Zambia continues to face an acute shortage of health care personnel which severely constrains the scale-up of the provision of anti-retroviral therapy (ART). The single most limiting factor to the scale-up of ART is the lack of trained providers - physicians, nurses, clinical officers, laboratory personnel, and others. The priorities of the National Human Resources Strategic Plan include recruitment, deployment, and retention of health workers. The Health Services and Systems Program's (HSSP) role in the ART program is to support the Ministry of Health (MOH) to retain critical staff in areas of greatest need, and provide support in the area of performance improvement and quality assurance. In FY 2005, HSSP recruited and placed nine Provincial Clinical Care Specialists to enhance ART coordination and quality assurance; initiated the recruitment of 35 doctors under the rural retention scheme; and developed the minimum criteria for the certification of providers and ART sites.

In FY 2006, HSSP's focus was on continued support to Clinical Care Specialists (CCSs) and placement of medical doctors to serve in remote areas; recruitment of non-physician health care workers for the retention schemes; recruitment of nurse tutors; and the development of minimum criteria for certification of providers and ART sites. Since modalities of recruitment and management of the doctors' retention scheme are just being finalized by HSSP and MOH, and the retention of other cadres and the nurse tutors is just getting started in FY 2006, results on retention will not be available until FY 2007. Agreement on modalities of recruitment and management of doctors' retention scheme has been slow with the dissolution of the Central Board of Health - the managers of the existing retention scheme; further, there was an upward adjustment of the package by the Ministry of Health necessitated by the sudden appreciation of the local currency against the US dollar.

In FY 2007, HSSP will continue to address the human resource crisis and increase access to HIV/AIDS services. HSSP will pay salaries and provide maintenance and fuel expenses for supervision trips to the CCSs in each of the nine Public Health Offices (PHOs). The CCSs will continue to support district hospitals and clinical HIV/AIDS programs and to strengthen referral and continuity of care within health facilities. They will also provide technical backstopping and supervision to junior doctors implementing HIV/AIDS activities in the provinces. They will work with the MOH CCSs to coordinate ART scale-up in hospitals and health centers, serve as provincial ART trainers, and monitor and supervise the private sector ART provision. CCSs will assist other USG programs in the provinces, including Zambia Prevention, Care and Treatment Partnership (ZPCT) (#8885), Health Communication Partnership (#8901), and Centre for Infectious Disease Research in Zambia (#9000).

These nine CCSs will serve as the major conduit for provincial coordination and quality assurance efforts.

The MOH continues to face severe human resource shortages, especially in the country's most remote districts. Currently, the Government of the Republic of Zambia (GRZ's) rural retention scheme supports 80 medical doctors, funded by the Netherlands. HSSP will provide ongoing support to the MOH for the retention of 23 additional physicians by covering the $805/month hardship allowance and $3,000 one-off payment per doctor for house renovation. This scheme is designed to maintain quality ART services for 4,000 patients in 23 of the most remote districts. The intention was to support 35 doctors; however, the number has been reduced to 23 due to the appreciation of the local currency and alignment of the monthly hardship allowance to the MOH revised figures. The previous level of the hardship allowance ($250/month) was too low to meaningfully attract and retain the physicians in remote areas. The $805 hardship allowance is a lump-sum. No other allowances, such as education allowance in the previous arrangements, will be provided. The Antiretroviral Therapy Information System (ARTIS) will track the assignment of physicians and monitor increases in the number of patients receiving ART services in their districts.

The GRZ's ART policy promotes a multi-disciplinary approach to ART delivery, requiring the availability of other health workers in addition to physicians. Shortages of these other health workers have led the MOH to expand its retention scheme. Therefore, HSSP will provide support for the retention of 63 health workers (22 nurses, 22 clinical officers, nine pharmacists/pharmacy technicians, and 10 lab technicians) required to provide ART

services in 10 of the 38 remote districts. Each health worker retention package, including hardship allowance, will cost $480 per month. The shift from original numbers of health workers in FY 2006 to be supported under this scheme and the monthly hardship allowance of $200/month is due to the alignment with MOH revised figures. This staff will contribute to achieving the national ART target and will be tracked through the ARTIS. It is expected that there will be 15% increase of trained staff in remote (C) and the most remote (D) districts for delivery of HIV/AIDS services. Districts fall in one of four categories ranging from city to rural (A being urban and D the most remote) determined by state of deprivation including state of access roads and other infrastructure and availability of banks and gas stations.

