Zambia continues to face an acute shortage of health care personnel which severely constrains the scale-

up of anti-retroviral therapy (ART). The most limiting factor is lack of trained providers - physicians, nurses,

clinical officers, laboratory personnel, and others. The priorities of the National Human Resources Strategic

Plan include recruitment, deployment, and retention of health workers. The Health Services and Systems

Program's (HSSP) role in the ART program is to support the Ministry of Health (MOH) to retain critical staff

in areas of greatest need and provide support in performance improvement and quality assurance. In FY

2005, HSSP recruited and placed nine Provincial Clinical Care Specialists (CCSs) to enhance ART

coordination and quality assurance; initiated the recruitment of doctors under the rural retention scheme;

and developed the minimum criteria for certification of providers and accreditation of ART sites. A certified

HIV/AIDS care and ART provider is a physician, a medical licentiate, clinical officer or a nurse who has

successfully completed MOH approved ART/OI in-service training program (short courses, on-the-job

training and updates) which is recognized by an appropriate regulatory authority e.g. Medical council of

Zambia or General Nursing Council.

In FY 2006, HSSP's focus was on continued support to CCSs and placement of medical doctors to serve in

remote areas; recruitment of non-physician health care workers for the retention schemes; recruitment of

nurse tutors; and development of minimum criteria for certification of providers and accreditation of ART

sites. Modalities of recruitment and management of retention schemes for doctors, nurse tutors and other

cadres were finalized by HSSP and MOH. Agreement on modalities of recruitment and management of

doctors' retention scheme has been slow with the dissolution of the Central Board of Health - the managers

of the existing retention scheme; further, there was an upward adjustment of the package by the MOH

necessitated by the sudden appreciation of the local currency against the US dollar.

In FY 2007, HSSP continued to support the nine CCSs and the retention scheme for doctors, non-

physician health providers and nurse tutors. HSSP paid the salaries and provided maintenance and fuel

expenses for supervision trips of the CCSs in the nine Provincial Health Offices (PHOs). The CCSs

continued to provide technical backstopping and supervision to junior doctors implementing HIV/AIDS

activities in the districts as part of human resource capacity development. They also worked with the PHOs

to coordinate ART scale-up in hospitals and health centers, served as provincial ART trainers, and

monitored and supervised the private sector ART provision. CCSs assisted other USG programs in the

provinces, including Zambia Prevention, Care and Treatment Partnership (ZPCT), Health Communication

Partnership, and Centre for Infectious Disease Research in Zambia. CCSs served as a conduit for

provincial coordination and quality assurance.

In FY 2008 HSSP will continue to support the nine CCSs through payment of salaries and provision of fuel

expenses for supervision and coordination of ART scale up in hospitals and health centers. The Rural

Retention Scheme for medical doctors, nurse tutors and other health workers will be supported using

funding already received from FY2005, FY 2006 and FY 2007.

In FY 2006, HSSP supported MOH and Medical Council of Zambia (MCZ) to develop an ART accreditation

plan, consensus-building on ART standards and accredit 21 private ART sites. In FY 2007, HSSP

continued to roll out the accreditation system to more districts. An additional 21 private ART facilities were

accredited. In FY 2008, HSSP will support MCZ to monitor, document and improve the overall functioning of

the accreditation system. HSSP will continue to work closely with the CDC, ZPCT and the WHO to support

the MOH in improving services for HIV/AIDS patients in health facilities.

In FY 2007, HSSP and other partners supported the integration of HIV/AIDS services into MOH

Performance Assessment tools and developed minimum quality assurance standards for HIV/AIDS

services. The tools and minimum standards were approved by MOH and are in use in all districts. In FY

2008, HSSP will focus on monitoring of implementation of the Performance Assessment tools and

standards and strengthening supervisory services that focus on case management and quality

improvement.

To ensure sustainability, HSSP works within the existing GRZ structures and plans. HSSP facilitates the

development and dissemination of appropriate standard guidelines, protocols, plans, and budgets. The

tools and guidelines are disseminated for use by relevant MOH structures. This enables them to plan and

implement activities independently. HSSP also assists GRZ in implementing a facility-level quality

improvement program. All project activities are integrated into the existing programs and structures to

ensure continuity of services after HSSP concludes.

All FY 2008 targets will be reached by September 30, 2009.

