SBH program officers on how best the concept can be applied in SBH target districts to influence attainment of core project indicators.

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2.1.3 Sub-task 1.3: Strengthen MOH Capacity to Oversee Delivery of Key Health Programs

In Year One, SBH is working with the MOH to strengthen stewardship at the central level. The process will begin with a capacity assessment to guide the capacity building activities. To facilitate this, SBH has seconded some technical specialists to the MOH as part of the strategy to strengthen key MOH systems, processes, tools, and training materials. SBH started to engage the Central MOH on how to conduct the capacity assessment, although no firm decisions have been taken.

Strengthen MOH Performance Monitoring and Improvement In this quarter, SBH supported the MOH performance monitoring and improvement activities which included the revision of key treatment guidelines during the period. The SBH Senior Manager of Provincial Programs and the Quality Improvement (QI) Specialist attended a combined Technical Working Group (TWG) meeting for Adult and Paediatric Antiretroviral Therapy (ART) and Prevention of Mother to Child Transmission (PMTCT). The combined TWG reviewed recommendations in the 2016 World Health Organization Consolidated HIV Guidelines and proposed to adopt several treatment guideline changes, including: 1) addition of nucleic acid testing at birth, 2) immediate initiation of ART for every person who tests positive for HIV, and 3) viral load testing six months after treatment initiation and once every twelve months thereafter. Adaptation of the National HIV guidelines is underway.

SBH funded a meeting in August to review and update the first edition of the QI Guidelines which the Ministry published in 2012. The SBH QI Specialist worked with diverse experts at a meeting held to review the current document and develop a draft of the second edition of the Guidelines. The QI Guidelines required revision and updating because of challenges in operationalization experienced by personnel. The final draft was completed and the process of hiring a consultant has commenced.

The SBH Senior Manager of Provincial Programs and the QI Specialist in collaboration with the Ministry of Health Directorate of Clinical Care and Diagnostic Services (DCCDS) facilitated a review meeting for the 2012 National Clinical Mentorship Guidelines and drafting of various health program mentoring tools. This review built on a meeting in June at which partners agreed to develop harmonized mentoring tools and a mentor training package and use MOH structures and processes for project mentoring activities. The September meeting focused on integrating recommendations made in June into the national mentorship guidelines. Some of the key recommendations included the splitting of the national level mentorship team into a northern team (based at Ndola Central Hospital) and a southern team (based at the University Teaching Hospital), with mentoring to be conducted by service providers while MOH, PMO and DMO take a coordinating role.

The project further supported the development of a simplified community QI training package for community volunteers aimed at helping to engage communities in facility-level quality improvement activities. The SBH QI Specialist and Community Health Specialist worked with the team of experts responsible for developing the training package. The training package was based on a framework developed in August by the QI TWG for proposed content of a simplified training package on QI for community health volunteers. The QI Specialist and Community Health Specialist presented a concept note on community engagement in QI to the experts at the TWG which took place in Kabwe. The TWG team of experts will incorporate a section in the QI Guidelines on community engagement in quality improvement at health facility level.

The training package will assist health workers and community members to work together to identify health care quality improvement needs. The QI Specialist and Community Health Specialist will work with the QI Technical Working Group (QI TWG) and other stakeholders to constitute a smaller technical team which will further refine the training package and develop a facilitator’s manual. SBH will support MOH to hire a technical consultant and a graphic designer. SBH will support printing and dissemination of the package in December 2016, and will begin to train community teams in January 2017.

The SBH Health Care Financing and Planning Specialist provided technical assistance to an MOH meeting in July on the electronic Performance Assessment (ePA) tool. Meeting participants refined the tool based on recommendations made during a training workshop held in May for provincial and district level staff. In addition, MOH plans to revise the current PA guidelines to incorporate guidance on the use of the electronic version of the PA tools.

The Health Care Finance (HCF) and Planning Specialist in collaboration with MOH facilitated the drafting of the National Health Strategic Plan (NHSP) for 2017-2021. This was a follow up to the process in June, during

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which program managers and cooperating partners prepared an analysis of strengths, weaknesses, and opportunities in ten thematic areas to establish the foundation for the next NHSP. The HCF and Planning Specialist collaborated with his MOH counterparts in the Directorate of Policy and Planning to consolidate the reports from the thematic working groups into a first draft of the NHSP. The MOH will engage a consultant to help finalize the plan after the TWGs refine the draft at the end of the quarter under review.

Strengthen National Training Materials to Support Implementation of Nutrition Policies The SBH Nutrition Specialist met with the Ministry of Agriculture’s (MOA) Director of Agriculture on August 26th at Mulungushi House to provide an overview of the SBH Project and engage the Ministry on areas of collaboration in nutrition activities. The Director commended SBH for taking the initiative to communicate with the central MOA and requested assistance from the project to engage other partners in developing a harmonized approach to addressing nutrition challenges through the agriculture sector. The Director said that the nutrition focus in the agriculture sector should extend beyond food production and also address food quality and safety. He proposed that the collaboration with SBH should champion a harmonized approach for the communities.

SBH participated in and provided financial and technical assistance to a consensus meeting held to endorse the finalized Growth Monitoring and Promotion - Community and Health Worker training packages. The meeting participants incorporated comments from all MOH and stakeholder technical reviewers into the final manual. The MOH nutrition team will soon submit the training manuals to the MOH Permanent Secretary for his endorsement prior to printing.

Strengthen District Health Information System (DHIS) 2 and Health Management Information System (HMIS) at the National Level This quarter, SBH conducted interviews with MOH representatives to recruit a Health Management Information System (HMIS) Data Use Officer who will work in the MOH Monitoring and Evaluation (M&E) Unit. The HMIS Data Use Officer will report to the MOH M&E Unit in October 2016. Discussions with the M&E Unit regarding the scope of work for this position delayed the hiring process. The HMIS Data Use Officer will work with the MOH Directorates to promote analysis and use of HMIS data among national and sub-national MOH personnel.

During the quarter, the SBH HMIS Officer coordinated with four MOH Directorates to develop a list of indicators and data elements for HMIS program monitoring dashboards. The HMIS Officer will use the list of data elements and indicators to develop draft dashboards on the District Health Information System 2 (DHIS2) platform for further discussion and finalization with MOH Technical Working Groups (TWGs). The MOH Disease Surveillance and Research (DSR) Director and Deputy Director expressed particular interest in supporting development of the dashboards.

The SBH Surveillance Manager met with the MOH M&E Unit to plan a demonstration activity which will test the feasibility of entering HMIS data directly into DHIS2 at the health facility level. The MOH selected Nyimba and Chipata districts for the demonstration, and proposed to experiment with desktops and laptops in different facilities in order to determine which type of hardware works best. The MOH selected one rural and one urban district in order to allow comparison of reporting rates in each setting. The SBH Surveillance Manager developed draft materials for DHIS2 data entry to train the facility in-charge and the data entry clerks. The MOH M&E Unit will review the training materials in October. The Surveillance Manager will support the M&E Unit to launch the pilot after SBH and the M&E Unit complete the protocols and procure the necessary hardware.

The SBH Health Management Information Systems (HMIS) Officer met with the MOH Director of Technical Support Services (DTSS) to discuss how SBH could assist the MOH to improve the use of Performance Assessment (PA) data by establishing PA reports on the District Health Information System2 (DHIS2) platform. SBH proposed to create dashboards within DHIS2 from PA data which would display annual trends and compare districts or provinces. The HMIS Officer will hold further consultations with key MOH units to better define the support needs. SBH and DTSS will meet in October to discuss which indicators to employ through simple charts and graphs to display PA results.

The SBH HMIS Officer reviewed the data for various MOH programs captured in the HMIS to extract a list of program indicators and drafted two pilot dashboards: one for Child Health and one for Tuberculosis. These

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draft dashboards will give Program Officers at national level tangible examples of a more useful and simple trend analysis tool that they can access automatically upon logging into the District Health Information System2 (DHIS2.) The SBH HMIS Officer will coordinate with the Program Officers to adapt dashboards for each program based on their strategic targets. SBH will facilitate the orientation of subnational staff to the dashboards.

