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2014 ANNUAL PROGRESS REPORT PERFORMANCE OF GLOBAL FUND – SUPPORTED HIV, TB AND MALARIA PROGRAMS MANAGED BY UNDP AS PRINCIPAL RECIPIENT IN ZAMBIA : April 2, 2015
2014 ANNUAL PROGRESS REPORT
PERFORMANCE OF GLOBAL FUND – SUPPORTED HIV, TB AND MALARIA PROGRAMS MANAGED BY UNDP AS PRINCIPAL RECIPIENT IN ZAMBIA :
April 2, 2015
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About this report The Global Fund partnership with Zambia starts since its inception in 2002. The Fund has been one of major partners to the Government of Zambia in the national response to HIV and AIDS, TB and Malaria programs. The country has benefitted from the Global Fund grants under Round 1, 4, 7, 8 and 10 and through the recently awarded new funding model (NFM) for HIV/TB and Malaria.
With UNDP acting as temporal Principal Recipient of the Global Fund grants, on behalf of the Ministry of Health, Zambia mobilized more than US$ 352 million between 2011 to 2013.
This report presents a snapshot of the status of implementation of Global Fund supported HIV, TB and Malaria in the year 2014- only for grants for which UNDP is the PR and implemented by the MoH, MSL, CHAZ and WFP as Sub-Recipients.
It is important to make it clear , from the onset, that the performance reported in this report are of national nature- not attributed to the Global Fund resources alone - but a result of concerted interventions and contribution of resources from the GRZ and all the partners supporting national response to HIV and AIDS, TB and Malaria in Zambia.
Evidently, however, the Global Fund support has contributed remarkably to scaling-up of high impact interventions, notably, HTC, PMTCT, VMMC, ART, TB and Malaria programs as presented in this report.
A Disclaimer The views expressed in this report are those of the author(s) and do not necessarily represent the views of the United Nations Development Programme (UNDP).
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Table of contents
Acronyms ...................................................................................................................................................... 4 Executive Summary ..................................................................................................................................... 6
1. Introduction: The Global Fund Support to Zambia ........................................................................... 12 1.1 Resources mobilized between the years 2011-2014. ............................................................... 12
1.2 Global Fund Projects Implementation Arrangements, Under UNDP PR-Ship ................... 13
2.0 Financial and Programmatic Performance of SSF-HIV/AIDS Grant .............................................. 15 2.1 Financial Performance SSF-HIV/AIDS Grant ......................................................................... 15
2.1 The scope of Global Fund HIV/AIDS Supported Activities .................................................. 15
2.2.2 HIV/TB Integrated Services, including HIV-positive TB patients treated with ARVs: ....... 20
2.2.3 Expanding the provision of ART to Prevent Mother-To-Child Transmission - PMTCT ..... 23
2.2.4 Reinforcing prevention by expanding HIV testing and counselling: ................................ 26
2.2.5 Expanding voluntary medical male circumcision (VMMC): ............................................... 30
3. Status at a glance: The Performance of core TB indicators, 2014 ................................................... 34 3.1.1 TB case detection and notification:......................................................................................... 35
3.1.2 TB case management to improve treatment success rate: .................................................. 37
3.1.3 Addressing MDR-TB as a public health crisis .......................................................................... 39
3.1.4 Accelerating the response to TB/HIV: .................................................................................... 39
4. Malaria Grants: Finance overview as at end of December 2014 .......................................................... 46 4.1 Overall Performance Of The Malaria Programs ................................................................. 47
4.1.1 Procurement of Insecticide Treated Mosquito Nets by UNDP ......................................... 47
4.1.2 Planning for and implementation of ITNs distribution to homes of end users ................ 48
4.1.3 Transportation, Storage and Handling of Insecticide Treated Mosquito Nets ................ 49
4.1.4 Actual distribution of ITNs to end users .............................................................................. 51
5. Progress in implentation of Capacity Development and Transitional Plan, 2014 ........................... 56
5. Key Results, Changes and Success Stories across GF Functional Areas......................................... 59
6. Challenges experienced in Implementation of the Grants, and Responses ................................... 61
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Acronyms
ACTs. Artemisinin-based Combination Therapies
AIDS Acquired Immune Deficiency Syndrome
ART Antiretroviral therapy
ARVs Anti-retroviral
CHAZ Churches Health Association of Zambia
DOTS Directly Observed Treatment, Short-Course
FNDP Fifth National Development Plan
GRZ Government of the Republic of Zambia
HIV Human Immune-deficiency Virus
HMIS Health Management Information System
IPT Intermittent Presumptive Treatment
IRS In-door Residual Spraying
ITN Insecticide-Treated Net
LLITNs Long Lasting Insecticide Treated Nets
MDGs Millennium Development Goals
MDR Multi-Drug Resistance
MoH Ministry of Health
NAC National HIV/AIDS/STIs/TB Council
NASF National AIDS Strategic Framework
NCPI National Commitments Policy Index
NGOs Non-Governmental Organisations
PEPFAR United States President’s Emergency Fund for AIDS Relief
PLWHA People Living with HIV/AIDS
PMI United States President’s Malaria Initiative
PMTCT Prevention of Mother to Child Transmission
RDTs
SSF
Rapid Diagnostic Tests
Single Stream of Funding
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STIs Sexually Transmitted Infections
TB Tuberculosis
UA Universal Access
UN United Nations
UNAIDS Joint United Nations Programme on AIDS
UNDP United Nations Development Programme
UNGASS United Nations General Assembly Special Session (typically referring to the watershed one on HIV and AIDS in 2001)
UNICEF United Nations Children's Fund
USAID United States Agency for International Development
VCT Voluntary Counselling and Testing
WHO World Health Organisation
ZDHS Zambia Demographic and Health Survey
Executive Summary
The latest data gathered from around the country tell a story of clear success. Sustained investments by the GRZ the Global Fund and other partners to expand access to prevention, care and treatment of HIV and AIDS, TB and Malaria have led to record numbers of lives being saved over the last year.
This report presents a snapshot of the status of implementation of Global Fund supported HIV, TB and Malaria in the year 2014- only for grants for which UNDP is the PR and implemented by the MoH, MSL, CHAZ and WFP as Sub-Recipients.
The performance reported in this report are of national nature- not attributed to the Global Fund resources alone - but a result of concerted interventions and contribution of resources from the GRZ and all the partners supporting national response to HIV and AIDS, TB and Malaria in Zambia.
Antiretroviral therapy initiation, retention and adherence: More people than ever who are living with HIV are being helped to live longer, healthier and more productive lives. Sustained progress in scaling up access to HIV treatment has put within reach the goal of providing antiretroviral therapy to 671,066 people by 2014. The performance in 2014, of 625,546 adults aged 15+ years receiving ART has doubled from the
323,357 base-line in 2010 . Reports from the last four years have shown increase from 371,658 in
2011 to 446,841 reported in 2012, and had reached 530,702 in 2013. Similarly, for the children aged
0-14, results show upward trends from 21,050 in 2010 to 30,785 in 2011; 34, 084 in 2012 to 49,168 in
2013.
However, access to treatment varies considerably within and between provinces, with especially
poor coverage for children. By end of 2014, HIV treatment coverage for children (about 52%)
remains far below the adults (84%).
Although the number of children receiving antiretroviral therapy increased by about 45% in
comparison to 2012, the pace of scale-up was substantially slower than adults. According to 2013
AIDS Global Report produced by UNAIDS, ART coverage for children (34% (31-39%)) remained half
of coverage for adults 64% (61-69%) globally.
The gain in access to ART, especially among the adults, is largely a results of policy and strategic shifts in treatment guidelines implemented from 2014, including starting on treatment HIV positive people with 500 CD4 count threshold from 350; implementation of Option B+ for PMTCT and systematic enrolment into treatment - regardless of their CD4 counts- of HIV positive children, discordant couples and HIV/TB co-infected patients. The number of site providing ART increased from 564 in 2012 to 592 in 2014, with GF supporting
renovation and creation of 39 sites. Throughout the year 2014, the country had stable and
regular supply of ARVs and OIs, with supplies from the GRZ, GF, USG, and other partners.
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However, isolated cases of stock-out of ARVs at certain health facilities were reported, due to
existing gaps in supply chain management systems from the central MSL, through sub-national
drugs deports to service delivery points. As a result, on average, 4% of ART sites experienced
stock-out of first line and second line ARVs at some points during the last quarter of 2014.
