NEW ACTIVITY

This activity is linked with Strategic Information (#3714), provincial office strategic information activities

(#9693, 9696,16979) and adult and pediatric care and treatment program areas, and Chest Diseases

Laboratory (#15510), Centers for Disease Control and Prevention - Technical Assistance (CDC-TA #9022),

Lusaka Provincial Health Office (LPHO #9796), Eastern Provincial Health Office (EPHO #9795), Southern

Provincial Health Office (SPHO #9797), and Western Provincial Health Office (WPHO #9799).

Laboratory Information System (LIS) is another component of laboratory management tools to strengthen

and improve laboratory capacity. While most laboratories in the public sector in Zambia (provincial, district,

and health centers) are still using paper-based record and reporting systems, several non-governmental

organizations (NGO's) have already implemented LIS in their central laboratories using either commercial or

institutional software. Currently, there is no standard national LIS that is endorsed by the Ministry of Health

(MOH).

There is a need to develop an LIS system in the country in order to collect lab testing data that: 1) can

provide rapid and efficient monitoring of laboratory quality, 2) is well interfaced with the national electronic

health record system (SmartCare) widely used in the country to ensure fast and accurate clinical services

for patients, and 3) the information is rapidly available "in aggregate" to inform national disease and

epidemic notification processes, and population level interventions. A routine and systematic data stream of

aggregate lab results will be invaluable to the MOH for program monitoring and clinical policy guidance.

In FY 2009 the MOH will use the allocated funds to conduct the following activities: 1) to hire and train a

technical laboratory information system specialist with software adaptation, localization, and configuration

skills to work closely with the MOH and United States Government (USG) clinical information and

laboratory information systems teams in Zambia, 2) Training of the specialist to receive LIS training in other

PEPFAR countries, and 3) to conduct LIS training for 80 lab personnel (three one week sessions of 25-30

persons per session).

The hired specialist will be able to evaluate and select options appropriate for the needs of the country.

Through this activity local skill and capacity will be built in laboratory information technology within the MOH

for sustainability purposes.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $60,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 17 - HVSI Strategic Information

Total Planned Funding for Program Budget Code: $15,590,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The U.S. Mission in Zambia will continue to support the Government of the Republic of Zambia's (GRZ's) Ministry of Health, the

Zambia Defense Force, the Central Statistical Office (CSO), the University of Zambia (UNZA), national laboratories, the National

Blood Transfusion Service, and the National HIV/AIDS/STI/TB Council (NAC) by: improving information systems infrastructure

and management; upgrading quality assurance procedures; providing essential staff training and support; and providing technical

assistance in developing sustainable systems and workforce in the areas of monitoring and evaluation (M&E), epidemiology and

surveillance, scientific research methods, health information systems (HIS) including electronic health records (EHR), and

information and communication technology (ICT). In addition, the U.S. Mission in Zambia has been a key partner in the

implementation of HIV/AIDS-related surveillance, including the ANC Sentinel Surveillance, the Zambia Sexual Behavior

Survey/AIDS Indicator Survey (ZSBS/AIS), the Demographic and Health Survey (DHS+), the Service Provision Assessment

(SPA), the Nakambala Migrant Farm Workers Health Study, and the PLACE Study. As a result, Zambia is a nation rich in data for

decision-making.

The primary strategic information challenges are to: implement, integrate, and institutionalize sustainable systems; triangulate and

strengthen the use of data for programmatic decision-making and improved quality of HIV/AIDS services and activities; build

infrastructure that supports effective SI systems; and train Zambian professionals to help ensure the sustainability of activities in

the strategic information program area. The U.S. Mission in Zambia will support the training of 1,799 people in strategic

information and provide assistance to 506 organizations.