Review of Clinical Protocols The Senior Manager for Provincial Programs in collaboration with the MOH Clinical Care Directorate facilitated a workshop to review Clinical Protocols. During the meeting, experts from Level 2 and 3 hospitals, some Clinical Care Specialists from the PMO and several Clinical Care Officers from selected DMOs reviewed the clinical protocols that were drafted in 2014 under the ZISSP Project. In addition, draft neo-natal Intensive Care Unit (ICU) guidelines, emergency care protocols and referral forms were reviewed among the documents and job aides to be printed. SBH will hire a graphic designer to prepare the documents and job aides for printing. Once printed and disseminated, the protocols and job aides will be used mostly by primary health centers and Level 1 hospitals. The protocols and job aides to be used for mentoring will foster improvement in the quality of case management at district level.


Second Program Specialists to support the Ministry to develop, disseminate and foster implementation of guidance documents

Facilitate drafting of the National Health Strategic Plan (NHSP) for 2017-2021. Reviewed Quality Improvement (QI) Guidelines. Reviewed Infection Prevention (IP) Guidelines. Developed Community Health Quality Improvement Guidelines. Draft revised mentoring guidelines and tools. Update and finalize the treatment protocols and job aides for primary health care level at the district to enhance quality of service delivery.

Design and conduct assessments of central MOH capacity

SBH still consulting MOH on the modalities of the capacity assessment.

Strengthen MOH performance monitoring and improvement

Technical and financial assistance to MOH to refine the Computerized Performance Assessment (CPA).

Strengthen national training materials to support implementation of nutrition policies

Supported National Food and Nutrition Commission to validate the Growth Monitoring and Promotion (GMP) implementation guidelines. The validation meeting agreed that the GMP health worker training package and the Community GMP training packages be submitted together with GMP implementation.

Strengthen DHIS2 and HMIS at the national level SBH and MOH jointly interviewed candidates for the HMIS Data Use Office. SBH hired the Data Use Officer and will orient and present him for secondment to the MOH M&E Unit in October. SBH and the European Union-funded HMIS Project sponsored the MOH M&E Unit to draft an HMIS Stakeholder Access Guideline/ Policy. The guideline open HMIS access for relevant MOH staff at all levels for the first time.

2.2 Task Two: Design, Implement, and Monitor Interventions to Strengthen Program Management Capabilities of Provincial and District Teams

Task Two targets provincial and district level capacity to manage health programs and deliver quality health services. Effectiveness of activities under this task are dependent on the improvements achieved under Task One at the national level. The SBH approach to strengthen provincial and district capacities is similar to the approach at the national level in that it will be guided by participatory capacity assessments and will focus on strengthening existing systems and processes.

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2.2.1 Sub-Task 2.1: Strengthen Program Management Capacity This sub-task will utilize strategies to improve key MOH management capacities at the provincial and district levels that support effective delivery of quality health services. These include: designing, implementing, and monitoring health programs; annual planning; HRH management; use of data; performance monitoring; Quality Improvement; and supply chain management.

SBH provided technical and financial support to target provinces and districts during their activities to launch the 2017-19 planning cycle. All SBH personnel seconded to the Provincial Health Offices (PHOs) and District Health Offices (DHOs) worked with their counterparts to adapt the national planning updates to their specific circumstances using local data. As an example, in Southern Province the SBH Clinical Care Specialist, the Reproductive Maternal Newborn Child and Adolescent Health (RMNCAH) Specialist, and the Provincial Coordinator for Saving Mothers Giving Life (SMGL) supported the PHO to hold a preparatory meeting before the launch. The team reviewed data from Performance Assessment Reports, HMIS data, the 2013/14 Zambia Demographic and Health Survey, and other reports to prepare tailored planning updates for the launch. This was the first time that the PHO team held a meeting to prepare for the launch. After the experience, the PHO team included this activity in its 2017 action plan. Details on other provinces and districts planning activities will appear in the quarterly report.

The SBH HMIS Officer developed training materials on Data Use Through DHIS2 for provincial and district health officers and SBH staff members. The training materials demonstrate how to use the data contained in DHIS2 for program monitoring and management. The objective is to equip participants with the skills to generate reports and analyze program data using DHIS2 analytical tools including maps, charts, and tables. The SBH HMIS Officer will work with the MOH M&E unit to ensure that all trained program managers and officers at all levels have valid login credentials and position-specific user roles and in line with the draft HMIS Access for Government Agencies, Implementing Partners, and Stakeholders. MOH is expected to open up DHIS2 to subnational program officers in October 2016.

Strengthening Management & Leadership Capacity In September, the SBH HRH Specialist assisted the management team at Levy Mwanawasa General Hospital to conduct refresher training on the Annual Performance Appraisal System (APAS) for 33 key personnel, most of whom are department and unit heads in Kabwe. The objective of the training was to ensure that all section and unit heads at the facility understand how to use APAS to improve staff performance. Facilitators led the participants to identify factors in their daily activities which help or hinder effective performance, and then assisted participants to set overall objectives, targets, and individual work plans. Participants learned how to use change management strategies to improve attitudes and work culture. During the training, all participants formulated Individual Work Plans for 2017.

SBH partner BroadReach Institute for Training and Education (BRITE) collaborated with the SBH Senior Manager of Health Systems Strengthening to mentor the ZMLA trainees from Central Province to strengthen the design and implementation of their ZMLA individual and group projects. The mentorship addressed the identification and refinement of problem statements and correct usage of the analytical tools introduced during the classroom training. In order to receive the National Institute for Public Administration higher diploma at the end of the course, the ZMLA participants must design and complete projects to improve the performance of their health institutions.

Strengthening Supply Chain Management To support the SBH SCM, SBH’s SCM Specialist, the Technical Advisor from Imperial Health Sciences, and their counterparts from the MOH, PMO, and DMO assessed the supply chain management in eight target districts and forty health centers. This was a continuation of assessments started in June in Lusaka and Shibuyunji districts. The assessments took place in Eastern, Southern, Central, and Copperbelt provinces. Key challenges included poor inventory management, over-stocking of drugs, and some stock-outs of critical drugs. For example, the team observed overstocks of Depo-Provera in most of the health centers in Copperbelt province while Eastern province had very low stocks of Depo-Provera. The assessment team also observed that none of the personnel managing vaccines had been trained in cold chain and vaccine logistics management, and that most health centers did not have an active system for monitoring nutrition products.

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Table 4. Summary of Year One Benchmarks for Sub-task 2.1 Expected Year One (2016) Benchmarks Achievements this Quarter

Second program specialists All seconded staff established and providing continuous technical assistance to their counterparts.

The following staff were seconded to PMOs and DMOs: Clinical Care Specialist – Copperbelt Province, two SMGL Coordinators – Eastern Province and Livingstone district, an RMNCH Specialist for Eastern Province, and eight Drivers.

Design and conduct assessments of provincial and district MOH capacity

The assessment was successfully done through a workshop. Feedback to the PMO/DMOS will be done in quarter four.

Strengthen MOH performance monitoring and improvement

Developed training materials on Data Use Through DHIS2for provincial and district health officers and SBH staff members.

Strengthen DHIS2 and HMIS at sub-national level SBH HMIS Specialists and Surveillance Manager trained facility and district staff on data quality, analysis and use prior to DIMs in four target districts. The team also emphasized critical data analysis and application during another two DIMs and one PIM.

2.2.2 Sub-Task 2.2: Improve Technical Capacity of Provincial and District Health Teams to Deliver Quality Health Services in Facilities

SBH will apply a number of strategies to improve the technical capacity of provincial and district teams to deliver quality health services, including: provision of technical assistance and training, mentoring, strengthening MOH structures, leadership and skills for performance monitoring and improvement, and strengthening supply chain systems.

