The Zambia Integrated Systems Strengthening Program (ZISSP) works with the MOH at the national, provincial, district, and community levels to strengthen skills and systems for planning, management, and delivery of health services for HIV/AIDS, malaria, family planning, nutrition, and maternal newborn and child health. This project operates in all the nine provinces and in 27 focus districts. ZISSP applies a whole systems approach to strengthen the health system at each level. It particularly seeks to addresses gaps in the four of the health systems building blocks: service delivery, health workforce, information, and leadership and governance. In addition to PEPFAR funds, ZISSP receives funding from the Presidents Malaria Initiative (PMI), family planning (FP), maternal and child health and nutrition subaccounts.ZISSP seconds 37 staff members to MOH national and provincial offices to help the ministry to develop better strategies, tools, and systems for planning, management, supervision, and evaluation of the delivery of health services. ZISSP seeks to build the skills of ministrys personnel, and focuses particularly on strengthening high-impact public health programs for HIV, FP, emergency obstetric and newborn care (EmONC), child health and nutrition, and malaria. ZISSP Clinical Care Specialists are helping the provincial health offices (PHOs) and district health offices (DHOs) to establish, train, and mentor multi-disciplinary clinical care teams. Management specialists are building skills for planning, budgeting, management, supervision, and reporting. The community component of the program will continue to work primarily with district health management teams and communities to improve the interface between the health system and the community.

ZISSP will strengthen the quality of HIV/ART data collection, use, and reporting to support HIV program management at the facility, district, and province. ZISSP will rely on standard data elements, collection, and reporting tools already developed by the predecessor Health Services and Systems Program (HSSP) in collaboration with other partners including Catholic Relief Services, Center for Infectious Disease Research in Zambia (CIDRZ), and Zambia Prevention Care and Treatment Partnership (ZPCT II). The project will train health facility staff to use the data consistently for planning, performance assessment, and technical support supervision.

The project will work under the direction of the MOH and coordinate with ZPCT II and Centers for Disease Control and Prevention (CDC) to conduct data audits. The intent of the audits is to improve the quality and utilization of information to plan for HIV/AIDS programs and to strengthen quarterly and annual progress reports that link clearly to the district and facility action plans. In addition, the audits strengthen the routine information management system to enhance data quality.

ZISSP participants in the district annual action plan process have observed that many plans are not based on evidence or sound epidemiological data. Management specialists seconded by ZISSP in each province will work with the provincial health office staff to improve data quality and utilization at service delivery level.

As part of the sustainability plan, ZISSP works closely with the Ministry of Health, Provincial Data Management Specialists, and other partners (ZPCT II, and CIDRZ) to maintain and strengthen HIV/AIDS reporting systems that are integrated into the national health management information system HMIS. As the CCSs work with districts to train health facility staff in quality improvement through the performance improvement approach, they will focus on building capacity to analyze data in order to identify and solve problems.

In 2012, ZISSP will mentor MOH personnel in provinces, districts, and facilities to use the new planning handbooks for the province and the community that ZISSP helped the MOH to develop in 2011. These handbooks intend to strengthen planning for HIV/AIDS and other health services including malaria, FP, MNCH, and nutrition. The project will also mentor new provincial and district level planners. ZISSP trained these planners in 2011 on the MOH planning process in order to prepare them to lead development of the annual plan with the Provincial Medical Officer.

In FY2012, ZISSP will work with the MOH to strengthen policy and systems that support HIV/AIDS services in the following areas: 1) health services planning; 2) human resource planning and management as well as health worker retention; and 3) management and leadership skills development. In the area of planning, ZISSP will continue to assist the MOH to develop technical updates which identify the priorities for the annual plan and align with the National Health Strategic Plan. The project will develop a summary of national health priorities, including HIV/AIDS, and then assist the provinces and districts to tailor the national priority statements to guide participants in the lower level planning launch meetings.

ZISSP will assist the PHOs to use resource mapping tools to improve distribution of resources across program areas including HIV/AIDS. The ZISSP clinical care and management specialists will support the PHOs to develop the provincial statistical bulletins, which will be used for action planning and program monitoring. The ZISSP management specialists will work to strengthen governance systems and improve accountability. To do this, ZISSP will train non-financial managers and accountants in government financial procedures.

In collaboration with its subcontractor BRITE, ZISSP will provide MOH personnel from the center, provinces, and districts with management and leadership training that has been tailored to Zambia. The training is designed to increase the capacity of provincial and district management teams to perform technical and program management functions.

ZISSP will collaborate with CSH and the Partnership for Integrated Social Marketing (PRISM) within the National HIV/AIDS Strategic Framework to develop and disseminate messages to promote male circumcision. ZISSP will adapt key messages from the national mass media HIV prevention campaigns to create materials for use at the community level.

ZISSP and CSH will support the MOH to develop a community BCC framework to guide the development, implementation, and assessment of community BCC campaigns, outreach efforts, materials and capacity building efforts. This activity will also implement a distance radio learning program as a tool for capacity building.

ZISSP will support communities and local organizations to develop and implement locally-led BCC programs. The project also works in 27 target districts to help community groups identify and advocate for health needs as active participants in the health planning process. In FY2012, ZISSP will use results of a recently completed community mapping study to develop strategies to strengthen community engagement in health planning and implementation of effective BCC programs.

ZISSP will assist districts and facilities to train community volunteers including community health workers (CHWs), SMAGs, CBD, lay counselors, and others to enable them to deliver messages on male circumcision. ZISSP CHCs will help facilities to mobilize communities to participate in MOH national health events and traditional events which include key messages on HIV prevention. The CHCs will assist the district health offices to design male circumcision activities and ensure that these activities are included in the district action plans and budgets.

ZISSP works with the MOH and CSH to develop communication strategies which are adapted for mobilization of communities to intensify HIV/AIDS prevention activities nationwide. At community level, ZISSP works in the 27 target districts to help community groups to advocate effectively for their health needs as active participants in the health planning process. ZISSP also supports communities and local organizations to develop and implement locally-led BCC plans.

In FY 2012, ZISSP will use results of the community mapping study which it recently conducted in selected districts to develop strategies which will strengthen community engagement in health planning and implementation of effective health BCC programs at community level. The activity will facilitate the training of community volunteers including community health workers (CHWs), SMAGs, community based distributors (CBD), lay counselors, and faith based organizations (FBOs) to enable them to deliver messages on AB.

ZISSP will collaborate with CSH and the health promotion unit of the MOH to design and disseminate BCC messages that will promote behavior change with a focus on abstinence among the youth and the unmarried, and being faithful to one un-infected partner for the married individuals.

The project will engage traditional, religious and other community leaders as change agents in the community to spread AB messages and promote healthy behaviors. This activity will be linked to the adolescent reproductive health technical area of ZISSP and support the development of the adolescent communication strategy and revitalization of youth friendly corners in health facilities as these are vital channels through which messages on abstinence and delayed sexual debut can be delivered to the youth.

ZISSP will also implement the grants program where NGOs and FBOs implementing community interventions will be a channel for the various AB activities.

ZISSP CHCs, in collaboration with the district health promotion officers, will mentor and provide supportive supervision to district and facility staff in HIV prevention services.

ZISSP will collaborate with CSH, Corridors of Hope II, and PRISM to support the 2008 National Prevention Strategy (NPS). Together these partners seek to increase the number of people who know their HIV status and to support quality testing and counseling services and information.

CHCs will assist districts and facilities to engage key actors at the local level to promote demand for HIV counseling and testing services. These actors include: NHCs, SMAGs, CBDs, Lay Counselors, and Tuberculosis Supporters. These influential community members will create awareness of the importance of knowing ones HIV status.

ZISSP will strengthen SMAGs by integrating counseling and testing information with the MNCH activities to enable promoters to create awareness of CT in the community. The project will support the implementation of a community BCC framework which will be developed in collaboration with CSH. Through its CHCs, ZISSP will work to assure that districts include CT activities in the district plans and budgets.

ZISSP will support communities and local organizations to develop and implement locally-led BCC programs to increase demand for CT services. The project also works in 27 target districts to help community groups identify and advocate for health needs as active participants in the health planning process. In FY2012, ZISSP will strengthen community engagement in health planning and implementation of effective health BCC programs at community level.

ZISSP will engage traditional, religious, and community leaders who will be trained in BCC, leadership skills, advocacy, and management of change, and oriented to HIV/AIDS and other health programs. Traditional ceremonies occur every year in most districts and they attract huge crowds of both local communities and others from outside the areas. These ceremonies provide an opportunity to update the health knowledge of the traditional leaders and allow for provision of CT and other services as deemed appropriate by the MOH. The leaders will be engaged to act as role models in championing positive behaviors and sensitizing the community members to go for counseling and testing

ZISSP will collaborate with CSH and the Partnership for Integrated Social Marketing (PRISM) within the National HIV/AIDS Strategic Framework to develop and disseminate messages that address the main drivers of the HIV epidemic in Zambia. ZISSP will adapt key messages from the national mass media HIV prevention campaigns to create materials for use at the community level. The OP messages focus on reducing risk by avoiding multiple and concurrent partnerships and transactional sex, as well as through correct and consistent condom use.

ZISSP will also engage traditional, religious, and community leaders to promote healthy behaviors in the community and also create awareness on the potential risks associated with some traditional practices such as sexual cleansing, dry sex, Gender Based Violence (GBV), and initiation ceremonies through radio and community outreaches.

ZISSP and CSH will support the MOH to develop a community BCC framework to guide the development, implementation, and assessment of community BCC campaigns, outreach efforts, materials and capacity building efforts. This activity will also implement a distance radio learning program as a tool for capacity building for SMAGs as well as a link between families and the community.

ZISSP will support communities and local organizations to develop and implement locally-led BCC programs. The project also works in 27 target districts to help community groups identify and advocate for health needs as active participants in the health planning process. In FY2012, ZISSP will use results of a recently completed community mapping study to develop strategies to strengthen community engagement in health planning and implementation of effective BCC programs.