The PEPFAR Strategic Information (SI) team in Zambia comprises surveillance, management information systems (MIS), and

M&E experts from all five U.S. agencies working in Zambia: USAID, CDC, Peace Corps, DOD, and State. The SI team very

much works as a collaborative, consensus-based team that guides all SI and SI-related activities. The team meets twice each

month, and there are SI representatives on each programmatic technical working group (TWG). Members of the SI team sit on

Zambia TWGs for M&E, surveillance, geographical information systems (GIS), and HMIS convened by the NAC and MOH. SI

team representatives also work closely and collaboratively on all national SI activities and priorities, such as: the DHS and Zambia

Sexual Behavior survey; integration of HMIS; support for SI for clinical services through SmartCare (the nationally adopted

electronic health record (EHR) system designed to support all outpatient clinical services); implementation of the national M&E

plan; surveillance systems; sentinel surveillance; and Biologic and Behavioral Surveillance Surveys (BBSSs).

The SI team works closely with partners in all programmatic areas to help set targets and coordinate implementation of

information systems solutions. Partners submit targets annually during the COP process, and the SI team works closely with

technical program leads to ensure that targets are realistic and achievable. The SI team uses the Zambia partner reporting

system (ZPRS) for data management and reporting. Semi-annually and annually, the SI team - using ZPRS - generates partner

reports comparing targets to results. These reports are shared with partners, and technical leads engage in discussions with

partners regarding performance.

The SI team has developed an interagency SI strategy that includes strategic goals and objectives, timelines, and resource

allocations for all areas of SI: surveillance, surveys, program monitoring, HMIS/SmartCare, and capacity development. This

strategic plan is updated by the SI team on an annual basis, and is integrated into the Zambia National Strategic Framework. The

U.S. Mission in Zambia supports collaborative planning and implementation for all SI activities with GRZ and other cooperating

partners. Key components of this strategy include support for local SI capacity building to achieve long-term sustainability for SI

human resources (HR), and support to engineer best protocols, information flows, and procedures into durable systems that

persist institutionally long after the original ‘engineers' and HR staff have transferred vital SI functions to local management and

ownership.

The SI team prioritizes reporting and use of results data through a number of mechanisms. As mentioned above, ZPRS is the

partner reporting system for the U.S. Mission in Zambia. Several enhancements are being developed that will facilitate the use of

data by partners. The U.S. Mission in Zambia also conducts regular trainings on planning and reporting, with a focus on data

quality and utilization for program improvement. The U.S. Mission in Zambia has catalyzed M&E professionals at UNZA to act as

in-country experts on training for data utilization. Integrating ZPRS, NAC reporting and the MOH/SmartCare systems, and

continuing support for training in data use continue to be priorities. Currently, Zambia satisfies reporting requirements (including

those of UNGASS and the Global Fund to Fight AIDS, Tuberculosis and Malaria) on a national level through a combination of

NAC, MOH, and donor reporting systems.

Data are sent from facilities to district health offices on a monthly basis and then aggregated at provincial and national levels for

national reporting. Data are thus reported as part of the national response, but disconnected system elements remain. As a

result, an integration plan has been developed and will be implemented during the FY 2008-2009 time period that includes sharing

ZPRS with NAC for possible adoption to enhance district level results reporting.

Zambia has well-functioning data quality (DQ) processes, particularly through SmartCare and ZPRS; DQ will be a continuing

training priority in 2009. Overall, data are used by U.S. implementing agencies and national counterparts to inform an evidence-

based approach to planning, program revision, resource allocation, capacity development, as well as direct patient services.

Working together with other partners, the U.S. Mission in Zambia provides financial and technical support to national surveillance

activities to the MOH, Tropical Diseases Research Centre, CSO, UNZA, University Teaching Hospital, and the Zambia National

Cancer Registry. U.S. support in FY 2007 contributed significantly to a number of key achievements, including: implementation

of the 2006 DHS+; analysis of the 2006 Antenatal Clinic Sentinel Surveillance of HIV and Syphilis (including sentinel sites in

UNHCR refugee camps); use of the Sample Vital Registration with Verbal Autopsy (SAVVY) to pilot vital registration systems in

Zambia; and the dissemination of results from the 2006 ZSBS, two PLACE studies, and the Service Provision Assessment.