Improve the MOH Structures, Systems, Tools, and Skills for Performance Monitoring and Performance Improvement During the quarter, the SBH Reproductive, Maternal, Neonatal, and Child Health (RMNCH) Specialist for Lusaka Province participated in the Maternal Death Surveillance and Review (MDSR) meeting at Levy Mwanawasa General Hospital. This review considered four maternal deaths of which two were attributed to pre-eclampsia, one to a retained placenta, and one to TB/HIV. The participants concluded that the health provider that attended the case of the retained placenta lacked the necessary skills to handle the patient. The participants also observed that the patient who died of TB/HIV complications was late to enroll in antenatal care. The review observed that first antenatal visits commonly occur after fourteen weeks because of misconceptions and traditional beliefs. The SBH RMNCH Specialist and the district Maternal and Child Health Principal Nursing Officer provided guidance on clinical case management for all the cases reviewed. SBH conducted an Emergency Obstetric and Neonatal Care (EmONC) training for midwives and one doctor from Levy Mwanawasa General and the University Teaching Hospitals. This training will be followed up with mentorship.

Child Health In this quarter, SBH provided technical and logistical support to ten target District Health Offices during the National Measles Rubella (MR) Vaccination Campaign. The MOH in September introduced the MR vaccine to continue improving child survival standards and to meet recommendations by the United Nations Children’s Education Fund and the World Health Organization. The MR vaccine replaced the measles vaccine which has been administered to children in Zambia since the 1970s. The project supported orientation of health workers on the cold chain, vaccine administration, adverse effects and treatment, target population, and documentation. SBH also supported distribution of the vaccines and cold chain equipment, community mobilization, and provided on-site technical support and supervision.

The SBH RMNCH Specialists from Central, Eastern and Lusaka provinces supported Provincial Health Offices to train 72 health workers from three provinces in Emergency Obstetrics and Newborn Care (EmONC). The training was held to respond to key recommendations made during the Central Province Maternal Death

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Review Meeting. The training was recommended by hospital teams from by Levels 2 and 3 hospital teams with SBH personnel that assessed the referral hospitals in the target districts. Participants acquired the knowledge and skills to manage common obstetric and newborn emergencies. The EmONC training and the subsequent mentorship aims to improve maternal and newborn care and reduce mortality.

In September, SBH Nutrition Specialist assisted the MOH to train and mentor fifteen master trainers for Maternal Infant and Young Child Nutrition (MAIYCN) in Eastern Province. Participants demonstrated the appropriate skills to qualify as master trainers. SBH will continue to support master trainers to develop the appropriate skills to become mentors. The biggest challenge observed was the inadequate staffing in the facilities because service providers were overwhelmed with other duties and hurried through counseling and skill demonstrations in order to attend to other clients waiting for services. The Provincial Medical Officer mentioned the staffing challenges and requested support to improve the staffing levels in the districts and health facilities.

The project assisted the MOH to train twenty-seven trainers for the Integrated Management of Acute Malnutrition (IMAM) Out-Patient and In-Patient Therapeutic Program. The trainers completed both theory and practical sessions of the course which required training service providers. The trainees will complete the second half of the training in October. SBH also collaborated with Sida to train twenty-two participants from Eastern Province for the In-Patient Therapeutic Program (ITP). During the training, the organizers identified individuals to train as trainers in ITP.

Quality Improvement The SBH QI Specialist and Lusaka CCS collaborated with the Lusaka PHO team to organize quality improvement training for the provincial team and the SBH target districts. The team conducted training and prepared participants from target sites to implement QI activities that will improve systems and the quality of care. Twenty-one health workers from Luangwa, Shibuyunji and Lusaka districts including UTH, Cancer Diseases Hospital, and Levy Mwanawasa hospitals participated in the training. QI trainings were also conducted in Central province for twenty-six MOH health workers from SBH target districts. This brings the cumulative total health workers trained in QI from four provinces to one hundred and thirty-one.

Revitalization of Quality Improvement Committees The SBH CCS and RMNCH Specialist in collaboration with their PHO counterparts in Copperbelt Province supported a meeting held to reconstitute and revitalize the Provincial QI committee which had been inactive since its formation during ZISSP time. PHO program officers, Level 3 Hospital staff and partners based in Ndola attended the meeting. During the meeting the SBH team and MOH CCSs shared the terms of reference for a QI committee which included team composition, roles and responsibilities of committee members. The revitalized QI committee will provide technical support to the hospitals and district QI teams. It is envisioned that once the hospital and district teams are well supported and provided with the QI skills, they will be able to transfer those skills to lower levels of care. Consequently, facilities will be using QI as a way of solving their problems.

In Chipata, the HS Specialist and the DHO counterparts held a similar meeting for health facility staff in the district. Health centre in-charges from fifteen SBH-supported and five other health facilities attended the meeting. The objective of the meeting was to establish the level of QI activities taking place; identify training needs; and to share the structure, roles and responsibilities of the QI committees at health facility level. The meeting observed that eleven of the twenty health Centers present did not have QI committees in place and needed support for them to form QI committees. In addition, the meeting observed that most personnel in the health centers are not trained in QI. Sixty-nine health workers from the twenty facilities that attended the meeting require QI trainings. SBH will support Eastern Province to train and mentor the PHO, Chipata and Petauke DHOs in QI.


Second program specialists No Activities this quarter.

Use the results of the province and district capacity assessment to develop a data-driven capacity building plan

The capacity assessment finding will be used to develop capacity strengthening plans. This will be done in the next quarter.

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Improve the MOH structures, systems, tools, and skills for performance monitoring and performance improvement

Capacity building in data analysis prior to DIMs conducted in Kitwe, Mufulira, Kabwe and Livingstone.

Trained 10 PMO staff in the ePA tool and this culminated in the refinement of the tool. 35 ZMLA participants completed their didactic training.

Revitalized Quality Improvement Committees at Central, Copperbelt, Eastern, Lusaka and Southern Provincial Health Offices. Reactivated Quality Improvement Committees at Chipata, Kabwe, Kitwe, Livingstone and Lusaka District Health Office.

2.3 Task Three: Support the Government and Community-Based Organizations to Increase the Quality, Availability, and Use of Health Services

Task Three targets the ultimate levels at which health services are sought and provided: in facilities and communities. It addresses both supply and demand for health services, including the critical link between communities and health facilities. SBH will focus on making community-level activities more resource efficient by targeting to address gaps where they exist in specific areas instead of providing a uniform “package” of community-level interventions.

2.3.1 Sub-Task 3.1: Improve the Capacity to Deliver Quality Health Services in the Community

SBH will collaborate with the MOH to improve community participation in health and scale up health services in response to community needs. The project will also support community-level activities through social and behavior change communication strategies to increase demand, enhance the availability of health services, and improve referral systems.

Support the Government and Community-Based Organizations to Increase the Quality, Availability, and Use of Health Services This quarter, the SMGL Coordinator in Kabwe District collaborated with counterparts from Safe Motherhood 360+ and the DHO to create the first Safe Motherhood Action Groups (SMAGs) in the health facilities. Kabwe did not have SMAGs because it was considered as an urban district where the community should not experience difficulties in accessing health services. In spite of this perception, the district records numerous maternal deaths and has not engaged the community in response. For this reason, Safe Motherhood 360+ and SBH worked with the Kabwe DHO to initiate the SMAG program in the district by training thirty-four health facility personnel and two tutors from the Mwanchisompola and Ndola Community Health Assistant Schools as SMAG trainers. The new trainers will train 336 community volunteers as lead SMAG members with support from Safe Motherhood 360+ and SBH. The lead SMAG members will operate in specific catchment areas within each health facility catchment Kabwe district. The district expects that SMAG activities will boost antenatal attendance in the first trimester as well as institutional deliveries.

Design and Conduct Assessment of Community Capacity to Provide Quality Health Services In July, SBH conducted community capacity assessments in Eastern, Southern and Copperbelt province. The capacity assessments are meant to establish current operational capacities of communities in SBH target districts and health facilities. SBH teams collected data for the capacity assessment in six districts and thirty health facilities. The assessment will enable SBH and the MOH to design evidence-based capacity building interventions. Report writing is in progress.