An acute shortage of nurse tutors has led to poor quality of training, fewer courses, and the closure of four nurse training institutions. HSSP will provide ongoing support to the MOH's nurse tutor retention initiative designed to ensure availability of tutors in all 21 nurse training institutions for HIV/AIDS service delivery training. A total of 33 nurse tutors (reduced from 105 due to alignment of the monthly hardship allowance to MOH revised figures and the kwacha appreciation) will be retained in disadvantaged training institutions. HSSP will support a retention package of $640/tutor/month including a hardship allowance (increased from $300 in FY 2006). As a result of this retention program, tutor shortages will be reduced, trainees will receive higher quality, more comprehensive HIV/AIDS training, and more nurse training institutions will remain open. HSSP support will contribute to 80% retention of nurse tutors (currently at 70% per annum). Retained nursing tutors will play a central role in the incorporation of HIV/AIDS training modules into the nursing school's curriculum.

HSSP will continue support to the MOH and Medical Council of Zambia to establish an accreditation system of ART facilities and ART providers in public and private practice. In FY 2006, HSSP developed an ART accreditation plan and supported MOH consensus-building on ART standards. In FY 2007, HSSP will begin to roll out the accreditation system to districts. It is expected that all ART sites will be accredited by end of 2008.

HSSP will continue to work closely with the Centers for Disease Control, ZPCT, and the World Health Organization to support the MOH in improving services for HIV/AIDS patients in health facilities. HSSP and other partners will support the ongoing integration of HIV/AIDS services into MOH Performance Assessment tools and develop minimum quality assurance standards for HIV/AIDS services.

To ensure sustainability, HSSP works within the existing GRZ structures and plans. HSSP facilitates the development and dissemination of appropriate standard guidelines, protocols, plans, and budgets. HSSP also assists GRZ with the implementation of a facility-level quality improvement program. All project activities are integrated into the existing programs and structures to ensure that continuity of services remain after the program concludes.

In the area of strategic information, Health Services and Systems Program (HSSP) will develop and strengthen an ART (anti-retroviral therapy) data collection and reporting system to facilitate overall program management. This activity also links to HSSP's human resource development component under the Other/Policy Analysis and System Strengthening program area (#8793). HSSP will continue to link to other partners who are working in service provision and strategic information. The project will work under the direction of the Ministry of Health (MOH) and coordinate with the Zambia Prevention, Care and Treatment (ZPCT) Partnership (#8885), Centers for Disease Control (CDC), and other partners to develop standard data elements, collection, and reporting tools. HSSP will rely on partners such as Catholic Relief Services/AIDSRelief (#8828), Center for Infectious Disease Research Zambia (CIDRZ) (#9001), and ZPCT (#8885) to train and disseminate these standards and tools to facility staff.

During FY 2004, technical assistance was provided to develop the national ART Information System (ARTIS) in provincial and tertiary level hospitals. In FY 2005, HSSP provided technical assistance focused on: rolling out the paper-based ARTIS to all public health facilities providing ART; integrating ART data into the Health Management Information System (HMIS); developing an inventory of existing prevention of mother to child transmission (PMTCT) and counseling, testing, and care (CTC) indicators; and producing a Health Statistical Bulletin that includes ART Information. 72 district and nine provincial data managers were trained in the paper-based ARTIS thus achieving 100 percent coverage.

During FY 2006, HSSP's role was to assist the Ministry of Health (MOH) and partners to ensure that all HIV/AIDS service delivery data are reported through the MOH national HMIS. An ongoing challenge is to integrate public and private sector HIV/AIDS data on PMTCT, CTC, and tuberculosis (TB) into the mainstream HMIS. To address this challenge, HSSP will continue to assist the MOH to revise current HMIS data collection and reporting tools to integrate CTC, PMTCT, and TB services.

In FY 2007, HSSP will support all 72 districts' efforts in utilization of information to plan for HIV/AIDS services, develop quarterly and annual reports based on action plans, and provide support to routine information management system to enhance data quality. A total of 182 staff (72 District Health Information Officers, 72 Managers of Planning and Development, nine provincial data managers, 18 Clinical Care Specialists, and 11 Hospital Information Officers) will be trained in information utilization to achieve national coverage. It is expected that there will be improvement in the quality of action plans, implementation, and services in general.

It has been observed from the district action plan review that planning is not based on evidence or sound epidemiological data, hence the need to focus on data utilization at service delivery level.