The U.S. Mission in Zambia supports the national roll-out of an electronic clinical information system, SmartCare, which the MOH

has adopted for clinical facilities nationwide. In April of 2006, the MOH identified SmartCare as the national electronic clinical

information system for any clinic capable of sustaining computer equipment, compelled by the superior reporting and quality care

support. By early 2008, SmartCare was deployed in at least one facility in nearly all 72 districts in Zambia, following trainings for

provincial and district level leadership. This is part of the implementation of a provincial led ‘training of trainers' deployment

cascade, using existing personnel to assure sustainability. In 2007 and 2008, major strides were also made in improving

information communications infrastructure, and transfering technical expertise to key Zambian staff. Anti-Retroviral Therapy

Information System (ARTIS) paper system sites are being converted as infrastructure permits, but precede SmartCare in more

rural areas. SmartCare is credited with improving the quality of care, which translates into reduced expenditures for costly second

line drugs, labs, or acute care. SmartCare is currently serving over 200,000 patients in 198 facilities. In FY 2008, all remaining

sites using CareWare were successfully converted, and Pediatric HIV specialty services were initiated. SmartCare pharmacy

dispensation captures sufficient detail to support drug supply chain management and integration with SCMS is underway. Also in

FY 2008, a SmartCare based ‘SmartDonor' application was developed with the Zambia National Blood Transfusion Service

(ZNBTS) and is currently being pilot tested. Similarly SmartCare was ported to Ethiopia and is now being pilot tested in the

Durama Administrative Region of Ethiopia. By early FY 2009 clinical functionality will have been extended to all remaining areas

of outpatient services, and will increasingly be used to augment inpatient care, and the last remaining major EHR, ZPRS (Zambia

Perinatal Record System) will be converted. Also in 2009 links with a Laboratory Management Information System (not yet

selected) should be established.

In FY 2008, support to UNZA was expanded to offer additional M&E courses for professionals and MPH students. Between FY

2006 and FY 2008, over 300 student professionals and MPH students were trained in M&E skills. Additional students will be

trained in FY 2009. Activities to support the NAC's national M&E system will continue in 2009 with special emphasis on M&E and

data use capacity-building at the provincial and district levels. Communications infrastructure upgrades will be expanded in FY

2009 to support integrated information capture and use, including direct support to Provincial Health Offices to procure satellite

internet connectivity in remote regions.

In FY 2008, the U.S. Mission in Zambia supported the analysis, reporting, and country-wide dissemination of the DHS+ and

Sentinel Surveillance to diverse audiences in Zambia and the reporting of results in the scientific literature. In FY 2009, the U.S.

Mission in Zambia will continue to support the implementation of the 2008 Sexual Behavior Survey/AIDS Indicator Survey,

secondary analysis of the 2006 ZDHS, continued implementation of a system to monitor HIV drug resistance emerging during

treatment, and to build and transfer capacity in innovative geographic mapping and spatial analysis, data management, statistical

analysis, and scientific writing. The U.S. Mission in Zambia will: complete studies of recent HIV infections to estimate HIV

incidence in Zambia from 1994 through 2004, and also HIV and HSV-2 in migrant farm workers; strengthen surveillance of AIDS-

related malignancies; and partner with the private sector to learn more about risk behaviors that predispose high risk populations

such as men who have sex with men to HIV infection. The U.S. Mission in Zambia will also support the CSO to expand the

SAVVY System in selected regions in Zambia, to validate the data capture instruments, and to evaluate the SAVVY implementing

process. In addition, the U.S. Mission in Zambia will provide technical assistance to build government capacity to use GIS for

planning and monitoring interventions and GIS linked to real-time data will augment the value of the SmartCare system at facility

and district levels, as well as nationally.

Table 3.3.17: