The Government of the Republic of Zambia (GRZ), with the support of the US Government's President's Emergency Plan for AIDS Relief (PEPFAR), has experienced great success over the last 5 years implementing national strategies to address the HIV/AIDS epidemic. Results from the 2007 Zambia Demographic and Health Survey (ZDHS) found that Zambia's HIV prevalence rate fell from 15.6% in the 2002 to 14.3% in 2008. Women continue to be disproportionately affected with 16.1 % of women being HIV positive compared to 12.3% of men. Despite this high prevalence, many Zambians are not fully informed about HIV prevention. The majority have not gone for HIV testing and though nine in ten adults know where to get an HIV test, only 35% of women and 20% of men have ever gone for testing. The HIV prevalence is higher in urban areas than rural areas.

The Ministry of Health (MOH) oversees 9 Provincial and 72 District Medical Offices, covering 1828 rural health centers, clinics and hospitals. Strategies to decentralize care from the overburdened hospital clinics and task shift care to other cadres of health care workers in lower level facilities are urgently needed to increase access to care to the remotest areas of Zambia. This requires significant, appropriately focused technical resources directed towards all areas of the HIV prevention and treatment spectrum.

The MOH aims to achieve "universal access to HIV prevention, treatment, care and support services" for pregnant women and children through its national scale-up plan. It is estimated that with 468,000 deliveries a year, 89,000 HIV positive women give birth annually and currently there are approximately 130,000 children under the age of 15 who are living with HIV, of which 40,000 are still in need of ART (National Scale Up Plan for PMTCT 2007-2010).

In FY 2010, MOH will continue to provide national oversight in all program areas to ensure standard guidelines are followed and activities are coordinated all round. Focus will be on the following activities:

i) Systems strengthening

ii) Mentoring

iii) Monitoring and evaluation of PMTCT implementation plan.

iv) Increasing ARV uptake and rolling out more efficacious ARV regimens

v) Improving laboratory services through quality assurance (QA), accreditation and policies

The National TB Program (NTP) has developed a National TB Strategic Plan (2006 to 2011) which has recently been aligned to the Stop TB Strategy and is in accord with the Global Plan to stop TB. Though the strategic plan focuses on all the components of the Stop TB Strategy, in the coming year the four priority areas are:

(i) DOTS Expansion and enhancement:

(ii) Addressing TB HIV, MDR TB and Other challenges:

(iii) Engaging all care providers:

(iv) Advocacy, Communication and Social Mobilization (ACSM) through involvement of affected people and communities.

The Chest Diseases Laboratory (CDL) is Zambia's National Reference Laboratory for Tuberculosis with diagnostic and public health functions. It provides specialized TB diagnostic tests, conducts periodic drug resistance surveys and is responsible for the national QA program for TB smear microscopy.

The MOH Laboratory Service Unit oversees the quality of laboratory services in the laboratory network, It coordinates QA lab activities, generates and disseminates laboratory documents and provides supervisory visits. This unit will collaborate with the MOH IT unit to develop a laboratory information system that is suitable for Zambia.

SmartCare, The MOH Electronic Health Record System, is currently an outpatient medical record designed to capture data for all outpatient medical encounters. The SmartCare system contains data useful for epidemiologic analysis and surveillance as well as active patient data that is used for both clinical care and quality indicators.

SmartCare is a great opportunity for Zambia to integrate Health Management Information Systems (HMIS) from local to national levels and monitor program performance throughout all health sectors, but there needs to be continued leadership from MOH for a number of years, to build the necessary computer skills among all MOH staff to fully realize the extent of the opportunities. Ongoing training and on-the- job skills development through persistent practice, cognitive standards maintenance via certification testing, and oversight of facility performance by district managers who are newly empowered to observe and respond to information in continuously available reports, will be required to assure continuous quality improvement as staff continue to transition from paper operations.

Provincial level managers need to record observations of district utilization of information in all program areas during supervisory visits, and make full use of the provincial view of all HMIS data to monitor and report progress on all programs to MOH. Central leadership must in turn provide increasingly specific, but practical, responsive and timely guidance for using continuous information flow to manage continuous provision of quality services, and to continue to tailor systems to users.

The synergy between STIs and HIV continues to be underscored by a significantly higher HIV prevalence among STI clients, with reports of up to 40-50% in some settings, particularly those with ulcerative STI's. Controlling STIs, through prevention as well as early and effective treatment is therefore a high priority for the country and is one of the main strategies for HIV control advocated by the MOH.

Ministry of Health (MOH) will formalize the MOH ART Technical Team (MOHACTT) which oversees periodical review of technical guidelines for adult and general HIV Care. Bi-annual workshops will be conducted to: 1) Assess peer-reviewed literature and the implications for possible guideline revisions; 2) Formulate corrections and additions to current guidelines as required; 3) Create new guidelines for care and treatment service areas as required; and 4) Review and advise the Medical Council of Zambia on standard operating procedures required for both site and provider ART accreditation. The MOH will disseminate addendums and changes to guidelines in a timely and systematic fashion, including using existing and novel techniques such as distance learning and electronic media. In conjunction with supply chain management partners, MOH will project the impact of guidelines changes on commodities management, logistics, infrastructure, and costs.

MOH will conduct monitoring visits, provide training, develop and disseminate policy and guidelines and participate in national quality improvement efforts. We will provide targeted technical assistance to front line providers, clinics, provincial health managers, and other implementing partners.

We will provide training in Monitoring and Evaluation processes, using SmartCare's cross program capacity to begin to evaluate service integration and referral performance around HIV care in a more concrete manner, and integrating content from more specifically ART oriented reporting systems.

MOH in collaboration with the Pharmaceutical Regulatory Authority, Institute of Human Virology and all the other MOH Implementing Partners will build laboratory capacity to perform surveillance orientated genotypic HIV drug resistance testing, to support management and analysis of data to track level of HIV Drug Resistance.

MOH will provide leadership and support to meetings of health care providers that will focus on review and analysis of electronic data rolling up from the SmartCare Electronic Health Record System on a monthly basis and include training as the need arises. MOH will supervise and train health care providers and managers in data use and quality assurance.

The Ministry will continue to scale-up SmartCare, but with an increased emphasis to ensure implementation, evaluation of, and appropriate response to reports from sites running SmartCare. A special emphasis will be placed on commencing community-based electronic health record (EHR) data collection and use, for initiatives such as community level door- to-door CT.

This will begin with use of paper forms at point of service, electronic entry of forms, and linkage to full EHRs effected subsequently, at nearest health care facility. During FY 2010, however, one or more portable electronic platforms will be tested for candidacy as an immediate data capture device at the point of care.

This experience will inform other areas where there will be benefits in linking community services to facility services, via electronic capture and subsequent or immediate linkage of the community level service. Other areas of community services that might benefit from successful engineering of a more portable linkage to a longitudinal person oriented record system, include home deliveries, home based palliative care, nutrition, and OVC support programs, to mention a few, emphasizing the importance of thinking about integration and multi-purpose capacity as fundamental to evaluation of options and design.

To complement this oversight strengthening, additional counseling and testing (CT) resources have been added to several provincial health office budgets to aid substantial scaling -up of SmartCare CT services to all sites capable of supporting computer-based solutions.

Estimates for 2008 indicated that 85,000 - 120,000 children were HIV-infected in Zambia; of those, 35,000 were in immediate need of anti-retroviral therapy (ART). However, from the onset of the scale-up of ART services in Zambia, children have not been comprehensively addressed; this has resulted in few children accessing the much needed HIV care, support, and treatment services. The Ministry of Health (MOH) in conjunction with its cooperating partners embarked on a scale-up of children accessing care, support, and treatment services for Pediatric HIV. As a result of these concerted efforts, at the end of 2008, over 18, 000 children were on record as receiving anti-retroviral therapy.

The MOH will continue to scale-up access to Pediatric treatment in Zambia and strive to ensure that all children have access to early identification and treatment. The key to this will be:

1) Ensuring partners and front-line health care providers are adhering to the current guidelines including early initiation of infants on treatment. This will include revision of current guidelines and disseminating revised guidelines to all stakeholders followed by monitoring, supervision and mentoring of frontline healthcare providers to ensure appropriate application.

2) Enhancing community involvement and ownership of the program. This will require advocacy for Pediatric HIV care and treatment at community level.

3) We will hold a national level Pediatric HIV symposium to address ongoing changes and challenges to Pediatric HIV care and treatment.

The Ministry of Health will continue to expand, support and provide leadership in the various routine and ad hoc surveillance and survey activities. These activities include the Antenatal Sentinel Surveillance, the Demographic and Health Survey, the Zambia National Cancer Registry, and strengthening the Cancer Diseases Hospital in surveillance and reporting of AIDS-related malignancies. These efforts are among those that enable the MOH to monitor the impact of the joint interventions on the HIV epidemic and its many effects.

In 2010, the Ministry of Health will continue to provide national leadership in the deployment, implementation and use of the SmartCare Electronic Health Record System. As the system is deployed in more broadly, there will be need for continuous maintenance, monitoring and supervision to assure that data is continuously rolled up, to help management make informed decisions at District, Provincial and National levels.

Continuous training of staff at all levels in the maintenance and use of SmartCare is necessary and will have increased emphasis, recognizing that the Ministry has a high turnover of trained staff with less trained staff.

The MOH will continue monitoring and evaluation operations to coordinate data quality assurance and analysis meetings between the Provincial Health Offices and various partners working within the health sector in the country. The M&E Unit of the MOH will also ensure frequent data quality assessments are carried out countrywide to ensure data reported is of integrity and correct.

PMTCT one time plus-up funds are being added to support: Analysis and dissemination of information using Next Generation PMTCT indicators to assess program effectiveness including the impact of COP funding increases for operational costs and one-time plus-up funds.

The MOH will work with the General Nursing Council in the development of the SmartCare curriculum so that the national nursing curricula increasingly reflects the knowledge and skills, as well as the responsibilities and opportunities that come with providing health services in a nation with an electronic health record system.

Specifically, there will be need to address interpretation and use of line-listed patient reports for appointment management and patient follow-up; more efficient identification of various risk profiles based on previously documented information including but not limited to, multiply-at-risk-persons for HIV infection based on prior STI and other object clinical events in addition to using information client may volunteer, at risk pregnancies based on prior pregnancy complications or HIV results from other clinics; to find ART treatment failures risks, and lost to follow-up clients; to use aggregate statistical reports to improve patient care and facility operations; to monitor drug supply and prevent drug and other supply stock-outs; to measure and balance staff workload; to ensure complete and accurate documentation of patient care services in the EHR; to instill the need to review continuously the many other aspects of running a health facility well, which an EHR will enable them to do, and lastly to teach the primary users of the national system that they need to 'own' it and through feedback to MOH, make the system evolve in the most useful directions.

The national STI response and intervention includes the following emphasis areas:

1. Improved case management;

2. Enhanced in-service and pre-service training in syndromic management of STI's with an integrated approach;

3. Supervision and mentoring of primary health care workers;

4. Strengthening monitoring, evaluation, STI surveillance and reporting;

5. Strengthening STI supplies particularly drugs and condom supplies;

6. Improved community participation in prevention, control and early treatment; and

7. Development of synergistic relationships and networks with private sector and stakeholders in STI prevention and control.

In FY 2010, MOH will continue to implement the national STI program through strengthening coordination of partners working in various parts of the country implementing STI activities, through regular annual meetings with all stakeholders and key providers. MOH will ensure that health care providers adhere to the existing guidelines for STI management in order to ensure quality health care. We will provide supportive supervision to provincial levels to improve quality of routine data collected for HMIS, support routine provider initiated CT for STI clients, provide regular updates on evidence based practice that feed into national guidelines and improve the monitoring and evaluation of STI programs.

National PMTCT indicators in 2008 showed an improvement in performance with increase in:

HIV testing among pregnant women from 60% to 70%

ARVs from 39% to 50% in pregnancy

ARVs by HIV exposed infants from 17% to 29%

Cotrimoxazole from 14% to 23% in infants

PCR from 9% to 23% in exposed infants.

Pediatric ART uptake from 12,000 in 2007 to 18,040 in 2008

IN FY 2010 the Ministry of Health will focus on the following activities:

Support overall guideline amendments and implementation through all stakeholders in line with on-going WHO recommendations.

Continue to support and ensure capacity building for PMTCT staff. This is in recognition of the fact that turnover of skilled staff is still a challenge in Zambia

Implement a tool developed to build and maintain quality service delivery and programming at all levels, data recording and reporting and use for planning.

Improve service delivery through data use for planning, utilizing population-based analysis, peer review, sharing and documenting best practices and showcasing successes, addressing bottlenecks, giving technical assistance, and optimizing SmartCare use for program planning.

