The funding level for this activity in FY 2008 has decreased since FY 2007. Only minor narrative updates

have been made to highlight progress and achievements.

The Ministry of Health of Zambia (MOH) aims to develop an effective and sustainable prevention of mother

to child transmission of HIV (PMTCT) program. The MOH also plans to strengthen the PMTCT reporting

system, the supply management, and logistics systems for the program. In FY 2007, the MOH with support

from the President's Emergency Plan for AIDS Relief (PEPFAR), begun the process of finalizing the

monitoring system, through which data will be captured from facility level to national level using both paper-

based tools and the electronic based system which, in turn will, feed into the continuity of care project. The

data collection tools have been developed as well as the various user manuals. So far 168 provincial and

district data managers have been trained, in collaboration with United States Government partners. The

system is currently being rolled-out and district maternal and child health coordinators have been trained in

the use of this monitoring system. These will serve as trainer of trainers for roll-out into facilities providing

PMTCT in their districts. This is timely, and as services are expanded, it is critical to establish national

systems for PMTCT program monitoring. The PMTCT-MS has been designed to:

?Standardize data collection and monitoring procedures

?Provide program monitoring information to identify progress and challenges and to improve PMTCT

services

?Facilitate standard reporting of national and international PMTCT indicators

?Support a simple, national strategic information system for PMTCT

?Aid in tracking babies exposed to HIV.

?Enable MOH to plan, coordinate and supervise delivery of integrated services as well as informing policy.

The MOH has a shortage of manpower at the central level to effectively coordinate the program nationally,

and has challenges with pushing PMTCT logistics to the provinces. In FY 2008, MOH will use this funding

to build this capacity. The MOH aims to maintain two positions to provide logistical, monitoring and

evaluation technical assistance to the national program with support from CDC. Other activities to be

implemented include strengthening the reporting system at all levels of data capture, monitoring visits,

training, strengthening the supply chain for the PMTCT supplies, and support for PMTCT buffer logistics

In FY 2007, all MOH's implementing partners begun scaling-up efforts to reach many women based on the

population based coverage model. Direct support to MOH via a memorandum of understanding with

implementing partners has enabled key technical staff to plan, coordinate, and supervise the delivery of

integrated services across the country. In addition, MOH has ensured that the program is rolled-out as

elaborated in the national PMTCT expansion plan. This plan embraces routine opt-out counseling and

testing, universal access to PMTCT service targets for program performance and has been ensuring that all

HIV-positive women identified through the program are not only linked to antiretroviral therapy (ART) but

access ART and care services.

In FY 2008, the MOH plans to strengthen the gains achieved by maintaining a robust but simple paper-

based monitoring system whilst rolling-out Smartcare. This system will guide ongoing processes of further

scale-up, maintain quality of services, improve utilization and inform areas for concerted support supervision

as well as obligatory reporting.

The MOH PMTCT Program through the plus-up funds complements and supports other services such as

infant and young child nutrition, palliative care, ART services, reproductive health, and strategic information.

The PMTCT program is designed to ultimately be sustainable through incorporating the PMTCT services in

routine maternal and child health services. The direct funding requested for in this proposal will support

these other related services as well. The national routine information system will track contributions made

to attaining PMTCT and inform about the outcomes.

Targets set for this activity cover a period ending September 30, 2009.

Activity Narrative:

The funding level for this activity in FY 2008 has increased from FY 2007. Narrative updates have been

made to highlight progress and achievements.

This activity relates to activities in counseling and testing, laboratory infrastructure, palliative care, and basic

health support activity.

This activity provides support for the national implementation of tuberculosis (TB) and HIV activities through

the following: 1.) collaboration on TB/HIV activity meetings at National and Provincial levels; 2) provision of

technical support to the provinces and districts through supervision; 3) collaboration on national TB review

meetings; 4) and support for one full time TB/HIV Officer to be based within the Ministry of Health (MOH).

In FY 2006 and 2007, the US Government (USG) provided direct support to the MOH through CDC

Technical Assistance (TA) in the following areas: national integration of TB and HIV services through TA at

national and local levels; support for the development of TB/HIV guidelines and materials; and preparation

of TB clinical decision support systems.

