The Zambia Integrated Systems Strengthening Program (ZISSP) will focus on supporting health systems strengthening initiatives, selected aspects of facility-level health services delivery, and integrated community-level promotion and service delivery interventions. This five year project builds on experiences from the soon-to-conclude Health Services and Systems Program (HSSP) and adds an explicit and enhanced community component. The new project will operate at the national level, in all nine provinces and in at least 27 target districts. It will be linked to other USG-funded HIV prevention, care and treatment programs. The majority of funding for this project will come from non-PEPFAR accounts including the President's Malaria Initiative (PMI), Family Planning (FP) and Maternal and Child Health subaccounts.

ZISSP will strengthen the ability of the Ministry of Health (MOH) at the national level to plan, manage, supervise, and evaluate delivery of health services nationwide. It will provide additional Zambian staff to the MOH to help resolve difficult challenges facing the health sector, including human resources management capacity, recruitment and retention of skilled health workers, and the need for increased national capacity to oversee the delivery of FP, emergency obstetric care, child health and nutrition, and malaria services. These staff will, in tandem with USG staff, support Technical Working Groups (TWGs) that operate as part of the MOH's coordination mechanisms. Strong support for TWGs encourages meaningful joint planning and discussion of health policies, service coverage information, capacity building, and lessons learned across the country.

ZISSP will increase capacity of provincial health teams to perform technical and program management functions in support of the district health teams. It will provide a clinical care and management skills improvement team in each of the nine provincial medical offices (PMOs). The Clinical Care Specialists (CCSs) will help district and facility staff identify and solve technical problems, provide supportive supervision for key interventions, and, as required, train and mentor district health staff in HIV-related activities, malaria interventions, FP, maternal health, child health and nutrition interventions. The management specialists will coach district and facility based staff in management and leadership skills. The team will assist provincial, district and facility staff to strengthen the management skills needed to translate existing action plans into effective implementation.

ZISSP will improve community involvement in the production of health in targeted districts. It will implement activities targeted at individuals, families and communities to improve their ability to adopt appropriate health promotion and disease prevention behaviors, their capacity to provide appropriate health care services and prevention activities, and their linkages to the formal health care service delivery system. Community level activities will focus on prevention of new HIV infections, prevention education for HIV positive and negative individuals, equity of access to HIV services for males and females, and increased male involvement in health. ZISSP will support community-level service delivery and local organization capacity-building to facilitate sustainability of interventions.

ZISSP will implement a cohesive strategy to identify and address barriers to care, including cultural or economic barriers, misinformation about FP, malaria, maternal neonatal and child health (MNCH) and HIV practices. It will work with USAID's new health communication program to define the kinds of communication materials, methods, and channels that are needed to address these barriers. In most cases, ZISSP will not develop or generate behavioral change communication materials but will disseminate and/or utilize materials developed by other USG or partner programs in conformity with plans and strategies developed for country-wide implementation.

ZISSP will strengthen the involvement of traditional, faith-based, and other opinion leaders as change agents for health by building technical and programmatic management competencies of community groups for sustainable mobilization activities. It will also support the MOH's efforts to develop a Community Health Worker (CHW) Strategy which will define the set of services to be provided by the CHW, develop a standardized training curriculum and address issues of compensation and retention.

ZISSP will ensure that service delivery and other activities are effectively integrated at appropriate levels of the health system in target districts through joint planning and in-kind activities with partners. It will collaborate with partners to deliver integrated services for FP, MNCH, malaria, nutrition, and HIV/AIDS. Key targets for activity integration are other USG- and partner-funded activities. Integration will link HIV/AIDS, health, and related social services; develop systems and networks for coordination and referral within and between the community, district, and provincial levels of the health system; and lead to coordinated use of resources to maximize health benefits.

The contractor will develop a performance monitoring plan that enables tracking and attribution of higher level outcomes to project activities. These indicators will supplement those contained in the USG-defined indicator set.

This activity relates to those in ZPCT II, USAID's new health communication project, and Centre for Infectious Disease Research in Zambia (CIDRZ).