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Table 6. Summary of Year One Benchmarks for Sub-task 3.1 Expected Year One (2016) Benchmarks Achievements this Quarter (Y1Q1) 2016

Second health system specialists to support the districts and health facilities to engage the communities

SBH seconded a Community Health Specialist to the Directorate of Technical Support Services at the MOH to spearhead community health systems strengthening.

Design and conduct assessment of community capacity to provide quality health services

Information from the report will guide the MOH to develop National Community Health Strategy.

Strengthen and integrate approaches to informing and engaging communities to seek services

Trained District Health Office (DHO) teams to strengthen capacity to facilitate community health planning.

Improve supervision of Community Health Assistants No activities this quarter.

Test feasibility of community HMIS No activities this quarter.

2.3.2 Sub-Task 3.2: Strengthen Linkages between the Facility and the Community

SBH will collaborate with the MOH and other stakeholders to strengthen facility-community linkages by supporting health facilities in the engagement of communities in health planning and QI processes. The project will also pilot interventions for supporting children and adolescents in HIV treatment in Kitwe to address loss to follow up. SBH will support the MOH to improve linkages between CHAs, community health volunteers and health facility staff, and pilot a community-level information system to better monitor community-level activities.

By the end of the quarter, SBH trained personnel in target facilities to develop community action plans. The SBH Community Health Specialist helped the Mufulira DHO team train fifteen participants in service delivery, governance and leadership, resource mobilization, stakeholder engagement, gender integration, and monitoring and evaluation in order to strengthen the ability of communities to plan and implement activities to improve health.

Support Community Planning Process (TOT) During the quarter, SBH successfully conducted Community Capacity Assessments in July and later supported a trainer of trainers workshop in Kabwe from August 22-26, for health promotion focal persons, planners from twelve SBH target districts (Chipata, Petauke, Monze, Livingstone, Shibuyunji, Lusaka, Kabwe, Mkushi, Kitwe, Mufulira, Chingola and Chililabombwe districts). Others who attended the trainer of trainer’s workshop were Senior Health Promotion officers from five provinces (Eastern, Lusaka, Southern, Central, Copperbelt. The purpose of this activity was to build capacities for district and provincial teams to facilitate and manage community planning process, implementation, monitoring and evaluation of community programs.

HIV Pilot Baseline Assessment Addressing the health and social impact that HIV is having on children and the families that support them is integral to a comprehensive HIV response. In the period reported, SBH collaborated with partner Save the Children and held several consultative meetings with the Ministries of Health, and Community Development and Social Welfare, and other stakeholders involved in social and clinical services for children and adolescents to develop Case Management Modules for incorporation into current MOH Community Comprehensive Childhood and Adolescent HIV Care and Training Curriculum. The modules which aim to enhance case management skills for community-based para-professionals have been circulated to stakeholders for further review. The project also worked with Save the Children to select a consultant who will conduct the HIV Pilot Baseline assessment. The University of Zambia, School of Public Health met the criteria for carrying out the assessment which will commence in October once all protocols and data tools have been approved. A program manager for the pilot was recruited and her placement and orientation will be completed in October. In addition, job descriptions for the para professions were developed during the quarter and the recruitment is scheduled to begin in October.

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Support health facilities in strengthening community capacity to participate in health planning

SBH/MOH trained fifty-one trainers of trainers in community health planning.

SBH with DMOs trained 660 NHCs and other CBVs in community health planning.

Support QI projects No activities this quarter.

Test methods for supporting children and adolescents in HIV treatment

Recruitment of the HIV manager.

2.4 Cross-Cutting Technical Areas

2.4.1 Grants under Contract During this quarter, the SBH Capacity Building Specialist for non-governmental organisations, the Grants Manager and the Senior Technical Advisor from Initiatives, Inc. conducted a three-day orientation workshop for the Mkushi Grants Support Team (GST). The SBH HS Specialists and their DHO counterparts from Lusaka, Shibuyunji and Kabwe districts also participated in the training. The goals of the workshop were to pilot the revised GST orientation package, and to orient the HS Specialists to the SBH grants program and to the role of the grants support teams. The HS Specialists and their DHO counterparts will orient the Grants Support Teams in their districts.

The SBH Health Systems Specialist together with the Kabwe District Grant Support Team members invited twenty eight potential grant recipients working in the health sector to participate in mapping activity. The participating organizations included eleven non-governmental, three community-based, and fourteen faith-based organizations. The participants completed a mapping tool developed by SBH. The purpose of this exercise was to determine the legal status, focus area, experience in managing donor funds, and the number of people reached by each organization. These organizations will be the potential recipients of grants in Kabwe district.

Table 8. Summary of Year One Benchmarks for Grants under Contract Expected Year One Benchmarks Achievements this Quarter (Y1Q1)

Award Grants to CBOs, FBOs and NGOs Formation and orientation of grants support teams (GSTs) in all the ten phase one districts. Annual Program Statement (APS) developed.

2.4.2 Research, Monitoring and Evaluation The SBH approach to performance RM&E is designed to be cost-effective, accurate, reliable, and timely. The SBH RM&E team will lead performance management and evaluation of project activities, routine performance reporting, and research and evaluation to measure the effects of SBH work and generate evidence within priority technical areas. The RM&E team works closely with the SBH Senior Management Team and program staff to ensure that the SBH Activity Monitoring and Evaluation Plan (AMEP) guides project implementation, and that the program uses evidence to make decisions and modify approaches.

Activity Monitoring and Evaluation Plan During the quarter, SBH revised and finalized, and submitted the AMEP to USAID in July. The revised SBH AMEP includes outcome and output indicators with proposed new targets for each interim result (by program task) associated with systems strengthening, service quality and utilization improvements. The AMEP is a management tool that will serve both internal and external audiences over the life of the project. In addition, the project team uses the SBH AMEP to make mid-course corrections and adjustments as needed, provide lessons learned, and share new evidence with both internal and external stakeholders. During the quarter, some indicators have been deleted, replaced and revised in terms of wording and targets adjusted based on the baseline report.

13

SBH Baseline Assessment Report During the quarter, the project conducted and finalized the Baseline Assessment Report which was submitted to USAID in July. The Baseline Assessment Report provides a set of process, output, outcome, and impact level indicators that will collectively demonstrate the project’s performance and contributions to improved health indicators. The assessment provides a baseline value for the project’s pool of performance indicators. In addition, the baseline assessment will also facilitate the finalization of the AMEP by refining the performance indicator reference sheets and using the baseline values to inform the revision of indicator targets.

Data Quality Audit SBH RM&E team conducted Data Quality Audit (DQA) for the 2015 SBH baseline report in four provinces of the five targeted, and eight districts out of the ten targeted. These include: Eastern (Petauke, Chipata), Central (Kabwe, Mkushi), Copperbelt (Kitwe, Mufulira) and Southern (Livingstone, Choma). The DQA was conducted at Provincial and District Offices. This process will continue and be completed in the month of November for Lusaka province and the two targeted districts (Lusaka and Shibuyunji). The purpose of the DQA was to verify the source and quality of the data used for the baseline.

SBH Performance Review Meeting SBH RM&E team organized and facilitated SBH performance review meeting for all provincial and districts staff. The purpose of the meeting was to review SBH program implementation, performance, and challenges.

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3. Project Management

The major focus of activities in this quarter was to strengthen office services, recruit personnel, and develop deliverables. The key accomplishments are presented below.

3.1 Finance and Administration During the quarter, the Finance and Administration team:

Procured and distributed fourteen new vehicles to all target districts and provinces for easy implementation of program activities.

Installed a prefabricated office for the field staff in Southern Province PHO and completed arrangements to create office space for staff embedded at the central MOH office.

Trained accounting staff in the Information Standard Management Solutions (ISMS) site financial systems and rolled out the system to ensure timely recording, posting and online review of transactions for timely preparation of financial tracking reports.