A National level TB/HIV coordinating body within the MOH was convened with the following membership:

staff from TB, HIV, Counseling and Testing (CT) units in MOH; multilateral organizations; research groups;

faith based organizations; non-governmental organizations; and community representatives. This body was

tasked with developing and implementing a single, coherent TB/HIV strategy and communication message

based on the best existing evidence. As a result, national guidelines for the implementation of TB/HIV

activities were developed based on the World Health Organization (WHO) Interim Guidelines for TB/HIV

collaboration. Additional support was provided for the revision of TB data collection and reporting forms and

registers based on WHO forms that incorporate the collection of HIV data. The USG supported the MOH to

print the revised patient treatment cards, identity cards and registers that were distributed to all the

provinces and districts. Technical support was also provided for the orientation of health staff on the new

forms. In addition, the USG, co-funded with the MOH, WHO and JHPIEGO, a training of trainers course in

Diagnostic Counseling and Testing (DCT) using the National training of trainer's session for the initial group

of 25 trainers in DCT using the national training module adapted by JHPIEGO.

By the end of FY 2007, the USG will have provided continued support for regular meetings of the TB/HIV

Coordinating bodies at the National and Provincial levels. Other activities supported during 2007 include the

production and dissemination of the TB/HIV guidelines to the Provincial tuberculosis (TB)/HIV Coordinating

bodies and orientation of health staff on provision of routine counseling and testing to TB patients. Further

support during FY 2007 provided technical supportive supervision to the districts for the implementation of

these guidelines in conjunction with other partners such as USAID Child Survival Fund's for Tuberculosis

Assistance Program (TBCAP) and WHO.

The increased work load in the National TB program coupled with shortage of human resource has

impacted negatively in the implementation of some TB/HIV collaborative activities. To strengthen the human

resource capacity in the National Program, during FY 2007, the United States Government (USG)

supported the Ministry of Health (MOH) with the placement of a full-time TB/HIV Officer. The duties for this

officer are focused on the implementation of TB/HIV activities, working directly under the jurisdiction of the

National TB Program (NTP) Manager. To further strengthen the program, a TB/HIV review meeting is being

supported by the USG with participants drawn from the National TB program, Provincial Focal persons,

Partners, Focal persons from some hospitals and selected districts. During this meeting, data from all the

provinces will have been compiled, analyzed and used for planning.

With the FY 2007 plus-up funds, technical supportive supervision is being provided to all provincial health

offices and 35 districts. Through this supervision, the TB/HIV Program officers continue to identify the

strengths, weaknesses, opportunities and threats to the program and offer appropriate technical advice on

strategies to strengthen the program.. During FY 2007, a total of 800 health care providers will have

received on the job training.

In FY 2008, the USG will continue the support outlined above and expand activities in the following areas to

ensure sustainability: provide support for the quarterly meetings of the National and Provincial TB/HIV

Coordinating bodies and ensuring that they strengthened including monitoring and evaluation activities;

provide support regularly scheduled National TB/HIV review meetings and providing technical support

during these meetings; ongoing staffing support for the TB/HIV officer placed at the MOH; provision of

supportive technical supervision to all the provincial hospitals and 50% of districts every quarter, with

coverage of all districts by the end of FY 2008. In order to enhance the capacity for monitoring and

evaluation of TB/HIV program, the technical supervision visits will include a component of training in the use

of information for management decisions at provincial, district, health center and community levels including

ensuring that health care providers are competent in the use of data collection and reporting tools It is

expected that 850 health care providers will receive on the job training through this supervision.

In addition, the NTP has begun addressing the issue of Multi Drug Resistant (MDR) TB and has developed

a notification system for MDR cases nationwide and has appointed an MDR working group that is a sub-

committee of the main TB/HIV committee. This committee has been tasked with developing the guidelines

for the management of MDR TB and a training program for clinicians and 4 members of this committee

have participated in training of trainers in MDR by the World Health Organization. One of the main

concerns had been the development of a facility for the management of MDR, and to this end the MOH has

begun renovations of a building situated in the grounds of the main referral hospital, the University Teaching

Hospital in Lusaka with funds from Global Fund Round 1 phase 1 grant. However these funds were not

sufficient to complete the renovations and therefore funds available from the USG will be used to complete

the building that will serve as an isolation facility for all cases of MDR TB. Training will be provided in the

management of MDR TB for the clinicians and nursing staff that will provide care in this facility and personal

protective equipment will be procured based on the national guidelines. Patients will be referred to Lusaka

from the different health institutions in the country by use of an ambulance service to be based in Lusaka

and supported by the Ministry of Health National TB program. Personal protective equipment will be

purchased for use by the staff running this ambulance system using funds from other sources. The MOH

has plans to apply to the Green Light Committee (GLC) for second line drugs and the development of a

Activity Narrative: specific facility for the management of MDR TB is one of the requisites to qualify for consideration by the

GLC for second line drugs. In the interim the MOH will procure the second line drugs needed for the

management of the 50 MDR cases currently registered with the national program.

Targets set for this activity cover a period ending September 30, 2009.

The funding level for this activity in FY 2008 will remain the same as in FY 2007. Only minor narrative

updates have been made to highlight progress and achievements.

Activities related to this include monitoring visits, training, policy and guideline dissemination, participation in

national quality improvement efforts, and integration and scale-up of the national ART information system,

the SmartCare development and implementation, Elizabeth Glaser Pediatric AIDS Foundation support to

Ministry of Health (MOH) drug resistance monitoring. In FY 2006, the Zambian MOH started implementing

the policy of free antiretroviral therapy (ART) and related services provision and in 2007 expanded provision

of free services to all eligible Zambians.

The MOH has strengthened supervision and coordination by national teams of ART service delivery and

has improved linkages with the provincial and district ART programs in FY 2007 and intends to consolidate

this in FY 2008. Once FY 2007 funding is received, the new position of Quality Assurance Advisor for

HIV/AIDS services within the MOH will be filled. Direct support to MOH in FY 2007 will enable key technical

staff to plan and integrate services with partners and carry out the 2006-2008 HIV/AIDS Treatment, Care,

and Support Plan. This plan embraces the ideal of universal access and sets targets for program

performance and ensures sustainability of the ART services. Direct funding for ART service delivery and

technical assistance will complement other support to the MOH such as in tuberculosis (TB)/HIV (activity

#12445), PMTCT (activity # ) and strategic information (activity #). A second critical activity in FY 2007 for

the MOH is to launch a formal system of antiretroviral (ARV) drug resistance monitoring, in collaboration

with CDC and other United States Government -supported partners. Plans are advanced to implement pilot

HIV drug resistance monitoring in four sites in Zambia. A HIV Drug Resistance (HIVDR) Monitoring working

group has been established and already developed a country working plan for HIVDR monitoring. With FY

2007 funding, the activities of the working group and implementation of the work plan will be scaled-up.

In FY 2008, the MOH plans to continue supporting and consolidating the position of Quality Assurance

Advisor for HIV/AIDS Services for better supervision of expanding adult and pediatric ART services in the

country. The MOH also plans to strengthen the activities of the HIVDR Monitoring Working group and to

consolidate the coordination of drug resistance activities. From the results and experiences of the pilot HIV

drug resistance program the MOH intends with FY 2008 funding to establish four additional monitoring sites

across the country that will include a pediatric HIVDR monitoring site. Fifty thousand dollars will be spent on

pediatric HIV drug resistance monitoring. Other critical activities in FY 2008 are building the laboratory

capacity to perform genotypic HIV drug resistance testing, support of management and analysis of data on

the magnitude of HIVDR in the selected study population, and coordination of report dissemination to the

Government of the Republic of Zambia, health professionals, the public, and the scientific literature.

Targets set for this activity cover a period ending September 30, 2009.

The funding level for this activity in FY 2008 has increased since FY 2007. Narrative changes include

updates on progress made and expansion of activities.

This activity relates to EGPAF SI, JHPIEGO SI, AIDSRelief - Catholic Relief Services (CRS), Technical

Assistance/Centers for Disease Control and Prevention (CDC), Zambia National Blood Transfusion Service

(ZNBTS), COMFORCE, Tropical Diseases Research Centre, UTH Virology Laboratory, and the Central

Statistical Office.

This cooperative agreement (CoAg) with the Ministry of Health (MOH) supports Strategic Information (SI)

objectives of strengthening local health management information systems (HMIS) and improving human

resource capacity for monitoring and evaluation (M&E) and surveillance. By close of 2007, the system was

implemented in over 60 facilities including public, NGO, and military sites, and with close to 100,000

enrolled clients was helping to provide quality care to the majority of Zambians receiving ART. The system

extended much needed coverage to the complex realm of Paediatric HIV and ART services, and MCH

delivery services, in addition to implementing robust role based security administrative features and initial

GIS features at all levels of system implementation. The MOH reiterated its strong support for the

SmartCare electronic health record solution with a letter from the Permanent Secretary by establishing a

target of 900 implemented clinics by end of 2008 funding period, and acknowledging its role in sustaining

the system long term.