Lack of skilled health care workers is the most significant factor hampering the scale-up of antiretroviral therapy (ART) services in Zambia. This project is designed to increase access to ART services through financial and technical assistance to the retention of at least 119 skilled health workers (doctors, nurses, clinical officers, laboratory personnel, and others) in rural areas where the human resource crisis is most acute. This activity will also support the CCSs, placed in each PMO, in monitoring, and coordination of ART scale-up in hospitals, health centers, and mobile posts.

This activity will assist MOH to support implementation of the performance assessment tools and the minimum quality assurance standards for HIV services, and to strengthen supervisory services that focus on case management and quality improvement. As an extension of the work done by HSSP, this activity will collaborate with the Medical Council of Zambia to strengthen and monitor the accreditation mechanism for certification of private ART providers to ensure that the services and treatment protocols meet national standards. This, however, will be done with the view of graduating MCZ from receiving direct assistance.

An important component of this activity will be to strengthen the management capacity of district health offices and health facilities for planning, implementation, monitoring, and evaluation of key health interventions, including HIV/AIDS services.

To ensure sustainability, this activity will be implemented within the existing Government of Republic of Zambia (GRZ) structures and plans. The activity will facilitate the development and dissemination of appropriate standard guidelines, protocols, plans, and budgets. The tools and guidelines will be disseminated for use by relevant MOH structures. The activity will also assist GRZ in implementing a facility-level quality improvement program. All the components of this activity will be integrated into the existing programs and structures to ensure continuity of services after the activity concludes.

This activity is linked to the new health communication program and addresses both Zambian and PEPFAR's goals for increasing the number of people who know their HIV status and the provision of quality TC information. It is also tied to other program areas including MC, adult and pediatric treatment, and AB.

This activity will support the health communication program in the implementation of a comprehensive behavioral change communication (BCC) approach that is based on research and complements the NPS.

The facilitation of trainings for lay counselors and peer educators are to be conducted through this activity and materials developed by the health communication program will be used. At the same time, the activity will engage traditional, religious, and community leaders to encourage Zambians to seek testing and know their HIV status while attracting more men as counselors. Community volunteers will promote individual, couples', and family counseling, as well as increased male involvement and responsibility in health issues. This activity will also support the integration of TC promotion activities in FP and MNCH services, thereby increasing efficiency and expanding potential audience size. Furthermore, the activity will strengthen linkages between TC and care and treatment services.

Technical assistance will be offered to neighborhood health committees (NHCs), community-based organizations (CBOs), faith-based organizations (FBOs) and non-governmental organizations (NGOs) to expand access to TC and related services via mobile outreach programs.

Provincial CCSs will assist district staff in the training and provision of supportive supervision to community volunteers engaged in TC activities. The CCSs will also provide technical supportive supervision to district health office staff to improve their management skills and to health facilities that provide TC to assure quality of services. The CCSs will also assist the district health offices to plan for TC activities and ensure that these activities are included in the district action plans. This will ensure district ownership and sustainability of activities

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This activity relates to the adult treatment and counseling and testing activities.

This activity will support local organizations that deliver community-level health services. These services include the community component of Integrated Management of Childhood Illness (C-IMCI) which is provided by CHWs. The revised C-IMCI training modules include a component on HIV and training of CHWs in C-IMCI will equip them with skills necessary to manage sick children in the community and appropriately refer children for testing, counseling, and commencement of ART. CHWs will be linked to prevention of mother to child transmission (PMTCT) activities conducted by other USG- and partner-funded programs and they will be used to track HIV infected and exposed infants and children including those lost to follow up.

This activity will partner with the new USAID/Zambia health communication program to implement health education interventions as stipulated in the National Pediatric HIV/AIDS Communications Framework. The activity will support the MOH's efforts by improving parents/caregiver's knowledge of treatment program availability and adherence, and providing materials to health care workers which will enhance their ability to counsel parents of HIV positive children. This activity will also engage community, religious and other opinion leaders to advocate for pediatric ART services.