The Health Services and Systems Program (HSSP) works with the Ministry of Health (MOH), and in

collaboration with other partners to develop and disseminate standard data elements, data collection, and

reporting tools, and to train health facility staff. In FY 2008, in the area of strategic information, HSSP will

develop and strengthen an anti-retroviral therapy (ART) data collection and reporting system to improve

overall program management for the MOH. HSSP will also continue to link with other partners engaged in

service delivery and strategic information.

During FY 2004, technical assistance was provided to MOH to develop the national ART Information

System (ARTIS) in provincial and tertiary level hospitals. In FY 2005, HSSP provided technical assistance

focused on: rolling out the paper-based ARTIS to all public health facilities providing ART; integrating ART

data into the Health Management Information System (HMIS); developing an inventory of existing

prevention of mother to child transmission (PMTCT) and counseling, testing, and care (CTC) indicators; and

producing a Health Statistical Bulletin that includes ART Information. HSSP trained 72 district and 9

provincial data managers in the paper-based ARTIS, achieving 100 percent coverage.

During FY 2006, HSSP's role was to assist the Ministry of Health (MOH) and partners to ensure that all

HIV/AIDS service delivery data are reported through the MOH national HMIS. A major challenge was to

integrate public and private sector HIV/AIDS data on PMTCT, CTC, and tuberculosis (TB) into the

mainstream HMIS. To address this challenge, HSSP assisted the MOH to revise existing HMIS data

collection and reporting tools to integrate CTC, PMTCT, and TB services. A total of 81 data managers (9

from the provincial level and 72 from the district level) were trained to use the new tools. In FY 2007 HSSP

supported the 72 districts in the utilization of information to plan for HIV/AIDS services and develop

quarterly and annual reports based on action plans. One hundred and eighty two (72 District Information

Officers, 72 Managers of Planning and Development, nine provincial data managers, 18 Clinical Care

Specialists, and 11 Hospital Information Officers) were trained in information utilization. Two thirds of ART

sites are currently using ARTIS. In FY 2008, HSSP will continue to support and supervise districts and

hospitals to improve data quality and enhance utilization of data for informed decision making by

strengthening the provincial structures and competencies in supervision and technical backstopping for

ARTIS/HMIS. Nine provincial health staff and three MOH - headquarters staff will be trained for this

purpose. HSSP will also work with CDC to aggregate facility data (SMARTCARE CARD) and facilitate

overall integration into the HMIS. Currently, the European Union (EU) provides HMIS support to the MOH;

HSSP will work closely with the EU and MOH to ensure HIV/AIDS indicators are included in the national

HMIS system. Additionally, HSSP will provide support to MOH to develop an integrated package of HMIS

reference materials for HIV/AIDS services. It is expected that there will be improvement in the quality of

action plans, implementation, and services in general. Reviewing district action plans has revealed that

planning is not based on evidence or sound epidemiological data, hence the need to focus on improving

data utilization at service delivery level.

As part of the sustainability plan, HSSP works closely with the Ministry of Health, Provincial Data

Management Specialists, and other partners (ZPCT, CDC, CIDRZ, and the World Health Organization) to

develop, disseminate, and maintain the HIV/AIDS reporting systems which are integrated into the overall

Zambian Government HMIS. HSSP's mandate is to ensure integration of ART, PMTCT, CTC, and TB into

the mainstream HMIS and build capacity of the health workers and data managers in the use and

maintenance of the developed information systems.

All FY 2008 targets will be reached by September 30, 2009.

In FY 2008, the Health Systems and Services Program (HSSP) will continue to work with the Ministry of

Health (MOH) to build on FY 2005, FY 2006, and FY 2007 activities of strengthening policy and systems

that support HIV/AIDS services in the following areas: 1) planning; 2) human resource planning and

management (HRPM); 3) pre- and in-service training; and 4) HIV/AIDS coordination and Sector Wide

Approach (SWAP). In the area of planning, HSSP will continue to provide routine support to the MOH to:

develop annual technical updates for annual health sector planning based on priorities and objectives of the

National Health Strategic Plan; compile a summary of national health priorities integrating information on

HIV/AIDS; and conduct a desk review of 72 district action plans and 22 hospitals to assess the quality of

plans and the extent to which HIV/AIDS services are incorporated in the action plans. By linking with

HSSP's Strategic Information activity, district level managers and planners will improve their skills in using

data for planning especially as it relates to HIV/AIDS information and budgeting of HIV/AIDS-related

services to ensure efficient use of scarce resources.