Building on last years successes, in FY 2008, this activity will continue to support improved use of routine

health information through national patient level information systems, aggregate systems, survey efforts,

and monitoring and evaluation (M&E) activities. In this period, modules for the remaining key outpatient

services will be deployed, including support for Malaria, STD, and TB care outside the context of ART

services. With coordination by CDC TA and EGPAF commodity purchases, this activity also includes

beginning transitional procurement of equipment and commodities required for sustaining future deployment

of the nationally adopted Continuity of Care and Patient Tracking System (SmartCare) which may include

touch screens for data entry, electronic health record (EHR) Care Cards (smart cards) for data transport,

card readers, printers, computers, and computer and printer consumables. Highly competent and skilled

information technology (IT) and information systems (IS) personnel down to district level are essential to

support and ‘locally own' a national EHR system. Support will be provided for capacity building activities

within the MOH at Central, Provincial, District, and Facility levels by assisting the Ministry to hire appropriate

technical leadership staff holding internationally recognized standard certifications, and other objective

measures of skill and experience. In light of the new MOH structure, and the change opportunities

associated, this is a key time to support transition to higher level skills and authority in information systems

and management, as reflected in the role based security management aspects of the system, as an

example. Funding for the facilitation of roll-out and scale-up planning meetings as the system capacity

expands will be provided as well as technical assistance to provincial and district levels in handling system

upgrades. While the United States Government (USG) provides strong implementation support for this

project, for sustainability it is imperative to have the MOH continue to authorize and lead all aspects of the

deployment and management of the new national EHR system. This funding will provide support for

continued improvement of linkages between national clinical information systems such as SmartCare, and

the national HMIS. With collaborative support from WHO, growing numbers of CDC and USAID partners,

Peace Corps, DOD and others, training for the national SmartCare system at the central levels will continue

to expand in FY 2008 in the following areas: (1) software development training to build MOH's capacity to

maintain and develop enhancements to the system; (2) user training for staff facilitators having expertise

with the system; and (3) system maintenance training. As a result of these trainings, 10 people will be

trained in software development, 120 people will be trained as users of the system, and 70 people will be

trained in the maintenance of the system. JHPIEGO is providing on-the-job training to 250 clinical staff at

facility-level through a mobile team of IT professionals who train, install, and assist with troubleshooting and

data entry. Support will also be provided for MOH to include an M&E Data Use Specialist in the central M&E

Directorate to maximize information systems and train provincial and district counterparts on localized use

and feedback processes. This specialist will work with USG staff to assist in the SmartCare roll out, create

data use curricula and tools, and support national HMIS restructuring and file exchange.

FY 2008 funding will also enable the Zambia MOH to support the surveillance of HIV/AIDS and HIV-related

morbidity and mortality through the following activities: (1) report and disseminate results of the 2006/2007

Zambia Antenatal Clinic Sentinel Surveillance (ANC SS) and the Zambia Demographic and Health Survey

(ZDHS) on estimates of HIV and syphilis prevalence (and recent infections) in relation to important socio-

demographic factors and additional laboratory analyses; (2) implement the 2008 ANC SS of HIV and

syphilis; (3) support a survey to determine HIV prevalence and incidence in children attending under-five

clinic at the ANC sentinel sites; (4) monitor transmitted HIV drug-resistance among young women in the

ANC SS in urban areas where ART services have existed for the longest; (5) strengthen the Zambia

National Cancer Registry and the Cancer Diseases Hospital in surveillance and reporting of AIDS-related

malignancies to enable the MOH to monitor the impact of PEPFAR antiretroviral therapy scale-up on the

risk of important AIDS-related complications; (6) support the MOH as it works with the Central Statistical

Office to implement death registration and to ascertain cause of death in health facilities to obtain mortality

data; (7) support MOH staff in training in bioethics and human subject research protection to increase

awareness and proficiency in patient privacy and confidentiality, issues that are critical and fundamental to

all HIV/AIDS SmartCare, M&E, and surveillance data collection and reporting; (8) assist in the coordination

and implementation of a multi-agency working group to improve Zambia's geographic data layers and data

infrastructure needed to utilize geographic information and geographic mapping to support HIV/AIDS

monitoring, evaluation, and response, and 9) assist MOH in its use and reporting of health information to

inform planning to evaluate the impact of health programs, and to build capacity in health research and

evaluation methodology and communication of health information and research results to health

professionals, policy makers, and the general public. These activities aim to increase the proficiency of

MOH staff in the systematic collection, analysis, reporting, and use of data, effective communication of

results for MOH planning of HIV/AIDS services and program evaluation, and capacity building within MOH

so that these activities can be sustained by Zambian health professionals beyond FY 2008/2009.