Provincial CCSs will provide supervision, monitoring, and coordination of ART scale-up in hospitals, health centers, and mobile posts. They will also mentor health facility staff and facilitate their training in pediatric ART in collaboration with GRZ and other USG- and partner-funded programs.

This activity will support the integration of pediatric ART services at appropriate levels of the health system and ensure that districts include pediatric ART in their action plans. This will ensure district ownership and sustainability of the activities.

This activity will be linked to the new ZPCT II and current activities carried out by the Centers for Disease Control and Prevention (CDC) and CIDRZ.

Review of district action plans has revealed that planning is not sufficiently based on evidence and sound epidemiological data. This activity will assist the MOH to support and supervise districts and hospitals to improve data quality and enhance utilization of data for informed decision making. This will be accomplished by strengthening competencies of the PMO in supervision and technical backstopping for Anti-Retroviral Therapy Information System (ARTIS) which has now been integrated into the revised Health Management Information System (HMIS). PMO and MOH headquarters staff will be trained for this purpose. Additionally, the activity will provide support to the MOH to develop an integrated package of HMIS reference materials for HIV/AIDS services.

This activity will collaborate with CDC to aggregate facility data using SmartCare and facilitate overall integration into the HMIS. It will also collaborate with WHO and European Union (EU), which currently provides HMIS support to MOH.

To ensure sustainability, the activity will be implemented with the MOH, Provincial Data Management Specialists, and other partners (ZPCT II, CDC, CIDRZ, EU, and WHO) to develop, disseminate, and maintain the HIV/AIDS reporting systems which are integrated into the overall Zambian government HMIS.

This activity will link with the human resources for health activity.

This activity will assist the MOH to strengthen policies and systems that support HIV/AIDS services in general planning and human resource (HR) planning and management. In the area of planning, the activity will support the MOH to produce technical updates for the annual health sector planning meetings based on priorities and objectives of the National Health Strategic Plan.

This activity will assure that provincial and district health offices can better plan, manage, supervise and evaluate health services at district and community levels. It will improve the skills of district level managers and planners to use data for planning especially as it relates to HIV/AIDS services to ensure efficient use of scarce resources. It will also build and strengthen linkages between PMOs and technical offices of the MOH at national level; PMOs and the District Health Management Teams (DHMTs); DHMTs and health facilities; and health facilities and the community. Furthermore, ZISSP will support PMOs and DHMTs to coordinate stakeholders working in the provinces through organizing meetings, workshops and other means of increasing discussion and collaboration among those involved in delivery of HIV/AIDS, malaria, FP and MNCH services.

In the area of HR planning and management, the activity will support the MOH and PMOs to strengthen technical support supervision to districts in HR planning and management. Specifically, 72 district and 22 hospital action plans will be reviewed to determine the level of inclusion of HR requirements. Technical support supervision will be provided to districts that do not comply with the HR planning guidelines.

To ensure sustainability, this activity will be implemented within the existing GRZ structures and plans. ZISSP will support the MOH to provide leadership in planning, thereby facilitating the incorporation of these activities into the GRZ portfolio. The activity will collaborate with the MOH Planning Unit to strengthen and further decentralize the district planning process. The PMOs will be encouraged to play a stronger role in the review, monitoring, and evaluation of their respective district action plans.

This activity will relate to USAID/Zambia's new health communication program and the Zambia Prevention, Care and Treatment Partnership (ZPCT II). It links with other sexual prevention, counseling and testing, and adult treatment activities.

This activity will retain skilled health workers, including doctors, nurses and clinical officers in remote areas of Zambia through the ZHWRS. These health workers will provide a pool of health personnel who are available to participate in the roll out of male circumcision (MC) services. This activity will collaborate with other USG-funded activities to facilitate the training of health workers in the provision of MC services using World Health Organization (WHO) training materials in accordance with national standards. Provincial CCSs will mentor junior doctors and clinical officers and provide technical support supervision to facilities offering MC services to ensure that quality surgical procedures are provided to minimize post operative complications.

This activity will collaborate with the new health communication program in implementing a national MC awareness campaign that includes messages regarding TC with emphasis on couples' testing, the importance of knowing one's HIV status and the advisability of MC for men who have tested negative, the need to use a trained service provider, post-procedural care and abstinence during wound healing, and stigma/discrimination reduction. The initial target audience will be sexually active men, particularly HIV negative males in HIV discordant sexual relationships. Key messages will also be developed for other key audiences including women, parents, policy makers, community leaders, and HIV positive men and women. Additionally, this activity will work with community volunteers and leaders to advocate for MC as a means of preventing HIV acquisition in men and indirectly in women.

To ensure sustainability this activity will be conducted within existing GRZ structures. The activity will support local organizations that are involved in community-level service delivery thus building local capacity.

This activity links with other sexual prevention (OP), biomedical prevention (male circumcision), testing and counseling (TC), and pediatric and adult treatment activities. Abstinence/be faithful (AB) activities support Zambian and PEPFAR goals through a comprehensive approach that promotes better health seeking behavior.

This activity will be linked with the USAID/Zambia health communication program and will support the National Prevention Strategy (NPS), which was developed in 2008 by the MOH in collaboration with the National HIV/AIDS/STI/TB Council (NAC) and other local partners, to reverse the tide of HIV/AIDS by intensifying prevention activities nationwide. It will support the new health communication program in carrying out community and mass media campaigns targeting youth to adopt the healthy behavior of abstinence, being faithful and post exposure prophylaxis in the event of rape as a means to prevent HIV transmission. Messages targeted at adults will focus on mutual fidelity among couples and avoidance of multiple concurrent sexual partnerships.

This activity will engage traditional, religious, and community leaders and other role models who will assist in reaching out to youth and spreading appropriate AB messages. Additionally, this activity will support local organizations involved in community level service delivery including peer education programs for in- and out-of school youth. Youth friendly corners in health facilities will be revitalized and supported as these are vital channels through which messages on abstinence and delayed sexual debut may be delivered to the youth.

Provincial CCSs will mentor and provide supportive supervision to district and health facility staff providing HIV prevention services. They will assist district staff in training of and provision of supportive supervision to community volunteers engaged in AB activities. The CCSs will also assist the district health offices to plan for AB activities and ensure that these activities are included in the district action plans. This will ensure district ownership and sustainability of activities.

The main drivers of the HIV epidemic in Zambia include multiple or concurrent sex partnerships, in which consistent condom use tends to be low, transactional sex practices, gender based violence (GBV), and cultural practices that impact health negatively such as alcohol consumption. This activity supports Zambian and PEPFAR goals for appropriately targeting most at-risk populations (MARPs) with interventions promoting partner-reduction, GBV prevention, and condom use.

This activity will be linked to the new health communication program and support the development of mass media campaigns to promote reduction of concurrent partnerships and transactional sex through raising risk awareness. Messages on correct and consistent condom use will be complemented with in-depth information on behavior change and the development of respectful, gender-equitable relationships between men and women. Traditional, religious, and community leaders will be encouraged to serve as role models for men to affect change in male norms and behaviors that undermine risk avoidance efforts. These leaders will assist in creating awareness on the negative health impact of traditional practices such as sexual cleansing, dry sex, GBV, and initiation ceremonies through radio and community outreach efforts. Issues related to alcohol will be integrated in all communication interventions.

This activity will facilitate the training of community volunteers including CHWs, home based care providers, and safe motherhood action groups (SMAGs) to enable them to deliver OP messages in their communities. Community volunteers will promote healthy behaviors such as seeking prompt treatment of sexually transmitted diseases and rape cases. It will support integration of OP activities in FP and MNCH service, thereby increasing efficiency and expanding potential audience size.

Provincial CCSs will assist district staff in training and the provision of supportive supervision to community volunteers engaged in OP activities. The CCSs will also assist the district health offices to plan for OP activities and ensure that these activities are included in the district action plans. This will ensure district ownership and sustainability of activities.