3.2 Overall Budget and Expenditures As of September 30, 2016, SBH spent a cumulative total of $6,229,930.00 against obligations of $22,221,810.52. Cumulatively, SBH spent 11.53% of the total project estimated amount of $53,925,452.

3.3 Personnel In the previous quarter, SBH had 62 employees. During the reporting quarter, the project added 13 more

employees and dismissed one staff member (a driver) for misconduct. Staff additions included the Human Resources for Health Specialist, Clinical Care Specialist – Copperbelt Province, two SMGL Coordinators – Eastern Province and Livingstone district, an RMNCH Specialist for Eastern Province and 8 Drivers. As of September 30, SBH had a total of seventy-four staff members including five senior managers, thirty-six program personnel and thirty-three finance and administrative personnel. One candidate, the Health Systems Specialist for Petauke District, accepted an offer to start work in October.

The project is currently completing the hiring process for the following positions: Clinical Care Specialist for Eastern Province, two SMGL Coordinators for Luangwa and Lundazi districts, and three drivers for Lusaka Central, Monze and Lundazi districts.

SBH is still searching for candidates for nine positions: Maternal & Newborn Child Health (MNCH) Specialist to be based at MOH, HIV Specialist, Provincial Program Specialist, Research Specialist, Monitoring & Evaluation Data Analyst, Procurement Specialist, Logistics Officer, Health Systems Specialist for Monze, and SMGL Coordinator for Luapula. Five of these positions arose from a re-organization of the project’s organizational chart.

3.4 Subcontracts The SBH team worked with all six subcontractors during this quarter to implement activities under the Year One Work Plan. The subcontractors participated in the SBH planning and review meeting in September. Project members of staff and subcontractors gave presentations and participated in interactive sessions to help the project team develop a clear understanding of the role and potential contribution of each staff member and partner.

Save the Children collaborated with MOH to facilitate a meeting to validate the Growth Monitoring and Promotion, and Community and Health worker training packages and the GMP Manual. The meeting participants incorporated comments from all MOH and stakeholder technical reviewers into the final manual.

15

Save the Children, USA advisor together with SBH Nutrition Specialist held scoping discussions with the Ministry of Agriculture (MOA). The meetings discussed activities being undertaken, gaps and challenges. During this visit, Save the Children and the SBH Nutrition Specialist also held a meeting with eighteen partners implementing nutrition-specific intervention in the province. Save the Children worked with the MOH to prepare for the HIV Pilot Assessment set to start in October.

Akros met with the MOH Technical Support Services Directorate to discuss the performance Assessment and ePA tool, which the MOH is planning to roll out during the second round of PA activities in October. Akros also attended various performance review meetings in target districts at which SBH seconded staff were oriented on the current HMIS understanding and use by provincial, district, and facility staff.

In this quarter, Initiatives, Inc. collaborated with SBH and the MOH to conduct trainings to pilot the revised Grants Support Team (GST) orientation packages, and carried out orientation of GST teams in target districts.

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4. Success Stories

Creating an opportunity to improve data quality and data use in Zambian health facilities

Many Zambian health facility personnel struggle to understand and use the routine data they collect. Facility personnel drive the Health Information System by collecting the data from the patients they care for. However, facilities’ relationship with data typically ends after collection and does not include analysis or using their own data for decision making.

Previous assessments of the Health Management Information System (HMIS) such as the HMIS Mid-Term Review (2014) confirm that data use and demand are very low.1 A 2016 HMIS assessment completed by Akros showed that “health facility in-charges cited a need for an improved understanding of reporting forms and the needed calculations in order to better understand the relevance of the data.”2

The USAID Systems for Better Health Project launched a series of four Data Analysis Workshops at the facility, district and provincial levels. Beginning in June 2016, these workshops are

conducted immediately prior to quarterly district-wide Performance Review Meetings. The purpose of the workshops is to efficiently and powerfully illustrate the value of equipping facilities to submit quality monthly data, and analyzing and using data for more effective planning and decision making.

Kitwe is a copper mining district in Copperbelt Province, about 430 kilometres north of the country’s capital Lusaka. The 2016 HMIS assessment showed that facility staff spent about fifteen percent of their month compiling reports on the data they collect. With forty health facilities in the district, Kitwe performs above the national average with fifty seven percent of facilities reporting on time, and of which seventy percent submit complete reports.

Forty district and facility staff in Kitwe dedicated themselves to a one and half days’ Data Analysis Workshop. Using real examples, they practiced data analysis skills such as building a narrative based on trend analysis. They experienced the frustration of trying to map out a yearly plan and budget for malaria using low quality, incomplete data. Most importantly, by graphing and analyzing data submitted from their own facilities, over three quarters of the participants were confronted with data quality issues and the realization of how little they consult the data to monitor the services they offer or the resulting health outcomes.

Interactive training opportunities like the Data Analysis Workshops equip participants with insights into the importance of monitoring their data for quality and the value of analyzing it routinely. Feedback from

12014 HMIS Mid-Term Review. 2 Zambia HMIS Assessment 2016, under review.

Participants in Kitwe district hold up the charts they created during the first of four Systems for Better Health sponsored Data Analysis Workshop from June 27-July 1 2016 Photographer: Julie Doherty, Akros, USAID Systems for Better Health

“…demand for information is still low at all levels…it was observed from the review that they [facilities, district offices and provinces] do not necessarily use the data generated from the HMIS”

-- 2014 HMIS Mid-term review

17

participants in three other districts confirmed that the workshops provided a much needed opportunity to identify gaps and receive guidance on making feasible, measurable, and time-bound goals.

The first of four Data Analysis Workshops will reach the other eleven SBH districts and helped to spark a mentality shift for facility staff. Exposing managers to their own data and strengthening their ability to analyze it is essential. As facility staff gain a shared vision that the data they collect is to help them carry out their work of service delivery, they will in turn begin to collect, analyze, and apply the data with conviction and focused energy.

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5. Challenges and Solutions

Challenges Solutions

During this quarter, the project operated without adequate staff in Eastern province.

Recruited the Health Systems Specialist for Petauke and Saving Mothers Giving Life (SMGL) Coordinator for Chipata, while candidates for the positions of Clinical Care Specialist and SMGL Coordinator for Lundazi have been identified and are pending approval and deployment.

Transport challenges impacted smooth implementation of project activities continued throughout the quarter because of delayed procurement and delivery of project vehicles.

Motor vehicles procured and delivered.

New project personnel cited inadequate orientation to project and raised programmatic and administrative issues as challenge.

All project staff were re-orientated in administrative and finance procedure at project staff planning and review meeting held during the quarter (September 2016).

Delay in procurement of IT equipment and printers. Equipment and printers have since been delivered.

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Annex 1: Performance Indicator Tracking Table

This section will be presented in reports later in the year as the project finalizes its AMEP and is able to collect data. Below we include the SBH performance indicator table from the current AMEP.

Indicators in bold are mandatory as specified in the SBH contract. All non-mandatory (optional, custom program indicators) indicators are asterisked.

Relationships to select strategies/frameworks (including ZNHSP; USAID/Zambia CDCS; US Government Standard Foreign Assistance Indicators (USG/F); PEPFAR Next Generation Indicators; Feed the Future Indicators) are specified in the “Links” column. Although indicators are presented by task in this table, several indicators provide information relevant across tasks and sub-task/results and such relationships are highlighted in the cross-reference column. SBH will use an integrated M&E approach to cross-reference SBH indicators appropriately in analysis and reporting.

Relationships to select strategies/ frameworks (including ZNHSP; USAID/Zambia CDCS; US Government Standard Foreign Assistance Indicators (USG/F); PEPFAR Next Generation Indicators; Feed the Future Indicators) are specified in the “Links” column. Although indicators are presented by task in this table, several indicators provide information relevant across tasks and sub-task/results and such relationships are highlighted in the cross-reference column. SBH will use an integrated M&E approach to cross-reference SBH indicators appropriately in analysis and reporting.