As part of the sustainability plan, HSSP works closely with the Ministry of Health, Provincial Data Management Specialists, and other partners (ZPCT, CDC, CIDRZ, and the World Health Organization) to develop, disseminate, and maintain the HIV/AIDS reporting systems which are integrated into the overall Government HMIS. HSSP's mandate is to ensure integration of ART, PMTCT, CTC, and TB into the mainstream HMIS and build capacity of the health workers and Data Managers in the use and maintenance of the developed information systems. Seventy-two district and nine provincial data managers have since been trained in the paper-based ARTIS and an additional 182 staff will be trained in information utilization.

The Health Systems and Services Program (HSSP) will build on FY 2005 and FY 2006 activities to continue working with the Ministry of Health (MOH) at the national level to strengthen policy and systems that support HIV/AIDS services in the following areas: 1) planning; 2) human resource planning and management (HRPM); 3) pre- and in-service training; and 4) HIV/AIDS coordination among partners. HSSP will work with other USG partners and cooperating partners including United Nations (UN) agencies supporting HIV/AIDS service delivery to strengthen policy and systems and similar coordinating activities.

In the area of planning, HSSP will continue to provide routine support to the MOH to: develop annual technical updates for annual health sector planning based on priorities and objectives of the National Health Strategic Plan; compile a summary of national health priorities integrating information on HIV/AIDS; conduct a desk review of 72 district action plans; and help ensure that HIV/AIDS activities, resources, and priorities are appropriately reflected in overall health sector plans during the annual planning process. By linking with HSSP's Strategic Information activity (#8795), district level managers and planners will improve their skills in using data for planning especially as it relates to HIV/AIDS information. Skills will be honed in costing and budgeting of HIV/AIDS-related services to ensure efficient use of scarce resources.

In the area of HRPM, HSSP will provide ongoing assistance to the MOH in pre- and in-service training to ensure that all training is coordinated among partners and that skills enhancement is linked to strategic information as well as anti-retroviral (ARV) service provision.

In FY 2007 HSSP will work with the MOH to disseminate HIV/AIDS human resource (HR) planning and projection guidelines and to plan for HR requirements to deliver a minimum package of HIV/AIDS services. HSSP will support Provincial Health Offices (PHOs) to assess needs and develop 72 district HR staffing plans. It is expected that plans and standards will be operational in 72 districts in FY 2008. Under the five-year HR plan, HSSP's role will be to support selected strategies which include strengthening of the HR planning, management, and development systems at all levels.

In the area of pre-service training HSSP will continue to support MOH to integrate HIV/AIDS and related teaching modules into pre- and in-service programs, develop training materials and teaching guides, and train 160 teachers from Chainama College (Clinical Officers) and nursing schools on the revised curricula. The curriculum for the Clinical Officer General has already been developed. The next step is to revise the Nurses' and Physician's curricula. Twenty-one organizations (the MOH and all the 20 training schools for clinical officers, doctors, and nurses) will receive technical assistance for HIV-related institutional capacity building, thus achieving 100% coverage. It is expected that HIV/AIDS and related modules will be fully integrated into pre- and in-service training in FY 2008.

HSSP assisted the MOH to develop and launch a five-year, in-service training coordination plan, national training guidelines, and establish Human Resource Development Committees (HRDCs) in FY 2006. The focus for FY 2007 is to support PHOs and districts to plan for in-service training for HIV/AIDS services. It is expected that 35 district HRDCs will plan and coordinate anti-retroviral therapy (ART) and other HIV/AIDS-related training using the national training guidelines.

Finally, HSSP will continue to assist the MOH and partners (USG and cooperating partners including UN agencies) supporting HIV/AIDS service delivery to coordinate activities among themselves and with the private sector. Activities will include: providing technical assistance to the Sector Wide Approach program (SWAp) to ensure integration of HIV/AIDS services; and developing MOH proposals to global HIV/AIDS initiatives targeted at ART scale-up. Specifically, HSSP will continue to support the MOH to: mobilize resources through the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria; develop an annual report of Global Fund resource inflows and utilization; maintain a partners' database for HIV/AIDS service delivery; undertake a Mid-Term Review of the National Health Strategic Plan (NHSP) and HIV/AIDS Strategic Plan; and assist MOH to disseminate and ensure use of the Basic Health Care Package at different levels of the health care delivery system.

To ensure sustainability, HSSP works within the existing government structures and plans to develop and disseminate appropriate standard guidelines, protocols, strategic plans, and budgets. HSSP also assists the government to build the capacity of training schools through curricula development and dissemination. To avoid duplication of efforts, HSSP implements project activities in collaboration with other USG partners and the World Health Organization.