ZISSP will assist districts and facilities to train community volunteers including community health workers (CHWsS), SMAGs, CBD, lay counselors, and others to enable them to deliver messages on OP. ZISSP CHCs will help facilities to mobilize communities to participate in MOH national health events and traditional events which include key messages on HIV prevention. The CHCs will assist the district health offices to design OP activities and ensure that these activities are included in the district action plans and budgets.

Although more than 90% of pregnant women in Zambia attend at least one antenatal care visit, only 46% of births are attended by a skilled provider and the maternal mortality ratio stands at 591 per 100,000 live births (DHS 2007). The main causes of maternal mortality are postpartum hemorrhage, infections (including HIV) and hypertensive disorders. ZISSP will work with districts and facilities to establish and strengthen Safe Motherhood Action Groups (SMAGs) in order to increase the focus on maternal newborn and child health and mobilize communities to utilize these services. SMAGs will promote early (first trimester) antenatal care attendance, counseling and testing of pregnant women and their spouses, appropriate nutrition during pregnancy, use of insecticide treated nets and malaria prophylaxis during pregnancy and iron and folate supplementation. ZISSP will assist the MOH to test new training aides that support the SMAG trainers at the province, district, and facility level to impart key messages to SMAG members. The SMAG members in turn use the same materials to impart key messages in their communities. In each province and in the 27 target districts, ZISSP will assist the PHOs and DHOs to conduct training of trainers for staff that will train SMAG members at the facility level. In target districts, ZISSP will also provide support for facility-level SMAG members to train SMAG members in each of the zones that surround a facility. The project proposes to assist the MOH to improve reporting on SMAG outreach activities through the facility and district.

Zambia faces an acute shortage of health care personnel. The lack of trained providers is one of the biggest obstacles to the scale-up of quality ART services. ZISSP supports the MOH to retain critical staff in underserved areas and supports performance quality improvement.

ZISSP provides financial and technical assistance to the ZHWRS in order to attract and retain 119 health workers (doctors, nurses, and clinical officers) in rural areas where the human resource crisis is most acute. These added staff members contribute to achieving the national ART targets.

ZISSP seconds one clinical care specialist (CCS) to each of the nine Provincial Health Offices. The CCSs assist the PHOs, to develop annual plans, mentor health workers, monitor program performance, and coordinate ART scale-up in hospitals, health centers, and mobile clinics. The CCSs support district hospitals and health center HIV/AIDS programs and help to strengthen referral and continuity of care within health facilities. They provide technical backstopping and supervision to junior doctors implementing HIV/AIDS activities in the provinces.

The project will work closely with the Zambia Prevention Care and Treatment II Partnership ZPCT II and other stakeholders to finalize clinical mentorship guidelines and the health worker training materials. ZISSP will then use these materials to form multi-disciplinary clinical care teams (CCTs) in all the districts and provinces. Over time, the district CCTs will begin to lead mentoring activities in the facilities. Provincial CCTs will support the districts. This process will enable provinces and districts to expand and sustain clinical mentoring activities.

ZISSP will also contribute to the ART program by supporting the MOH to develop national quality improvement guidelines. The guidelines will help facilities to strengthen the quality of services. ZISSP will support provinces and districts to revamp the quality improvement committees and establish quality improvement activities in health facilities. The project will conduct training of health workers in the new QI package which will enable them to implement quality improvement programs using the performance improvement approach (PIA).

ZISSP CCSs will assist provinces and districts to strengthen the skills of facility-level providers in order to improve pediatric treatment services. This effort addresses the continuum from the antenatal period to testing and treatment of pediatric HIV. ZISSP will support the MOH to mentor and supervise healthcare workers in early infant diagnosis (EID.)Provincial CCSs will continue to 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 the MOH and other USG- and partner-funded programs.

ZISSP will help the MOH to nurture greater ownership of the transport referral system by health facilities, districts, and provinces.

ZISSP proposes to partner with the MOH and United Nations Childrens Fund (UNICEF) to design and implement an expanded child health corner concept that seeks to enable children to access all childhood services, including testing and treatment for HIV, in an integrated manner.

ZISSP will also work with the MOH to strengthen Integrated Management of Childhood Illness (IMCI) to ensure that the HIV elements are correctly implemented. ZISSP will train and mentor healthcare workers in IMCI-HIV to enable them to appropriately refer children. ZISSP will support the MOH to address Nutrition-HIV linkages and train and mentor healthcare workers in this area.

ZISSP will train NGOs and FBOs that deliver community-level health services including Community-based Integrated Management of Childhood Illness (C-IMCI) which includes HIV. The project will continue to assist districts to train community health volunteers (CHVs) in C-IMCI to equip them with skills necessary to manage sick children in the community and appropriately refer children for testing, counseling, and commencement of ART.

ZISSP will strengthen the focus in districts and facilities to link CHVs to prevention of mother to child transmission (PMTCT) activities conducted by other USG- and partner-funded programs. These programs can use CHVs to track HIV infected and exposed infants and children including those that are lost to follow-up.