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Annex 1. Systems for Better Health in Zambia Performance Indicator Tracking Table

No. Indicator Links Baseline Targets/Milestones

Data Source Frequency

of data reporting Year 1 Year 2 Year 3 Year 4 Year 5 EOP

SBH Goal: Improved health outcomes for Zambians by strengthening systems that underpin the delivery of high quality health services and increasing the utilization of high impact health interventions at district and community level.

SBH Impact and Outcome Level Indicators:

1

Proportion of deliveries with assistance from a medically trained provider in targeted districts

ZNHSP; CDCS

23.1% 23.1% 29.1% 33.2% 38.1% 43.1% 43.1% Ministry of Health-HMIS

Quarterly

2 Couple years of protection in targeted districts

CDCS 268,071 268,071 277, 322 430,217 440,141 446,360 1,862,111 Ministry of Health-HMIS

Quarterly

4

Percent of children aged 12 to 23 months fully immunized in targeted districts

CDCS ZNHSP

94% > 90% > 90% > 90% > 90% > 94% > 94%

Ministry of Health-HMIS and Central Statistics Census 2010 Projection

Semi-Annual

5

Percentage of adults and children known to be alive and on treatment 12 months after initiation of antiretroviral therapy in targeted districts 3

PEPFAR MER TX-RET; 3.1.1-78

79% > 79% > 82% > 84% > 86% > 90% > 90% PEPFAR DATIM Quarterly

3 The SBH contracts include the following metric “ARV retention rates in targeted districts,” which will be measured by this standard indicator per USG and PEPFAR MER indicator definitions.

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SBH Outcome and Output Level Indicators:

Task 1. Design, implement and monitor national level interventions to strengthen health stewardship by MOH[Result 1: Strengthened health stewardship of MOH ]

Sub-task 1.1: Strengthen Human Resource Planning and Management

8

Number of new health care workers who graduated from a pre-service training institution or program as a result of PEPFAR-supported strengthening efforts, within the reporting period

Indicator #H2.1.N/ 3.1.1-81; PEPFAR HRH-PRE

0 120 450 450 450 200 1,670

Institutional records, project records Register from the training institutions

Annual

9

Percent of targeted provincial and district level health offices that have access to and routinely use HRIS

SBH 40% PMO 40% DMO

65% 80% 70% 85% 90% 90% Staff Retention Report and Appraisal Forms

Semi-Annual

10

Proportion of PMO and DMO personnel who have received an annual performance appraisal in the past year in targeted districts

SBH 32.2% PMOs 33.3% DMOs

32.2% PMO

33.3% DMO

35% 50% 70% 80% 80% Staff Retention Report and Appraisal Forms

Annual

11

Number of non-finance based incentives to attract health professionals in remote areas identified, costed, and submitted for review by GRZ

SBH 0 0 1 2 -- -- 3 SBH records Annual

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Sub-task 1.2: Improve health care financing and public financial management

13

Percent of national government expenditure on health out of general government expenditure

USG, ZNHSP, SBH

7% (2015)4

7% 10% 11% 11.5% 12% 12% Ministry of Health – Budget Status Report

Annual

16

Number of months per year in which targeted districts receive monthly funding as per approved budget (within 30 days)

SBH 9.3 8 9 10 11 12 12

MOH Financial reports (central, disaggregated by district) District records (approved budget)

Annual

17

Proportion of funds disbursed to targeted districts out of total approved annual budget of districts

SBH 68.7% 70% 80% 90% 90% 95% 95% District Financial Annual Report

Annual

18

Proportion of funds disbursed (by targeted districts) to health facilities out of their approved total annual budget

SBH 55.9% 55.9% > 56% > 56% > 57% > 58% > 58% District Financial Annual Report

Annual

Sub-task 1.3: Strengthen MOH capacity to oversee delivery of key health programs.

19

Number of improvements to laws, policies, strategies, regulations, or guidelines

USG 0 0 7 2 2 0 11

SBH documentation, MOH legal/policy/strategy/guideline documents

Annual

4 Republic of Zambia Ministry of Health and World Health Organization Regional Office for Africa. Zambia Rapid Health Sector Performance Assessment, October 2015.

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26

Percent of targeted facilities submitting HMIS reports in a timely manner

ZNHSP 65% 65% 75% 80% 85% 90% 90% Ministry of Health-HMIS

Quarterly

Task 2: Design, implement and monitor effective interventions to strengthen program management capacities of provincial and district health teams[Result 2: Strengthened program management capacities of provincial and district health teams]

Sub-task 2.1: Strengthen program management capacity of provincial and district health teams

6

Percent of target provinces /districts that demonstrate capacity to sustainably plan, manage and oversee accessible high quality health services

SBH TBD 20% 40% 60% 80% 100% 100%

SBH records, capacity framework tools, TSS/mentoring tools, HMIS/DHIS2

Baseline, Midline, EOP

7

Percent of targeted facilities in target districts that demonstrate capacity to deliver high quality health services and engage with communities in their catchment area.

SBH TBD 0 30% 50% 70% 85% 85%

SBH records, capacity framework tools, TSS/mentoring monitoring tools, HMIS/DHIS2

Baseline, Midline, EOP

23 Capacity score of targeted provinces and districts

SBH TBD TBD TBD TBD TBD TBD TBD Capacity strengthening tool, SBH records

Semi-Annual (to be confirmed)

24

Percent of targeted provinces/districts that conducted at least two reviews of their annual action plans, in the past year

RFTOP

40% Province

90% District

40% Province

90% District

100% Province

100% District

100% Province

100% District

100% Province

100% District

100% Province

100% District

100% Province

100% District

Province and District Action Plans

Annual

24





25 Percent of targeted PMOs / DMOs that use HMIS data routinely

SBH

100% Province,

40% District

100%Province

40% Districts

100%Province

100% District

100%Province

100% District

100% Province

100% District

100%Province

100% District

100%Province

100% District

HMIS/DHIS2, SBH records

Quarterly

27

Number of health managers and providers trained in management and leadership

SBH 0 0 250 0 0 0 250 SBH, ZMLA M&E Training register

Quarterly, Semi-annually, Annually

28.a

Percent of target facilities that did not experience a stock-out of Coartem (ACT) during the reporting period

SBH 93.3% 93.3% 100% 100% 100% 100% 100%

HMIS/DHIS2; logistics management information system

Quarterly

28.b

Percent of target facilities that did not experience a stock-out of contraceptive (injectable)during the reporting period

SBH 73% 73% 80% 80% 90% 100% 100%

HMIS/DHIS2; logistics management information system

Quarterly

Sub-task 2.2: Improve technical capacity of provincial and district health teams to deliver quality health services in facilities

30

Number and percent of children who received DPT3 vaccine by 12 months of age in targeted districts

Indicator # 3.1.6-61

94% > 90 > 90 > 90 > 90 > 90 > 90 Ministry of Health HMIS (HMIS CHN3-045)

Semi-Annual

31

Percent of HIV-positive pregnant women who received antiretroviral treatment to reduce risk of mother-to-child-transmission in targeted districts

PMTCT_ARV_NAT, 3.1.1-86

TBD 90% 90% 90% 90% 90% 90% HMIS/DHIS2/SmartCare

Quarterly

25





32

Percentage of targeted DMOs that have completed their semi-annual performance assessment and technical supportive supervision visits to facilities in their catchment area

SBH 40% PA 10% TSS

40% PA 10% TSS

60% PA 60% TSS

60% PA 60% TSS

70% PA 70% TSS

80% PA 80% TSS

80% PA 80% TSS

PA Monitoring Tools, SBH records

Annual

33

Percent of targeted DMOs that demonstrate specific performance improvements since their previous performance assessment

SBH 90% 90% 100% 100% 100% 100% 100% HMIS/DHIS2, PA Monitoring Tools, SBH records

Annual

34

Percent of targeted primary care facilities that have received technical supportive supervision or clinical mentoring

RFTOP, SBH

57.5% - TSS

41% - Clinical Mentoring

60% - TSS

41% - Clinical

Mentoring

90% TSS

85% Clinical Mentoring

90% TSS 90

Clinical Mentoring

90% TSS 100%

Clinical Mentoring

90% TSS 100%

Clinical Mentoring

90% TSS 100%

Clinical Mentoring

TSS Monitoring Tools, Mentorship forms

Semi-Annual

35

Percent of targeted facilities in targeted districts that have up-to-date and gender sensitive job aids for HIV, FP, MNCH, and/or nutrition

SBH 0% 0% 60% 80% 100% 100% 100% SBH records, mentor/TSS records

Quarterly

26





36

Percent of targeted facilities in targeted districts that have initiated QI projects in ART, PMTCT, MC, FP, child health and nutrition, or maternal health services with documented process results5

SBH, PEPFAR

0% 0% 50% 50% 70% 85% 85% SBH records, Meeting minutes, QI Reports

Annual

37 Number of people trained in child health and nutrition6

Indicator #3.1.9-1

0 120 1,500 1,500 1,500 100 4,720 SBH Training Registers

Quarterly

38 Number of people trained in maternal and newborn health

USG/F 0 60 450 500 570 0 1,580 SBH Training Registers

Quarterly

39

Number of people trained in family planning/reproductive health

USG/F 0 40 100 150 150 0 440 SBH Training Registers

Quarterly

40

Number of new health care workers who successfully completed an in-service training program within the reporting period

Indicator #3.1.1-84

0 150 500 500 1,000 500 2,650 TSS and Mentoring Tools, SBH Training Registers

Quarterly

5 This indicator incorporates PEPFAR indicator “Percentage of PEPFAR-supported clinical service sites with QI activities implemented that address clinical HIV program processes or outcomes and have documented process results in the last 6 months” 6 In alignment with USG indicator guidance, the indicators 37, 38 and 39 will cover the following: health professionals, primary health care workers, community health workers, volunteers, and non-health personnel.

27





Task 3: Provide technical and financial assistance to the GRZ and community-based organizations to increase the quality, availability and use of priority health services at the community level in targeted districts [Result 3: Improved capacities of MOH and community-based organizations to increase quality, availability and use of priority health services, and promote better health through prevention and healthy behaviors, at the community level in targeted districts]

Sub-task 3.1: Improve capacity to deliver quality health services at the community level

43

Number of CHAs that receive routine supervision (from health facility staff) in target facility catchment areas

SBH 0 0 70 150 150 50 420

Mentorship forms, PA, TSS report or trip report, grantee records

Quarterly

44

Number of community volunteers (including SMAGs, others) that have received equipment to deliver priority community health services in targeted facility catchment areas

SBH 0 0 912 912 0 0 1,824 SBH Delivery and Goods Receive Notes

Quarterly

Sub-task 3.2: Strengthen linkages between the community and facility for key health interventions

46

Number of active beneficiaries served by PEPFAR OVC programs for children and families affected by HIV/AIDS in target areas

PEPFAR 0 0 1500 TBD TBD TBD TBD SBH Data Tracking Tool

Quarterly

28





48

Percent of target health facilities with a functional

facility/community-level Quality Improvement (QI) committee

SBH 0 0 80% 60%7 80% 80% 80% SBH records, facility/QI documentation

Quarterly

Sub-task 3.3: Implement community level Social and Behavioral Change Communication (SBCC) interventions to increase utilization of high impact health services

49

Percent of children under five years of age who received Vitamin A from USG-supported programs in target districts

Indicator # 3.1.9.2-3

171% 171% > 80% > 80% > 80% > 80%

> 80% in each

targeted district

HIMS/DHIS 2 Semi-Annually

Notes: EOP: End of Project HMIS: National Health Management Information System DHIS2: District Health Information System Version 2.0

HRIS: Human Resources Information SystemZNHSP: Zambia National Health Strategic Plan 2011-2015 ZDHS: Zambia Demographic Health Survey ZHWRS: Zambia Health Worker Retention Scheme

7 The target dips in Year 3 because interventions will be initiated in a new cohort of districts during this period, per the phased approach. In reporting, we will disaggregate results by phase cohort.

29

Annex 2: Quarterly Achievements Tracking Table

This section provides quarterly achievements for the period July-September, 2016 for each indicator.

No. Indicator July 2016 to September

2016 - Achievement

SBH Goal: Improved health outcomes for Zambians by strengthening systems that underpin the delivery of high quality health services and increasing the utilization of high impact health interventions at district and community level.

SBH Impact and Outcome Level Indicators:

1 Proportion of deliveries with assistance from a medically trained provider in targeted districts

N/A

2 Couple years of protection in targeted districts increased by 10% in targeted districts N/A

4 Percent of children aged 12 to 23 months fully immunized in targeted districts N/A

5 Percentage of adults and children known to be alive and on treatment 12 months after initiation of antiretroviral therapy in targeted districts

N/A

SBH Outcome and Output Level Indicators:

[Task 1. Design, implement and monitor national level interventions to strengthen health stewardship by MOH]

[Result 1: Strengthened health stewardship of MOH ]

Sub-task 1.1: Strengthen Human Resource Planning and Management

8 Number of new health care workers who graduated from a pre-service training institution or program as a result of PEPFAR-supported strengthening efforts, within the reporting period

0

Males 0

Females 0

9 Percent of targeted provincial and district level health offices that have access to and routinely use HRIS

N/A

Human Resource Information N/A

Provincial N/A

District N/A

10 Proportion of PMO and DMO personnel who have received an annual performance appraisal in the past year in targeted districts

N/A

Provincial N/A

District N/A

11 Number of non-finance based incentives to attract health professionals in remote areas identified, costed, and submitted for review by GRZ

TBD

TBD

Sub-task 1.2: Improve health care financing and public financial management

13 Percent of national government expenditure on health out of general government expenditure

N/A

N/A

30


2016 - Achievement

16 Number of months per year in which targeted districts receive monthly funding as per approved budget (within the month)

N/A

N/A

17 Proportion of funds disbursed to targeted districts out of total approved annualbudget of districts

N/A

N/A

18 Proportion of funds disbursed (by targeted districts) to health facilities out of their approved total annual budget

N/A

N/A

Sub-task 1.3: Strengthen MOH capacity to oversee delivery of key health programs.

19 Number of improvements to laws, policies, strategies, regulations, or guidelines 0

0

26 Percent of targeted facilities submitting HMIS reports in a timely manner N/A

N/A

Task 2: Design, implement and monitor effective interventions to strengthen program management capacities of provincial and district health teams

[Result 2: Strengthened program management capacities of provincial and district health teams]

Sub-task 2.1: Strengthen program management capacity of provincial and district health teams

6 Percent of target provinces/districts that demonstrate capacity to sustainably plan, manage and oversee accessible high quality health services

TBD

TBD

7 Percent of targeted facilities in target districts that demonstrate capacity to deliver high quality health services and engage with communities in their catchment area.

TBD

TBD

23 Capacity score of targeted provinces and districts TBD

TBD

24 Percent of targeted provinces/districts that conducted at least two reviews of their annual action plans, in the past year

N/A

N/A

25 Percent of targeted PMOs/DMOs that use HMIS data routinely N/A

Provincial N/A

District N/A

27 Number of health managers and providers trained in management and leadership 0

Management and Leadership Academy 0

Males 0

Females 0

28.a Percent of target facilities that did not experience a stock-out of indicator commodity Coartem (ACT) during the reporting period

N/A

N/A

31


2016 - Achievement

28.b Percent of target facilities that did not experience a stock-out contraceptive (injectable) during the reporting period

N/A

N/A

Sub-task 2.2: Improve technical capacity of provincial and district health teams to deliver quality health services in facilities

30 Number and percent of children who received DPT3 vaccine by 12 months of age in targeted districts

N/A

N/A

31 Percent of HIV-positive pregnant women who received antiretroviral treatment to reduce risk of mother-to-child-transmission in targeted districts

N/A

N/A

32 Percentage of targeted DMOs that have completed their semi-annual performance assessment and technical supportive supervision visits to facilities in their catchment area

N/A

PA N/A

TSS N/A

33 Percent of targeted DMOs that demonstrate specific performance improvements since their previous performance assessment

TBD

TBD

34 Percent of targeted primary care facilities that have received technical supportive supervision or clinical mentoring for clinical staff in the past six months

N/A

TSS N/A

CM N/A

35 Percent of targeted facilities in targeted districts that have up-to-date and gender sensitive job aids for HIV, FP, MNCH, and/or nutrition

TBD

District TBD

36 Percent of targeted facilities in targeted districts that have initiated QI projects inART, PMTCT, MC, FP, child health and nutrition, or maternal health services with documented process results.

TBD

TBD

37 Number of people trained in child health and nutrition 39

M-IYCF 39

Males 17

Females 22

M-IYCF ToT 0

Males 0

Females 0

38 Number of people trained in maternal and newborn health 60

Health Workers (EMoNC Providers) 24

Males 6

Females 18

32


2016 - Achievement

SMAGs Master Trainers 36

Males 21

Females 15

SMAGs Health Workers 0

Males 0

Females 0

39 Number of people trained in family planning/reproductive health 0

Health Workers 0

Males 0

Females 0

Community Based Distributers 0

Males 0

Females 0

40 Number of new health care workers who successfully completed an in-service training program within the reporting period

0

Clinical Mentorship 0

0

CHA Supervisors 0

Males 0

Females 0

Financial Management 0

Males 0

Females 0

Planning 0

Males 0

Females 0

Strategic Information 0

Males 0

Females 0

Gender 0

Males 0

Females 0

33


2016 - Achievement

Task 3: Provide technical and financial assistance to the GRZ and community-based organizations to increase the quality, availability and use of priority health services at the community level in targeted districts

[Result 3: Improved capacities of MOH and community-based organizations to increase quality, availability and use of priority health services, and promote better health through prevention and healthy behaviors, at the community level in targeted districts]

Sub-task 3.1: Improve capacity to deliver quality health services at the community level

43 Number of CHAs that receive routine supervision (from health facility staff) in target facility catchment areas

0

CHA Students 0

Males 0

Females 0

44 Number of community volunteers (including SMAGs, nutrition groups, others) that have received equipment to deliver priority community health services in targeted facility catchment areas

Community Volunteers 0

Males 0

Females 0

Sub-task 3.2: Strengthen linkages between the community and facility for key health interventions

46 Number of active beneficiaries served by PEPFAR OVC programs for children and families affected by HIV/AIDS in target areas

0

0

48 Percent of target health facilities with a functional facility/community-level Quality Improvement (QI) committee

0%

0%

Sub-task 3.3: Implement community level Social and Behavioral Change Communication (SBCC) interventions to increase utilization of high impact health services

49 Percent of children under five years of age who received Vitamin A from USG-supported programs in target districts

N/A

34

Annex 3: Short-term Technical Assistance Plan for Next Quarter

The following table summarizes the short-term technical assistance planned for July – October 2016.

Scope of Work Individual Timeframe Deliverable(s)

Support Grant Support Teams (GSTs) to learn how to facilitate the capacity assessment training

Donna Bjerregaard Oct 1st–15th, 2016 Revised capacity assessment training Facilitator’s Guide for the capacity assessment training Training curriculum Trip Report

Provide technical support to implement the USAID and DFID funding planning workshops to 4 provinces and 45 districts

Bonnie Kligerman, Senior Capacity Building Advisor, Abt

Oct 3rd–24th, 2016

Debrief report of planning workshops

Conduct training of trainers for midwifery educators from 3 schools (Livingstone, Chikankata and Kitwe supported under ZISSP) to conduct Introduction to Midwifery Workshop Mentor midwifery educators (from 3 old schools) as they facilitate a workshop for 12 midwifery educators from 4 new schools (UTH, Monze, Kabwe, Mufulira)

Support completion of simulation scenarios for schools

Patrice White-ACNM Senior Technical Advisor, and Cheryl Jemmott, Consultant, ACNM

Oct 3rd–14, 2016 Oct 17th–28, 2016

TOT and mentoring for midwifery educators, work plan activity inputs Newly equipped skills labs for midwifery schools set-up and functional

Landscape analysis for nutrition.

The Senior Nutrition Advisor will work with SBH Nutrition Specialist to conduct meetings in Eastern province with the PMO and partners to assist the MOH and the NFNC to develop a nutrition mapping analysis

Carolyn O’Donnell, Senior Nutrition Advisor Save the Children

Sept/Oct, 2016 Landscape analysis on how to assist the MOH and the National food and Nutrition Commission to strengthen nutrition activities.

Report on meeting with partners in Eastern Province on how to collaborate and build linkages.

Participate in the Zambia Health Care Financing (HCF) Strategy Planning Meeting and provide support during the strategy development

Conduct desk review of various background documents to ensure clear understanding of the Zambian health system. Draft HCF Strategy and share with HCF TWG for comments.

Initiate development of the HCF Strategy document. Work with Zambian HCF TWG members (MOH and University of Zambia, Project staff and other stakeholders) to develop the HCF Strategy as part of capacity building.

Hailu Zelelew-Health care Financing Advisor, Abt. Dr. Dale Mudenda Dr. Chitalu (Local consultants)

Oct 3rd–7th, 2016

Oct 25th–Dec 5th, 2016

Inputs to the HCF strategy development process

Final draft copy of the National Health Care Financing Strategy

35

Scope of Work Individual Timeframe Deliverable(s)

Provide technical support planning and preparation of the Year 2 Work Plan and act as Activity Manager for development of work plans and budgets for direct USAID and DFID funding to 4 provinces and 45 districts

Suzanne Powell, Technical Program Officer, Abt

Oct 29th–Nov 12th, 2016

Finalized work plan and budget, Activity plans and budgets for direct USAID and DFID funding ready for submission

Design and carry out a training institution capacity assessment for CHA training and to work with project staff to identify the Human Resources for Health (HRH) activities to include in the Year 2 work plan

Rebecca Furth, Senior Technical Advisor, Initiatives

Nov 3rd–19th, 2016

HRH activity items for Year 2 Work Plan

CHA training institution capacity assessment protocol and tools CHA training institution database

Participate and contribute to the review and completion of the 2017 work plan and budget

Julie Urban Jaser, Senior Contract & Finance Manager, Abt

Nov 7th–11th, 2016 Finalized work plan and budget

Participate and contribute to the review and completion of the 2017 work plan

Ellen Pierce, Portfolio Manager, Abt

Nov 7th–18th, 2016 Finalized work plan and budget

Presentation of work plan activities for Year 2 under Save’s HIV component

Dr. Abdulhamid Isehak, Save the Children

Nov 21st-25th, 2016

Trip Report. Finalized Work plan for HIV component

Contribute to capacity building of MOH and University of Zambia to Manage the National Health Accounts as part institutionalization of the process, and assist the team to prepare for the next NHA exercise. Conduct training for national, provincial MOH and UNZA team using the SHA 11 methodology

Provide technical support planning and preparation of the Year 2 Work Plan and act as Activity Manager for development of work plans and budgets for direct USAID and DFID funding to 4 provinces and 45 districts

Tesfaye Dereje, Senior Associate, Abt

(TBA) Nov, 2016 20 MOH and UNZA program officers to be trained to take lead in the organization and conduct of the NHA using Systems for Health Accounting 11 Methodology.

Simple step-by- step tool which will serve as reference document by the Zambian NHA team

National Health Strategic Plan M&E Framework:

Development of M&E framework for the revised NHSP requires bringing together technical stakeholders to discuss the indicators and data elements needed at national and sub-national levels to monitor progress against the new plan

TBA Nov, 2016 (3rd/4th week)

Updated M&E Framework Draft of International Standards

usaid/zambia systems for better health

Documents