Coordinate support to training programs (in both pre-service and in-service) to increase coverage of service delivery. This includes new focus on: specific prevention messaging, improved community-based efforts to increase male participation in PMTCT, improved links to early infant diagnosis and improving the rates of provision of accurate electronic health records to patients for the purposes of continuity of care and referral linkages.

MOH shall maintain quarterly data audits and population based review interactive meetings involving all districts, provinces, the Center, and partners in the health sector.

The PMTCT unit will in collaboration with the M&E unit work towards assuring that there is a continuous feedback

The objective of these activities is to strengthen the quality of laboratory testing and services in Zambia through quality assurance, accreditation, policies, and laboratory information system. The following activities are designed to accomplish this objective:

1. CDL will continue to strengthen the national QA program for TB smear microscopy to increase the national coverage down to cover health centers. This will be done in 2 provinces (Southern and Western). We will create a national QA TB database, manage, analyze and disseminate data to the TB lab network. We will enroll in QA program with supranational laboratories, support our staff for further training, maintain laboratory equipment, procure lab supplies, prepare staining reagents and distribute among the TB lab network, and coordinate meetings with TB lab working group ($150,000).

2. The MOH Lab services unit will: a) Develop annual operational plans based on the national strategic plan; b) develop or update, and disseminate national laboratory guidelines, policies, standard operation procedures, bio-safety manuals, and other lab-related documents to its laboratory network; c) develop and implement laboratory accreditation plan; d) oversee the national QA plan for laboratory testing including rapid HIV testing and other clinical laboratory testing; e) meet with partners quarterly to update on the QA and other laboratory-related issues; f) provide on-site supervisory visits to its laboratory network; g) hire two staff dedicated to QA and laboratory accreditation process; h) establish a QA laboratory unit through extension, furnish and equipat MOH Chainama College; and i) organize national QA workshops to disseminate policies and QA data ($400,000). In addition, the MOH will work with Beckton Dickinson to improve quality of phlebotomy and other blood drawing and specimen handling procedures; strengthen needle stick injury prevention, surveillance and Post Exposure Prophylaxis (PEP); and revise existing policies, guidelines, and Standard Operating Procedures (SOPs) for phlebotomy,and PEP ($150,000).

3. The MOH IT and lab service units will continue to identify and evaluate appropriate laboratory information systems software that is applicable for the laboratory network in Zambia. Once it is identified, we plan to train staff and pilot this software on 2-3 selected MOH laboratories. We will procure soft-, hard wares plus other accessories ($150,000).

The MOH notified 47,333 TB cases all forms, in 2008. Among these, 655 were tested for HIV and 68% were positive, 465 on CPT and 41% on ART. In FY 2010, MOH will continue to support its national TB reference laboratory (CDL) in order to reduce TB burden.

MOH will improve the microscopy network infrastructure and its QA systems, develop a safe courier system to transport specimens and implement the national QA systems for TB smear microscopy.

MOH will address TB/HIV, MDR TB and other challenges through implementation of TB/HIV collaboration activities by devising and distributing guidelines, training, supervision support, and monitoring and evaluation. MOH will train health workers in Provider-Iinitiated Testing and Counseling (PITC), MDR TB surveillance, management, and infection control. The MOH will conduct a national TB review to evaluate the program, hold bi- annual TB/HIV data review meetings and quarterly TB/HIV coordinating body meetings and hire a TB/HIV Medical Officer

MOH will strengthen MDR TB Surveillance, engage private practitioners, empower people with TB and communities through information on TB/HIV.

In FY 2010, CDL will conduct the following:

1. Provide specialized TB laboratory diagnostic services to other healthcare facilities including TB culture, drug susceptibility testing by culture and molecular methods, identification of multi-drug (MDR) and extra multi-drug resistance (X-DR), and TB smear microscopy.

2. Develop, print and disseminate a) standard operating procedures for TB culture and sputum smear microscopy), b) TB bio-safety manuals, and c) training materials.

3. Train healthcare personnel for TB smear microscopy and rapid HIV testing using the MOH standard training package and protocols to ensure high quality of TB and HIV diagnosis.

4. Train laboratory personnel in TB laboratory bio-safety and infection control In order to reduce risk of infection among laboratory personnel

5. Procure a fluorescent microscopy and 10 LED microscopes for training and bulk reagents for culture, DST, and microscopy to serve the diagnostics services done at CDL.