In FY 2007, HSSP worked with the MOH to disseminate HIV/AIDS human resource (HR) planning and

projection guidelines and plan for HR requirements to deliver a minimum package of HIV/AIDS services.

HSSP supported Provincial Health Offices (PHOs) to assess their district HR needs and developed 72

district HR staffing plans. In FY 2008, HSSP will support MOH and PHOs to strengthen the role of

Technical Supportive Supervision (TSS) in HR planning and management. Specifically, HSSP will review

72 district action plans to determine the level of inclusion of HR requirements and participate in the

provision of TSS to districts that do not comply with HR planning guidelines. It is expected that the support

system for the utilization of HR planning guidelines will be strengthened in all the nine PHOs.

In the area of Pre and in service training HSSP will provide ongoing assistance to the MOH to ensure that

all training is coordinated among partners and that skills enhancement is linked to strategic information as

well as anti-retroviral (ARV) service provision. In FY 2007, HSSP supported MOH to integrate HIV/AIDS

and related teaching modules into pre- and in-service programs, develop training materials and teaching

guides, and train 160 teachers from Chainama College (Clinical Officers) and nursing schools on the

revised curricula. The curriculum for the Clinical Officer General was developed and is currently being

implemented. In FY 2007, the nurses' curriculum was revised and work on the Physicians' curriculum

began. Twenty-one organizations (the MOH and all the 20 training schools for clinical officers, doctors, and

nurses) received technical assistance for HIV/AIDS-related institutional capacity building, thus achieving

100% coverage. In FY 2008, HSSP will continue to support the same 21 organizations as it works

collaboratively with the MOH to strengthen the quality of training and supervision for the 20 training

institutions. HSSP will continue to work with Chainama College and General Nursing Council (GNC) to

evaluate the implementation of the revised Clinical Officer General (COG) and nurses' curricula. Additional

training activities for 160 teachers will include strengthening teaching methodologies, reorienting faculty,

and monitoring implementation of the physicians' curriculum.

Parallel to curricula review process, in FY 2005/FY 2006 HSSP supported the training of 637 graduates in

the provision of HIV/AIDS services. A follow up assessment of these students was conducted in 2006 to

facilitate lesson learning. In FY 2008 HSSP will also continue to strengthen the role of the Human Resource

Development Committees (HRDCs) through technical support supervision in order to improve planning and

coordination of HIV/AIDS training activities in all 72 districts. This support will include building capacities of

HRDCs, to effectively utilize the national in-service training coordination system and the national training

guidelines.

In regards to HIV/AIDS coordination and SWAP, in FY 2008 HSSP will continue to assist the MOH and

partners (USG, cooperating partners and UN agencies) that support HIV/AIDS service delivery to

coordinate activities among themselves and with the private sector. Activities will include: providing

technical assistance to the Sector Wide Approach Program (SWAP) to assist MOH to meet milestones

under the Sector Program Assistance (SPA) and ensure collaboration and effective coordination of

HIV/AIDS services. Specifically, HSSP will continue to assist the MOH to: improve HIV/AIDS work plans;

provide technical support supervision; mobilize resources through the Global Fund to Fight HIV/AIDS,

Tuberculosis and Malaria; monitor implementation of the HIV/AIDS coordination mechanism for the health

sector and sustainability framework; and maintain a partners' database for HIV/AIDS service delivery. In

FY2006 HSSP supported MOH to develop the HIV/AIDS coordination mechanism which serves as a guide

for coordinating HIV/AIDS services in health institutions.

To ensure sustainability, HSSP works within the existing government structures and plans to develop and

disseminate appropriate standard guidelines, protocols, and strategic plans. HSSP also assists the

government to build the capacity of training schools through curricula development and dissemination. To

avoid duplication of efforts, HSSP implements project activities in collaboration with USG partners and other

stakeholders. HSSP will support MOH to provide leadership in planning, thereby paving the way for HSSP

exit. HSSP will also work extensively with the MOH planning unit to strengthen and further decentralize the

district planning process. The Provincial Health Office will be encouraged to play a stronger role in the

review and monitoring and evaluation of their respective district action plans.

All FY 2008 targets will be reached by September 30, 2009.