Expanding the provision of antiretroviral medicines to prevent mother-to-child transmission Ensuring a mother living with HIV has access to HIV treatment not only has health benefits for
her, but also for her family.
By end of 2013, 83% of all 1956 health facilities were providing PMTCT. The national PMTCT
coverage was recorded at 95%. According to Global AIDS Report, 2013, Zambia is among 4 priority
countries that have already met the goal of providing ART to 90% of pregnant women living with
HIV.
The uptake of PMTCT services has increased over the last five years. With contribution of GRZ and partners, including the Global Fund, USG, UN agencies, the number of pregnant women receiving ART for PMTCT has increased from 54,597 in 2010 to 80,607 in 2011 and reached 84,351 in 2012. In 2013, the number dropped slightly from last year to 75,165. Strategic gains of PMTCT in Zambia have been as a result of reinforcing prevention of new HIV
infections; helping women living with HIV avoid unintended pregnancies; ensuring that pregnant
women have access to HIV testing and counselling; and that those who test HIV positive have
access to ART for PMTCTV during pregnancy, delivery or breastfeeding; and providing HIV care,
and treatment support for women and children living with HIV and their families
Expanding HIV testing and counselling: Increased access to antiretroviral treatment in Zambia can be partly attributed to a growing number of people who want to know their HIV status. The number of people who opt for an HIV test has increased consistently from 1,636,182 in 2010 to 1,866,775 in 2011; reaching 2,138,961 in 2012 and, was reported at 2,231,974 in 2013. In 2014, the number had hit 2,712,237 (reports from 95% of HFs). The MoH has strengthened the integration of HTC services with VMMC, PMTCT, TB and MCH (family planning) services. Western, Luapula and Eastern Provinces have the highest number of people using HCT services, with at least 2 in 10 people having tested for HIV in 2014. The Provinces that have lower trends are Lusaka, Cooperbelt and Southern. Scaling-up voluntary medical male circumcision (VMMC): According to the ZDHS-2013/14, HIV prevalence is slightly higher among non-circumcised men (12 percent) than those who have been circumcised (10 percent). The VMMC program is scaling up rapidly, currently, provided in 472 static health facilities. In 2013, 294,446 MC were performed, with 60% of these being within the target age range 15-49 years of age, and 39% in the age group of 1-14 years old. In 2014, the number reduced to 199,057. The Program intends to revise national targets to align with the current trends of MC needs according to age groups. The VMMC program in Zambia has clearly demonstrated that only when a comprehensive set of HIV prevention initiatives is rolled out at a national scale, with sufficient access to, and frequent use of, quality services, will countries realize the optimal prevention returns.
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Support to Health systems strengthening through training of health care workers.
This grant has supported training of a total of 559 health care workers in 2012, and in 2013, 465 health workers were trained in PMTCT, adult ART and paediatric ART. This year, a total of 1,704 health care workers and 175 community health workers were trained in IMCI, PMTCT, adult and paediatric ART.
Stock status and stock-out of key pharmaceutical products
The pointers to notable progress in scaling- up of prevention care and treatment of HIV and AIDS
are largely in regular and un-interrupted supply of ARVs, OIs, HIV test kits Lab reagents and other
pharmaceutical products. The Global Fund has contributed significantly in procurement and
supplies of these products in the country, including supporting operational costs at MSL to
improve storage and distribution to service delivery points.
Diagnosis and treatment of TB
The central pillars of TB control include finding, treating and preventing TB in order to avoid TB deaths and reduce transmission. The country has noted a reduction in the number of cases being notified. Globally, the rate of new TB cases has been falling worldwide for about a decade. Likewise, in Zambia the notification rate for all forms of TB was 284/100,000. This shows a further reduction from 313/ 100,000 reported in 2013 and 347 per 100,000 reported in 2012. According to the TB prevalence survey (2014) preliminary results, Zambia has TB case notification
rate of 482/100,000 (386-578). This estimate implies that there are huge cases that were either
not diagnosed, or diagnosed but not reported to national TB programmes (NTPs). Major efforts
are needed to close this gap. Expanded uptake of ART could have influenced, to certain extent,
the declining numbers of HIV positive people developing TB.
Further, in 2012, the country notified 12,645 New Smear Positive TB cases, and the number
dropped to 12,198 cases in 2013. In 2014, 12,070 cases were notified.
The NTP will need to reinforce a multifaceted TB screening programme focusing on high-burden areas high-risk populations, which included mines and prisons, household contact tracing, HIV counselling and testing campaigns, community mobilization, door-to-door enquiry in areas with a high burden of smear-positive TB. The NTP has started rolling out the use of more sensitive TB diagnostics such as Xpert MTB RIF,
the use of fluorescent microscopy and Line Probe Assay. So far 29 Xpert MTB RIF machines have
been deployed to various health facilities in the country, and the UNDP has ordered 15 more
Xpert MTB RIF expected before end of April 2015.
TB case management and improvement of treatment success rate:
Zambia implements, universally, the DOTS strategy, and hence, the universal coverage of TB
services in all the public sector- with TB anti-drugs being provided free of charge. The Private
sector facilities also provide TB treatment.
Since 2010, the program reports have shown a stable treatment success rate - ranging between
87% and 88%.
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In 2014, the treatment Success Rate has increased to 90% from 88% recorded in 2013. The country
has so far met the 2015 target as set in the revised Global Plan to Stop TB 2011 - 2015. This
performance is largely attributed to uninterrupted supply of TB drugs and the wide coverage of
the TB DOTS treatment strategy in about 2,000 health facilities across the country.
Addressing MDR-TB as a public health crisis: The numbers of MDR-TB cases on category IV enrolled for second line treatment Ndola Central Hospital (NCH) and the University Teaching Hospital (UTH) were reported to be 73 patients, the annual target was 80 patients. The current centralised treatment model where only UTH and NCH initiate and follow-up patients and also provide in-patient and out-patient care has not been very effective. In order to address this, the NTP is now moving towards implementation of a decentralised model of care to the provincial level and district level. This will reduce the distances and will facilitate quick initiation on MDR-TB treatment and patient monitoring. With the funding from the GRZ and the Global Fund, there has been a consistent supply of anti-TB
drugs in the country.
Accelerating the response to TB/HIV: There has been improved collaboration between the NTP and the HIV/AIDS programmes which has reinforced the implementation of TB/HIV collaboration activities. An increasing number of health care workers are adhering to the treatment guidelines and are offering Diagnostic Counselling and Testing to 99% of all TB patients. The top priority is now to increase coverage of ART for HIV-positive TB patients towards the 100% target, as is to expand coverage of TB preventive treatment among people living with HIV. The program has progressively made improvements over the last three years increasing the HIV testing rate among TB patients from 87% in 2012, to 91% in 2013 and reached 93% in 2014. Out of those who tested for HIV, 61% were HIV positive and 73% of all the HIV/TB co-mobility cases were enrolled into HIV care, and increase from 66% reported in 2013 and 60% reported in 2012.
In order to improve treatment outcomes, the program has trained care providers in case management of TB/HIV co-infected patients including the training of treatment supporters on the management of side effects.
Procurement and supply of TB drugs:
The country has sustainable stocks of 1st line anti-TB drugs at the central warehouse, with an
average of 20 months of stock and approximately 3 months at service delivery points. This is
inclusive of buffer stocks. For second line drugs, the stocks were not adequately covered for
Kanamycin 1g and Levofloxacin 250mg tablets as there was approximately 3 months of stock at
the MDR TB sites, with upcoming orders by UNDP for Kanamycin 1g (995 boxes of 50 vials) and
more funding under the GF NFM HIV/TB grant to be managed by the MoH.
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Responding to the burden of Malaria:
The main activity under this grant was the procurement and distribution of LLITNs to contribute
towards the country target of universal coverage (100%) of LLITNs, according to the national
malaria control strategic plan 2011-2016.
The commitments made for the year 2014, were the GF ( 4,641,147 ITNs); USG/ PMI (540,000
ITNs); GRZ (200,000 ITNs) and DFID (800,000 ITNs).
Based on these commitments a total of 6,369,387 ITNs were distributed in the country. Out of
these 4,810,300 nets (76%) were procured by UNDP and 4,725,357 were already distributed by
end of 2014 by MoH and CHAZ in the 6 provinces as follows: Eastern Province (1062917);
Southern Province (1,036,939); Central Province (921,461); Muchinga Province (465,942);
Northern Province (754,971); North Western Province (483,127)
Status of implementation of MoH Capacity Development and Transition Plan to the PR-ship:
UNDP in collaboration with the MoH have successfully completed the implementation of Phase 1
of the detailed Capacity Development and Transitional Action Plan ( CDTP) which was jointly
developed by UNDP and MOH in consultation with the key stakeholders, eventually approved by
the Global Fund ( GF) and implemented since July, 2012. This plan has brought about sustained
positive change in the MOH’s ability to manage GF grants and enabled the MoH to resume the
Principal Recipient (PR) role since January 2015 when the NFM grant with the portfolio of about
$240 million was signed to finance HIV/TB and Malaria programmes for two years period ending
2017.
The UNDP in collaboration with MoH, MCDMCH and MSL have submitted the Phase 2 of the
capacity development plan, focusing on MoH’s GF sub-recipient management, institutional and
program management , financial management and monitoring and evaluation capacity of
MCDMCH, and strengthening MSL’s storage and distribution systems.
Challenges and immediate responses:
Inadequate funding: The country experienced resource gaps to ensure a balanced match between prevention, care and treatment of the three diseases. While the GRZ tripled its annual contribution for ARVs from USD 12 Million in 2011 to USD 35 Million from 2013, the in-country partner support did not increase from the 2013 levels, hence there is still financial gap based on the needs between 2014 and 2017.
Forecasting and quantification of health items: The country experienced problems of forecasting reliable quantities of health products (ARVs, test kits, ACTs, RDTs, TB drugs… etc.) largely due to non-availability of accurate data on consumption levels at Health facilities. This is, indeed, due to the fact the national supply chain systems, managed by MSL, ends at the District level.
Regular changes in treatment Guidelines: The evolution of clinical services, especially around PMTCT and ART, has resulted into changes in treatment protocols. This has, and will continue to require alterations of orders placed (ARV drugs, HIV test kits, etc.). Existing Therapeutic committees within the MOH are being strengthened while the capacity to monitor the quality of
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commodities coming into the country, both by the PRA, through the National Quality Assurance Laboratory and MSL at facility level.
Programmatic/M&E risks: While commendable progress was made to upgrade the functioning of health management information systems (HMIS), including revision and printing of HMIS tools, DHIS.2 roll-out and training of all Health Information Officers at central MoH, Provincial and Districts; Data sources for the outcome and impact indicators rely heavily on donor supported resources. These include the DHS, PMTCT study, Sentinel Surveillance Survey and other operational programme-specific studies. Lack of resources and sometimes failure by the partners to honour commitments has hindered the completeness of these surveys and, subsequently delays in release of results/findings - when they are needed to inform policy orientation and strategic planning.
Human Resources for Health: Inadequate levels of HRH (trained and quantity) at different levels, particularly in rural services delivery points. Low staffing levels in the main implementing units at MoH and MCDMCH, coupled with competing priorities, is the major cause of slow rate of some program implementation
The MOH in collaboration with partners are working together to improve the capacity of health care workers at different levels, through training.
Financial Management of Cash and Imprest under GF grants: The MoH will need to reinforce full function of NAVISION for all grants directly managed by MoH, and improve cash and imprest management.
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1. Introduction: The Global Fund Support to Zambia
The Global Fund partnership with Zambia starts since its inception in 2002. The Fund has been one of major partners to the Government of Zambia in the national response to HIV and AIDS, TB and Malaria programs. The country has benefitted from the Global Fund grants under Round 1, 4, 7, 8 and 10.
In 2013 Zambia further benefitted from the GF interim new funding for TB and Malaria to ensure continuity of essential services. Subsequently in 2014, the country was awarded two grants, one for HIV/TB and the other for Malaria under new funding model (NFM)
1.1 Resources mobilized between the years 2011-2014. With UNDP acting as temporal Principal Recipient of the Global Fund grants, on behalf of the Ministry of Health, Zambia mobilized more than US$ 352 million between 2011 to 2013. These gains in resources mobilization have helped the country to ensure that has less interruption of essential HIV, TB and Malaria services. Table 1 Resources mobilized from the Global Fund 2011-2014, by disease component
Status of Active Grant Portfolio by end of December 2014 Total US$ Mobilizes
2011-2014 TB grant Malaria grant HIV/AIDS SSF
Approved Budget 15,174,213 37,123,387 156,509,071 387,918,261
Disbursed from GFATM
12,855,382 35,446,881 130,099,401 350,736,730
% already disbursed in-country
85% 95% 83% 90%
Grants end date June 2015 December
2015 August 2016 N/A
Source: UNDP/PMU, March 2014.
The progress made in the mobilization and negotiations of funding, and implementation of these grants was made possible largely due to strong coordination by the MoH, UNDP and with support from the cooperative partners. The oversight leadership of the CCM, and good working relationships and cooperation from the Global Fund Country Team contributed remarkably to success achieved in implementation of Global fund-financed grants.
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1.2 Global Fund Projects Implementation Arrangements, Under UNDP PR-Ship
Key players Role Played Main roles and responsibility
United Nations Development Programmes (UNDP)
Principal Recipient (PR) In close collaboration with the MoH, elaborate and negotiate with the GF to have the grant’s work plans and budget, procurement plan and performance framework to have the grants approves and signed. The Principal Recipient is fully accountable for financial and program management of the GF grants, including procurement of pharmaceutical, non-health items and monitoring, evaluation and reporting on the performance of the grants. Strengthening the capacity of the Ministry of Health with plans to hand over the PR-ship to the Ministry. Details of project implementation arrangements, including financing modalities are outlined in in the PR and SR agreement for MoH and MSL, respectively
Ministry of Health (MOH)
Main Sub Recipient (SR)
Coordinate and ensure efficiency and effectiveness in programmatic and financial implementation of GF support programmes. The MoH has a PMU, set- up exclusively to oversee the program design, planning and coordinating implementation of GF projects. The MOH/PMU plays a key role in ensuring implementation of the work plan co-signed between the MoH and UNDP through engaging the MoH, and MCDMCH departments responsible for delivery of HIV, TB and Malaria programs. The MoH submits, quarterly, request of funding to UNDP through advance cash transfer (ACT) or requests for advance payment/support (RDP/RDS); and is accountable for all the funding disbursed by the UNDP. The MoH/PMU produces quarterly financial and programmatic progress reports to the UNDP, in line with the SR agreements.
Ministry of Community Development Mother and Child Health (MCDMCH)
Implementing Primary Health Care Programs
Coordinates implementation of Community based and Primary Health Care programmes supported under the grants. Funding to implement activities is currently received through the MoH. In the current SSF grants, allocation of resources was made to support capacity development of the MCDMCH to be able to take the sub-recipient role in implementation of the GF grants.
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Key players Role Played Main roles and responsibility
Church Health Association of Zambia (CHAZ)
Signed an SR agreement with UNDP to implemented ITNs distribution
CHAZ managed the distribution of ITNs in Southern and North western provinces.
Medical Stores Limited (MSL)
Sub-Recipient Storage and Distribution of Pharmaceutical and Health Products to the Service Delivery Points. Details of project implementation arrangements, including financing modalities are outlined in the UNDP and MoH agreement
Zambia Country Coordination Mechanism (CCM)
Oversight of the Global Fund Projects
Plays key oversight role over the PR and the SRs in ensuring that the country access to the waves of GF funding; and once grants are received by the PR, the CCM provided oversight guidance to ensure that activities are implemented as planned, that results are being reported, and programs are meeting intended targets. The CCM membership draws from the GRZ, UN agencies, Local and International NGOs, and Civil Society.
Cooperating Partners in Health
Technical Support and co-financing Health Programmes
Play important roles in co-financing of health programs, including pharmaceutical, health products and equipment to the Ministry to ensure national targets outlined in the NHSP and disease – specific NSPs are met. They also provide technical support, including membership to the MoH technical working groups; support training of Health care workers, and participate in programme review meetings, to mention but some.
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2.0 Financial and Programmatic Performance of SSF-HIV/AIDS Grant
2.1 Financial Performance SSF-HIV/AIDS Grant
Status of Active Grant Portfolio by end of December 2014 Total US$ Mobilizes
2011-2014
TB grant Malaria grant HIV/AIDS SSF
Approved Budget 15,174,213 37,123,387 156,509,071 387,918,261
Disbursed from GFATM
12,855,382 35,446,881 130,099,401 350,736,730
% already disbursed in the country
85%
Cumulative Expenditure by end of December 2014
62,529,060.92
2.1 The scope of Global Fund HIV/AIDS Supported Activities
This project, a Single Stream of Funding (SSF) for HIV and AIDS , with a grant portfolio of US$
156 million, is intended to contribute to reduced HIV transmission and AIDS mortality through
scaling up prevention, treatment, care and support services to people infected and or affected
by AIDS.
The Scope of Funding under this grant is mainly Procurement of ARV drugs (first and second line adult and pediatric drugs); Support implementation of PMTCT, including roll-out of option B+ by train of service providers to deliver PMTCT; Voluntary Medical Male Circumcision (VMMC); HCT( train service providers to deliver HCT services); Blood safety and universal precaution; Strengthen procurement and supply management; strengthening national M&E and health management information system (HMIS); Strengthen the health system capacity for Public Financial Management; capacity development of the MoH to manage Global Fund grants as PR, as well as the MCDMCH and MSL, and support program management and administration related costs
Table 2: Status at a Glance: Performance of Key HIV-related Programmatic Indicators
Note: These results were verified by the GF/LFA in March 2014
Core output Indicators Year of performan
ce
Intended Targets
Actual Result % achieveme
nt
Trend of Results
2014
Overall grant performance 2013 A2
2014 A2
# of people counselled and tested for HIV
2013 2,485,720 2,231,974 89
2014 2,951,793 2,712,237 92%
# of HIV-infected pregnant 2013 92,715 74,142 80%
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Core output Indicators Year of performan
ce
Intended Targets
Actual Result % achieveme
nt
Trend of Results
2014
Overall grant performance 2013 A2
2014 A2
women who received ARV drugs for PMTCT
2014 94,847 68,820 73%
# of male circumcised 2013 270,528 294,466 109%
2014 297,581 199,057 67%
# of adults with advanced HIV infection on ART
2013 517,184 530,702 103%
2014 569,527 625,546 110%
# of children aged 0-14 with advanced HIV infection on ART
2013 29,053 34,084 117%
2014 42,115 45,520 108%
% of TB/HIV Co-infected patient put on ART
2013 70% 66% 94%
2014 80% 73% 91%
Number of ART sites 2013 564 (2012) 582 (2013) N/A
2014 N/A 592 N/A
# of health care personnel trained in PMTCT, IMCI and paediatric ART
2013 315 344 109%
2014 1,994 1,704 85%
# of community health care workers trained as adherence supporters in paediatric, PMTCT and adult ART
2013 125 121 96.8%
2014 250 175 70%
% of health facilities reporting no stock-out during the last month for the first line ARV drugs
2013 100% 96% 96%
2014 100% 96% 96%
Source: MoH/HMIS , February, 2015
2.2 Progress in the Performance of HIV/AIDS supported programs:
2.2.1 More people living with HIV know their status and are receiving antiretroviral treatment
The latest data gathered from around the country tell a story of clear success. Sustained investments in access to antiretroviral therapy by the GRZ, the Global Fund, USG and other
partners have led to record numbers of lives being saved over the last years. The remarkable increase in access to life-saving ART continued in 2014. Sustained progress in scaling up access to HIV treatment has put within reach the goal of providing antiretroviral therapy to 671,066 people by 2014. However, access to treatment varies considerably within and between provinces, with especially poor coverage for children.
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Reports show a consistent annual increase in the number of adults receiving ART from 323,357 in 2010 to 371,658 in 2011 and 446,841 reported in 2012, and the number reached 503,702 in 2013. In 2014, the number rose to 625,546. For children aged between 0-14 years, reports in the last three years, similarly, shows upward trends from 21,050 in 2010 to 30,785 in 2011; 34, 084 in 2012 and had reached 49,168 in 2013. In 2014, the number was reported at 45,520.
Figure 2 : Trends in the number of children and adults receiving ART 2010-2014.
The gains in access in enrolment and retention of people on ART has been possible due to regular
supply of ARVs and OIs drugs in the country through the support of the GRZ, the Global Fund,
USG and other partners.
Throughout the year 2014 the country had stable and un-interrupted regular supply of ARVs.
However, isolated cases of stock-out of ARVs at certain health facilities were reported. On
average, 96% of all ART sites experienced no stock-out of first line and second line ARVs. The
number of site providing ART increased from 564 in 2012 to 592 in 2014
During the reporting period, the MoH and MCDMCH in collaboration with partners started the implementation of new ART guidelines which has expanded antiretroviral treatment eligibility criteria, including starting on treatment HIV positive people with 500 CD4 count threshold from 350; implementation of Option B+ for PMTCT and systematic enrolment into treatment - regardless of CD4 counts all HIV positive children, discordant couples and HIV/TB co-mobility patients.
Source: MoH/HMIS , February, 2015
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Zambia has also endorsed implementation of ART tasks shifting where nurse are now certified as
prescribers to provide ART. This strategy has helped to link prevention and treatment services to
both mothers and their children. Currently, PMTCT services are implemented in 83% of all 1956
facilities in the country.
Figure 3: Proportion distribution of the total number of people receiving ART by end of 2014, by
sex, adults and children.
Source: HMIS/MOH, February 2015 While sustained progress in scaling up access to HIV treatment has put within reach the goal of
providing universal coverage of antiretroviral treatment; access to treatment varies considerably
within and between provinces, with especially low coverage for children.
Figure 4 : Distribution of number of people receiving ART by Provinces, 2014
Source: MoH/HMIS, February, 2015
58,141
130, 939
25,766
15,990
24,830
87,618
16,238
64,425
42,230
175,679
0 20000 40000 60000 80000 100000 120000 140000 160000 180000 200000
Eastern
Copperbelt
Northern
Muchinga
Luapula
Southern
North Western
Central
Western
Lusaka
Number of peope currently on ART
19
Fewer deaths from AIDS-related illnesses have transformed societies: more people, regaining
their health, are returning to work and taking care of their families.
A cohort of patients who were initiated on ART between Jan to December 2013 , and were retained during the period Jan to Dec 2014 was followed, retrospectively, in 203 ART sites to establish those that were alive and still on ART by end of December 2014, twelve (12) month after initiation on antiretroviral treatment. The data shows that (85.42%) of the patients enrolled were still alive and active on treatment. The trends for the previous years have been 76.5% in 2011 to 80% in 2012, and rose slightly up to 81% in 2013.
However, the gap between people who can access treatment and people in need, especially among the children is still very large . With the recent shifts in treatment policy and strategies, this treatment, coupled with demand for treatment as prevention, the needs for antiretroviral treatment will increasingly outstrip availability.
Figure 5 : Trends in the coverage of ART services and rate of survival and retention on art after 12 month of treatment.
Source MoH/ Spectrum and HMIS, February 2015
By end of 2014, HIV treatment coverage for children (about 52%) remains far below the adults (84%). According to 2013 AIDS Global Report produced by UNAIDS, ART coverage for children (34% (31-39%) remained half of coverage for adults 64% (61-69%) globally. What has driven a drop in ART coverage among the adults? Comparing to the results reported in 2013, the percentage of adults receiving ART has dropped between 86% reported in 2013 to 84% in 2014. This is largely attributed to expanded eligibility as a result of recent national policy and strategic shifts in improving scale-up of care and treatment of people with advanced HIV , including 500 CD4 count eligibility thresholds from 350, implementation of Option B+ for PMTCT and systematic enrolment into treatment - regardless of CD4 counts- of HIV positive children, discordant couples and HIV/TB co-infected patients.
0
20
40
60
80
100
2011 2012 2013 2014
% survival and retention on treatment at 12 month on ART
% of eligible patients receiving ART
20
Why lower coverage for the Children? The failure to expand access to early infant diagnosis, especially in rural settings, is an important reason explaining why HIV treatment coverage remains much lower for children than for adults. There is, further, limited number of health care providers trained and authorized to prescribe paediatric ART mainly at primary health care level, the low coverage of provider initiated testing and counselling, and parental stigma. There are strategies in place to increase ART coverage for the paediatrics and children The new ART treatment guidelines rolled out by the MoH and MCDMCH in 2014 provides that all
the HIV positive children are eligible to start ART irrespective of their CD4 counts or clinical stage.
Zambia has endorsed implementation of ART tasks shifting where nurse are now certified as
prescribers to provide ART. This strategy will help link prevention and treatment services to both
mothers and their children.
Other strategies include PITC for paediatric, where MoH and MCDMCH initiated HIV testing of all
children 0 – 14, presenting at both the well and sick clinics whether exposed or not . It is
expected that the EID will improve paediatric and children ART uptake. To this effect, in 2014,
automated viral load and EID machines were deployed in 9 provincial centers in an effort to
strengthen EID.
2.2.2 HIV/TB Integrated Services, including HIV-positive TB patients treated with ARVs: There are remarkable improvements from trends reported previous years in abiding to ART
treatment guidelines, which call for systematic enrolment of all HIV/TB co-infected patients on
ART. During the year 2014, 73% of all the TB patients who were diagnosed HIV positive were
started on ART. This is an improved performance from 66% achieved in 2013. The program has
also reported increased percentage of TB patients who are testing for HIV from 91% in 2013 to 93%
in 2014.
Figure 6: HIV prevalence in the general population compared to prevalence among the TB
patients, by provinces 2014
52.7%
60.4%
37.3%
45.3%40.0%
65.7%
37.1%
71.5%
49.1%
68.9%
60.9%
9.3%
18.2%
10.5%6.4%
11.0% 12.8%
7.2%
12.5%15.4% 16.3%
13.3%
Eastern Copperbelt Northern Muchinga Luapula Southern NorthWestern
Central Western Lusaka 2014ZambiaResults
HIV prevalence among TB patients HIV prevalence among the general population
Source:NTP/MCD
MCH (February,
2015) and
ZDHS 2013-2014
(March, 2015)
21
Figure 7 : Trends in percentages of TB patients who tested for HIV, and proportion of those who
were found to be HIV+ that were put on ART. Comparison by Provinces in 2014
Source : NTP Program data ( 2014) and ZDHS 2014 – CSO/MOH
The comparison analysis in the figure above shows that Southern Province is by far performing
well in implementation of HIV/TB collaboration activities. All the TB cases were tested for HIV
and, of those who were found to be HIV positive, 88% were put on ART. Other provinces that
have shown improvement from the 2013 trends are Northern Provinces and Muchinga. The
provinces are not performing well on these indicators are Lusaka, North Western and Central
Province.
During this year, the roll out the 3Is project was implemented targeting the high burden
provinces (i.e. Copperbelt, Central, Lusaka and Southern). The country has installed a total of 14
Xpert MTB RIF which have helped in testing sputum for TB among People Living with HIV
(PLHIV). Currently, there are 14 Xpert MTB RIF in public health facilities. With support of Global
Fund , 15 additional GeneExpert machine have been procured and are expected in the country by
April 2015
Key factors affecting the performance of these indicators include the low number of accredited
ART health facilities (592) compared to the number of all health facilities (1956) which provide TB
treatment services.
This therefore means that some HIV/TB co-infected clients have to cover long distances from
their TB treatment sites to access ART at another facility leading to some not started ART,
dropping out or not being consistent on the treatment.
98 90 94 93 91
100
77
89 97 94
76 78 83 81
72
88
67 67 70 67
0
20
40
60
80
100
120
Eastern Copperbelt Northern Muchinga Luapula Southern NorthWestern
Central Western Lusaka
Percentage of TB patients tested for HIV Percentage HIV+ TB patients enrolled on ART
22
PROCUREMENT AND SUPPLY CHAIN MANAGEMENT OF ARVS:
Throughout the implementation of SSF grants, there has been regular supply of ARVs and OIs drugs in the country with the support of the Global Fund, GRZ, USG and other partners. The most-up-to date stock status at
central MSL level shows a fairly secure
ARV drugs stock both at central level and
service delivery points except for NVP
syrup which is currently at 3 months of
stock cover (91,792 packs at central level
with average monthly issues at 26,837
packs).
Health and Pharmaceutical Products procured by UNDP in 2014
Antiretroviral drugs (ARVs)
Source: UNDP – Global Fund Projects Management Unit, March 2015.
ITEMS PLANNED FOR PROCUREMENT IN 2014 PACK QUANTITY
PLANNED
PLANNED
BUDGET
QUANTITIES
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
TENOFOVIR / EMTRICITABINE (TRUVADA), TAB 300/200MG 30 54,299 311,676.26 54,299 311,676.26
TENOFOVIR 300MG/EMTRICITABINE 200MG/EFAVIRENZ 600M 30 755,127 8,791,404.49 755,127 8,791,404.49
ABACAVIR 60MG + LAMIVUDINE 30MG 60 41,000 246,000.00 158,617 919,027.20
ABACAVIR, TAB 300MG 60 100,000 1,640,000.00 81,450 895,135.50
ATAZANAVIR300MG+RITONAVIR100MG TAB(30,S)(ANZAVIR) 30 0 - 27,850 551,000.00
EFAVIRENZ, TAB 200MG 90 10,000 93,000.00 7,000 65,100.00
LAMIVUDINE / ZIDOVUDINE, TAB 150/300MG 60 160,000 1,256,000.00 151,600 1,039,644.00
LAMIVUDINE, TAB 150MG 60 80,000 284,800.00 234,282 433,421.70
LAMIVUDINE/ZIDOVUDINE 30MG/60MG 60 25,000 75,000.00 3,919 11,561.05
LOPINAVIR / RITONAVIR (KALETRA), CAP 200/50MG 120 120,000 4,320,000.00 57,565 1,087,978.50
LOPINAVIR / RITONAVIR (KALETRA), SUSP 80MG/ML & 20 1 1,140 35,135.00 17,386 535,836.25
NEVIRAPINE SUSP, 50MG/50ML, 100ML BTL 1 86,343 105,715.30 86,343 105,715.30
NEVIRAPINE, SUSP 50MG/5ML, 240ML BTL 1 21,671 42,258.45 21,671 42,258.45
TENOFOVIR 300MG 30 5,376 19,353.60 5,376 19,353.60
TENOFOVIR/LAMIVUDINE,TAB 300/300 30 600,000 5,250,000.00 231,888 1,071,322.56
TENOFOVIR/LAMIVUDINE/EFAVIRENZ,TAB 300/300/600MG 30 2,020,000 31,815,000.00 3,100,160 33,311,680.00
Total costs 49,192,114.86
23
ARVs Products in the pipeline
UNDP placed an order of 150,000 packs which is expected to arrive in the country at the end of
March 2015. This will last the country for another 6 months. For 3TC + AZT 150/300mg, the
country has 2,7 month at the central warehouse, with planned staggered shipments throughout
the year of a total of 832,880 packs from the various funding sources (UNDP - 242,000 packs to
arrive in April 2014, SCMS - 80,040 packs to arrive in June 2015, GRZ -251,000 to arrive in August
2015 and another GRZ shipment of 259,620 packs to arrive in December 2015). The average
monthly issues from MSL are 76,303 packs so the planned orders are equivalent to an average of
11 months stock cover.
The stock level for EFV 600mg at central level is low at the moment, however there are planned
shipments to bridge the gap; these include 106,416 packs ordered by SCMS arriving in March
2015, and 110,700 packs arriving in July 2015 and the order by UNDP of additional a 120,500 packs
whose shipment will arrive in November 2015). These consignments will be sufficient for the
country for 11 months given the current average monthly consumption 30,692 packs.
For Abacavir 300mg, there are 6 months of stock at central level. There is a planned shipment of
100,000 packs expected into the country in April 2015. This will beef up the stocks to an additional
6 months. At central level we have an average of 12 months of stock for TLE.
UNDP is in the process of ordering ARV drugs supplies worth USD52 million for the year 2015
which will be delivered in a staggered fashion to curb any logistical challenges that may arise due
to manufacturing pressures from the suppliers and storage constraints at the central warehouse.
In carrying-out the procurement functions, the UNDP has reduced lead time for procurement of drugs and pharmaceutical supplies resulting in availability of right quantities and quality of supplies at the service delivery points. The GF resources also supported MSL’s operations through provision of delivery trucks and warehouse equipment.
2.2.3 Expanding the provision of ART to Prevent Mother-To-Child Transmission - PMTCT
Ensuring a mother living with HIV has access to HIV treatment not only has health benefits for her
but also for her family.
The country has recorded
progress in scaling up of
PMTCT services. During this
year, the MCDMCH and MoH
intensified the rollout of
Option B+ across the country,
and endorsed implementation
of ART task shifting where
nurses are now certified as
prescribers to provide ART.
24
The GRZ in collaboration with partners, including the Global Fund have supported training of
health care workers and community health workers in Option B+ to support rollout at facility
levels. The availability of adequate supply of HIV test kits and ARVs has contributed to successful
implementation of PMTCT program. The country has had adequate supply of HIV test kits and
ARVs during the reporting period.
The uptake of PMTCT services has increased over the last five years. The number of pregnant women receiving ART for PMTCT has increased from 54,597 in 2010 to 80,607in 2011 and reached 84,351 in 2012. In 2013, the number dropped slightly from last year to 75,165. FIGURE 7 : Distribution of number of pregnant women who received ARVs for PMTCT in 2013, by Provinces.
(Sources: Zambia HMIS- February 2015) Figure 8: Proportion distribution of women receiving ARVs for PMTCT, by treatment categories
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
4,095
15,194
2,467 1,237
4,112
6,605
2,170
7,937 5,946
19,057
25
(Sources: Zambia HMIS- February 2015) FIGURE 9 : Trends in the number of HIV+ pregnant women who received ARVs for PMTCT between 2012 and 2014, and Estimated Number of pregnant women who actually need ARVs for PMTCT 2012-2017
Source: MoH/HMIS (February, 2015) and EPP SPECTRUM Outputs revised in June 2014 The trends in the number of HIV+ pregnant women who received ARVs for PMTCT between 2012
and 2014, and estimated number of pregnant women who actually need ARVs for PMTCT 2012-
2017 shows consistent down ward trends.
It is not clear yet why the country has continued to report low number of pregnant women
receiving ARVs for PMTCT. The new estimates are influenced by reduction in total fertility rate,
which according to ZDHS results 2013/14, the TFR among women aged 15-49 dropped from 6.2% in
2007 to 5.3%.
The recent SPECTRUM estimates have also shown reduction in the number of new HIV incidences
among the women of the same age from 34,252 in 2010 to 24,181 in 2014. The revised estimates
put results reported here in good range of performance.
According to Global AIDS Report, 2013, Zambia is among 4 priority countries that have already
met the goal of providing ART to 90% of pregnant women living with HIV.
HIV prevalence among the pregnant women is showing down ward trends.
Strategic gains of PMTCT in Zambia have been as a result of reinforcing preventing new HIV
infections; helping women living with HIV avoid unintended pregnancies; ensuring that pregnant
women have access to HIV testing and counselling; and that those who test positive have access
to ART for PMTCTV during pregnancy, delivery or breastfeeding; and providing HIV care,
treatment and support for women, children living with HIV and their families
54,597
80,607 84,351
75,165.00 68,820
77762 76629 75034 72923 70523
2010 2011 2012 2013 2014 2015 2016 2017
HIV+ pregnant women receiving ART Estimated HIV+ pregnant women in need of ART
26
Zambia being a country with concentrated epidemic, it has proved to be difficult to estimate the percentage of treatment-eligible pregnant women living with HIV who are receiving antiretroviral therapy. A national level research/survey/study is needed to determine why despite improving access to health care, reports continues to show annual drop-down in the number of pregnant women starting, or being reported to start antiretroviral therapy.
2.2.4 Reinforcing prevention by expanding HIV testing and counselling: The proportion of people who have received an HIV test and learned their results has increased
significantly. Increases in access to treatment can be partly attributed to a growing number of
people living with HIV knowing their HIV status.
Reports from health facilities show significant increase in number of people opting for a test to
know their HIV status.
During the year 2014 the number (2,712,237) of people who tested for HIV increased by 22%
compared to results of 2,231,974 reported in 2013- (reports from 95% of HFs).
These results could be attributed largely to adequate supply of test kits which enabled health
care workers to perform test to as many people as possible opting-in to know their HIV status.
FIGURE 10: Trends in the number of people who opted for HIV testing and received results from 2010 - 2014
The MoH and MCDMCH in collaboration with partners have continued to strengthen universal
HCT approached through mass campaigns, and integration of HCT services with VMMC, PMTCT,
TB, Cancer and MCH (family planning) services, including training of health care workers in HC&T.
Outreach mobile VCT services were also expanded targeting hard to reach areas and school
youth.
2010 2011 2012 2013 2014
1,636,182 1,866,775
2,138,961 2,231,974
2,712,237
0
500000
1000000
1500000
2000000
2500000
3000000
1 2 3 4 5
Source: MoH/HMIS (February, 2015)
27
FIGURE 11: Trends of HIV testing by Provinces, in comparison with HIV prevalence as reported in the ZDHS 2014. Trends shows that of people who opted for a HIV test at least once in 2014 based on the provincial population estimates (CSO, 2014); western, Luapula and Eastern Provinces have the highest number of people using HCT services, with at least 2 in 10 people having tested for HIV. The Provinces that have lower trends are Lusaka, Copperbelt, Nothern and North Western Provinces. The two Provinces that have high HIV prevalence rates, have also lower proportion of people who opt for a HIV test
12.5%
18.2%
9.3%
16.3%
11.0%
6.4%
10.5%
7.2%
12.8%
15.4%
0%
10%
20%
30%
40%
50%
0
400,000
800,000
1,200,000
1,600,000
2,000,000
2,400,000
2,800,000
CentralProvince
CopperbeltProvince
EasternProvince
LusakaProvince
LuapulaProvince
MuchingaProvince
NorthernProvince
NorthWesternProvince
SouthernProvince
WesternProvince
Number Tested for HIV Estimated Population HIV Prevalence in the General population
Source: HMIS/MOH (December 2014) and ZDHS 2014 (March 2015)
28
The national stock status for the test kits shows adequate supplies, with the month of stock for
both Unigold HIV rapid test and Determine rapid test recorded at MSL well above month of
stock at 10 month and 4.2 month of stock for DETERMINE HIV 1/2 rapid test, respectively.
HIV Reagents and Test kits procured in 2014, cost in US $
Blood bank equipment procured in 2014, cost in US $
ITEMS PLANNED FOR PROCUREMENT IN 2014 PACK QUANTITY
PLANNED
PLANNED
BUDGET
QUANTITIE
S
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
BD FACSCOUNT % CD4 REAGENT KIT 50 2,400 748,896.00 2,400 748,896.00
BD FACSCOUNT CONTROL KIT (340166) 25 60 12,972.00 100 19,686.00
BD TRITEST CD3/CD4/CD45 (340383) FOR FACSCALIBUR 50 450 141,363.00 450 141,363.00
COBAS AMPLIPREP (COBAS TAQMAN) HIV-1 QUAL TEST 1 25 2,454.75 25 2,454.75
COBAS: KIT CAP-G/CTM HIV-1 V2.0 1 25 18,875.00 25 18,875.00
DNA PCR AMPLICOR KIT (HIV-1 MONITOR TEST,V.1.5 1 350 310,800.00 350 310,800.00
DNA PCR CONSUMABLES KIT 1 18 81,606.24 18 81,606.24
ROCHE DBS BLOOD COLLECTION KITS 1 400 37,896.00 400 37,896.00
BD FACSCOUNT % CD4 REAGENT KIT 50 1,550 543,849.00 1,200 342,000.00
DNA PCR AMPLICOR KIT (HIV-1 MONITOR TEST,V.1.5 1 300 282,000.00 350 310,800.00
DNA PCR CONSUMABLES KIT 1 10 33,000.00 18 81,606.24
ROCHE DBS BLOOD COLLECTION KITS 1 300 45,000.00 400 37,896.00
DETERMINE HIV 1/2 RAPID TEST INC CHASE BUFFER 100 27,000 2,160,000.00 27,000 2,376,000.00
UNIGOLD HIV 1/2 RAPID TEST 20 12,000 384,000.00 11,853 333,343.51
Total Costs 4,843,222.74
ITEMS PLANNED FOR PROCUREMENT IN 2014QUANTITY
PLANNED
PLANNED
BUDGET
QUANTITIES
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
DCU - DOMETIC COMMUNICATION UNIT, LAN 32 40,673.09 32 40,673.09
INTERCHANGEABLE BLOCKFOR 24 X 1.5ML MICROTUBES 8 4,065.26 8 4,065.26
LOGTAG LTI/USB INTERFACE CRADLE 50 2,690.89 50 2,690.89
VARIABLE TEMPERATURE THERMOSHER PCMT 8 6,857.46 8 6,857.46
BLOOD BANK REFRIGERATOR, 746LTR, DOMETIC BR750G 20 270,668.00 20 214,121.82
BLOOD TRANSPORTATION COOL BOX,LARGE,DOMETIC MB300 35 136,003.00 35 120,936.48
BLOOD TRNSPORTATION COOL BOX,SMALL 8LTR DOMET MT4B 500 144,849.00 500 149,078.06
FREEZER ULTRA-LOW TEMPERATURE UPRIGHT,900 SERIES 8 57,436.26 8 57,436.26
LAB REFRIGERATOR ES SERIES CAPACITY 151 LITER 8 5,535.21 8 5,535.21
PLASMA FREEZER, 738LTR, DOMETIC FR750G 12 178,641.00 12 130,911.41
TEMPERATURE LOG WITH USB INTERFACE 535 32,083.12 535 32,083.12
VARIABLE VOLUME SINGLE CHANNEL PIPETTE EL 20-200UL 16 2,768.88 16 2,768.88
VARIABLE VOLUME SINGLE CHANNEL PIPETTE EL100-1000U 16 2,768.88 16 2,768.88
TOTAL SPENT 769,966.82
29
General Reagents procured in 2014, cost in US $
ITEMS PLANNED FOR PROCUREMENT IN 2014 PACK QUANTITY
PLANNED
QUANTITIES
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
CHLOROFORM LIQUID, ANALYTICAL REAGENT 1 146 146 3,251.34
COBAS INTEGRA 400: CHOLESTEROL (20763012322) 400 64 64 7,076.48
COBAS INTEGRA 400: DEPROTEINIZER (20763071122) 1 7 30 4,328.70
COBAS INTEGRA 400: TRIGLYCERIDES (20767107322) 250 30 30 3,478.80
COBAS INTEGRA 400:TOTAL BILIRUBIN 350 TESTS 1 70 70 4,058.60
HUMAN GLUCOSE LIQUICOLOR, 1LITRE 1 70 70 3,070.20
HUMAN UREA, LIQUICOLOR, 100ML 2 45 45 961.20
KARMALI CAMPYLOBACTER AGAR (BASE).BOTTLE 500G 1 28 28 1,514.32
OLYMPUS AU400: ALT (OSR6107) 1 25 25 5,259.50
OLYMPUS AU400: AST 1 25 25 5,615.75
OLYMPUS AU400: GLUCOSE (OSR6221) 1 15 10 1,128.60
OLYMPUS AU400: TRIGLYCERIDES (OSR6133) 1 8 15 3,287.25
OLYMPUS SYSTEM CALIBRATOR (66300) 1 15 15 5,243.10
OLYMPUS: HDL CHOLESTROL 1 22 22 2,193.62
ACETONE LIQUID, ANALYTICAL REAGENT 1 29 29 1,628.07
ARCHITECT PROBE CLEANING SOLUTION 1 10 10 2,461.22
ARCHITECT REACTION VESSELS 1 30 30 2,643.39
CLOSURE GREEN 100 9 9 619.21
COBAS: KIT CAP-G/CTM HIV-1 V2.0 1 400 400 404,212.00
CONCENTRATED WASH BUFFER 1 290 290 20,995.44
HBS AG CALIBRATORS KIT 1 15 15 4,491.75
HBS AG CONTROL KIT 1 40 40 7,388.30
HBS AG REAGENTS 100TEST 1 400 400 53,789.94
HCV CALIBRATORS KIT 1 15 15 2,065.79
HCV CONTROL KIT 1 40 40 5,981.04
HCV REAGENTS, 400TEST 1 100 100 136,039.11
HIV AG/AB CALIBRATOR KIT 1 15 15 1,644.78
HIV AG/AB CONTROL KIT 1 35 35 4,691.57
HIV AG/AB REAGENT, 400 TEST 1 100 100 73,805.06
ITEMS PLANNED FOR PROCUREMENT IN
2014 PACK
QUANTITIE
S
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
HUMAN CHOLESTEROL LIQUICOLOR,
30ML 4 4 387.24
HUMAN GLUCOSE LIQUICOLOR, 1LITRE 1 186 8,076.12
HUMAN TRIGLYCERIDE GIPO LIQUICOLOR,
9X15ML 1 106 3,751.34
HUMAN UREA, LIQUICOLOR, 100ML 2 82 1,734.30
HUMAN: CONTROL SERUM HUMATROL P
KIT 6X5ML 1 90 3,204.00
KIT CAP-G/CTM WASH REAGENT 1 500 31,580.00
METHYLATED SPIRIT INDUSTRIAL 96%
(DEB) 1 1,500 5,790.00
OLYMPUS AU400: ALT (OSR6107) 1 85 17,362.10
OLYMPUS AU400: CHOLESTEROL
(OSR6116) 1 3 290.43
OLYMPUS AU400: GLUCOSE (OSR6221) 1 32 3,506.24
OLYMPUS AU400: TRIGLYCERIDES
(OSR6133) 1 66 14,042.82
OLYMPUS AU400: UREA (OSR6134) 1 23 2,569.10
OLYMPUS SYSTEM CALIBRATOR (66300) 1 26 8,823.36
ORANGE G 6 SOLUTION 1 10 448.04
PRE TRIGGER SOLUTION 1 20 2,117.21
PROBES 1 3 1,082.21
SALMONELLA PARATYPHI A-O (5ML) 1 20 84.84
SALMONELLA PARATYPHI B-H (5ML) 1 10 42.42
SALMONELLA PARATYPHI C-H (5ML) 1 10 42.42
SALMONELLA PARATYPHI C-O (5ML) 1 10 42.42
SENSITIVITY DISC,GENTAMYCIN 10UG 500 7 282.08
SYPHILLIS CALIBRATOR KIT 1 15 2,711.64
SYPHILLIS CONTROL KIT 1 35 8,787.99
SYPHILLIS REAGENTS 100TESTS 1 400 88,816.39
TRIGGER SOLUTION 1 22 1,367.43
TRIPLE SUGAR IRON AGAR (TSI) 1 29 1,134.48
BD FACSCOUNT % CD4 REAGENT KIT 50 1,251 356,535.00
BD TRITEST CD3/CD4/CD45 (340383) +
TRUCOUNT TUBES 50 180 59,400.00
CALIBRITE 3 CE 25 TESTS 1 36 3,600.00
COBAS 111: CREATININE 1 76 7,152.36
COBAS 111: MICRO CUVETTES SEGMENTS 168 12 4,720.20
COBAS 111: MICRO SAMPLE CUPS 250 40 1,508.00
COBAS C111:THERMAL PRINTER PAPER
ROLL 5 20 649.20
ROCHE DBS BLOOD COLLECTION KITS 1 625 59,212.50
Total Costs 1,473,778.01
30
2.2.5 Expanding voluntary medical male circumcision (VMMC): According to the ZDHS-2013/14, HIV prevalence is slightly higher among non-circumcised men (12 percent) than among those who have been circumcised (10 percent). Data from MC service delivery points in the last seven years show significant annual improvement in total number of males circumcised as illustrated in the graph below. The VMMC program is scaling up rapidly, currently, provided in 472 static health facilities. In 2013,
Zambia surpassed its annual VMMC target for the first time since program inception; however,
the target for this indicator in 2014 was under-achieved.
FIGURE 12 : Annual trends of scale-up of VMMC 2010 - 2014
Source: HMIS/MOH and National VMMC Unit MCDMCH- February, 2015
Unlike the previous year where the number of male circumcised were collected and reported
through the VMMC Coordination units in the MoH and later in the MCDMCH, this year results
reported here are generated from rom HMIS/DHIS.2.
2010 2011 2012 2013 2014
63,604 84,604
173,992
294,446
199,057
0
50000
100000
150000
200000
250000
300000
350000The VMMC program in Zambia has clearly demonstrated that only when a comprehensive set of HIV prevention initiatives is rolled out at a national scale, people will have sufficient access and use of these services, hence realize the optimal prevention returns.
31
The number reported here reflect lower performance because there are VMMC services that are
provided outside health facility setting and are not captured under any health facility reporting
through HMIS data base.
Source: HMIS/MOH (February, 2015)
The MCDMCH through the national VMMC will inform and trained the partners on the VMMC
recording and reporting tools and will reinforce coordination to ensure partners implementing
VMMC services align their reporting within the health facilities in areas where they operate.
The MCDMCH and MoH will further continue to engage the partners to ensure that more resources are available to implement the MC Operational Plan, including regular supply of VMMC kits and community outreach to sensitize the population (demand creation), and support for health care workers to conduct mobile MC, especially in rural settings. Support to training Health Care workers and Community Health Workers – HSS During this year, a total of 1451 health care workers benefitted from training in different domains.
The number of people trained during the reporting period (June-December 2014) include 309
HCWS trained in the new ART treatment guidelines (in Copperbelt, Western Province, North-
Western, Eastern Province, Northern Province ,Lusaka and Central Province); 144 trained in
PMTCT – Option B+ (in Muchinga, Eastern Province and Northern Province) ; Central level training
of 54 service providers in HC&T; 350 Health information officers trained in hospital HMIS from the
provinces of ( Lusaka, North-Western Copperbelt, Eastern Province Northern Province, and
Central Province) and additional 66 trained HIOs in use of SmartCare, drawn from Central
Province and Luapula.
32
Failure to achieve training target is largely caused by delays in finalization of designing of web-
based Hospital HMIS/DHS.2 which subsequently delayed training of hospital health information
officers in the use of Hospital HMIS/DHIS.2 web-based data base.
Training of Community Health Workers on Safe Motherhood and Early FANC Booking and Mother
Baby Follow ups: During the year 2014, a total of 175 CHWs were trained to actively support
PMTCT programme around early focused antenatal care (FANC) and mother-baby pair follow-
ups. Training of CHWs on SMAGs in FANC booking and mother-baby-pair follow-up is intended to
improve, among others, delivery in health facilities, return visit for ANC and to minimize loss to
follow-up. These training targeted CHWs working within health facilities in the Districts of Lusaka,
Shibuyunji, Kitwe, Ndola, Livingstone, Chilundu,sinda, Mufurila and Chibombo so that they can
adequately services the surrounding community.
ANNEX 1: SHOWS THE OVERALL FINANCIAL PERFORMANCE OF HIV/AIDS GRANTS (2013 -2014)
33
SUPPORTING THE NATIONAL TUBERCULOSIS PROGRAM
The main objectives of this project are to ensure improved access to first line and second line
anti-TB drugs; improved monitoring and evaluation capacity of the National TB Program (NTP)
and improved TB diagnosis through supporting External Quality Assurance of the national
laboratory system.
The funding scope is mainly to finance the procurement of health products, including first line
and second line drugs, laboratory reagents and related supplies, as well as supporting the
storage and distribution of these products to service delivery points (SDPs).
This grant with a total portfolio of US$ 16,215,534, carries over from Phase 2 of Round 7 grant
which ended on 30 June 2013. In June 2013, the Global Fund and UNDP signed Transitional
Funding of US$4.2 and in November 2013, the Interim New Funding of US$ 3 Million was signed to
ensure continuity of essential services, mainly procurement of TB drugs, human resource
support, procurement of laboratory equipment and supplies and supporting external quality
assurance activities.
This funding arrangement was aimed at ensuring continuity of services as the country prepares
to apply for the New Funding Model (NFM) in 2014. In January 2015, Zambia was awarded an NFM
grant for HIV/TB, which will be managed by the MoH and CHAZ as PRs.
Table 3: AN OVERVIEW OF FINANCE PERFORMANCE BY END OF DECEMBER 2014
Status of Active Grant Portfolio by end of December 2014 Total US$ Mobilizes 2011-2014 TB grant Malaria grant HIV/AIDS SSF
Approved Budget 15,174,213 37,123,387 156,509,071
387,918,261
Disbursed from GFATM
12,855,382 35,446,881 130,099,401
350,736,730
% already disbursed in- country
85%
Total Expenditure by end of December 2014
10,689,407.74
34
3. STATUS AT A GLANCE: THE PERFORMANCE OF CORE TB INDICATORS, 2014
The data below provides a comprehensive and up-to-date assessment of the TB epidemic and progress in implementing and financing TB prevention, care and control in Zambia, using reported data from the National TB Control Program (NTP).
Latest Overall Grant Performance Rating (GPR) A2 (June, 2014)
Table 4. Comparison of performance of key TB indicators ( 2012, 2013 and 2014)
Core TB Indicators Actual Result
reported in 2012
Results Reported in
2013
Results Reported in
2014
Intended Target
2014
% Achieve
ment, 2014
Trend of achievements
compared to 2013 Results
Notification rate of all forms of TB cases (new smear positive, new smear negative, extra pulmonary and relapse)
373/100,000
313/ 100,000
284/ 100,000
417/ 100,00
0
N/A
Treatment success rate: new smear positive TB cases
88% 88% 90% 90% N/A
Number of new smear positive TB cases notified
12645 12,198 12070 16342 74%
Number and percentage of TB patients with known HIV status
20,534/23,124 (89%)
41,348/ 45,664 (91%)
39,763/ 42,716 (93%)
63,200 (100%)
(93%)
Percentage of TB/HIV patients put on ART
60% 66% 73 80 91%
Number and percentage of new smear positive TB patients successfully treated among the new smear positive TB cases registered on treatment
10,523/11,918
(88%)
11,368/ 12,860 (88%)
10,995/ 12,238 (90%)
14,707/16,342
(90%)
(100%)
Number of MDR-TB cases on CAT IV Enrolled for 2nd line treatment
20 79 73 80 91%
Source: MCDMCH/NTP Program Data – aggregations done in February 2015.
35
3.1 ACCESS TO QUALITY TB CARE: DIAGNOSIS, TREATMENT, PREVENTION AND CURE.
3.1.1 TB CASE DETECTION AND NOTIFICATION: During the year 2014, the country recorded a further decline in the number of cases being
notified. The notification rate for all forms of TB has reduced to 284 per 100,000 population in
2014, from 313 per 100,000 population in 2013 and this
FIGURE 13 : Trends of TB cases detected in a 100, 000 population 2003 - 2014
During the year 2014, 42,070 people with TB were notified. Of these, the new smear positive TB
cases were 12,070, dropping from 12,247 reported in 2013. New smear negative TB cases were
15,568 with 8,584 Extra-pulmonary and 6,494 relapse cases.
Figure 14: Trends of TB cases notified in 2014, by Provinces
02000400060008000
1000012000140001600018000
New Smear Postive notified New smear negative Extra-pulmonary Relapse
36
Figure 15: The Distribution of TB cases by Provinces as reported in 2014
The NTP has started rolling out the use of more sensitive TB diagnostics such as Xpert MTB RIF,
the use of fluorescent microscopy and Line Probe Assay. So far 29 Xpert MTB RIF machines have
been deployed to various health facilities in the country.
Although the implementation of Xpert MTB/RIF is continuously being scale-up, there are
challenges to its implementation that needs to be considered. Xpert is not universally utilised.
Ensuring uninterrupted supply of cartridges will remain important.
The NTP in collaboration with partners has initiated a number of strategies such as the WHO
Three Is which has seen intensified TB screening in special settings such as prisons, among
PLWHA and contact tracing at community levels.
The program will further institute measures to capture TB cases in congregate settings such as
mining companies and their communities, and will strengthen interventions in paediatric TB.
Staff have also been trained and mentored in TB screening techniques and TB diagnostic
techniques. With the support from this project grant and USG partners, CDL and UTH have been
supported to undertake EQA visits in Luapula, Eastern, Lusaka, Western and Muchinga Provinces.
37
FIGURE 16: Trends of TB cases notified (all forms) and new smear positive TB cases 2009 - 2014
The NTP will need to reinforce a multifaceted TB screening programme focusing on high-burden areas, which included mines and prisons, household contact tracing, HIV counselling and testing campaigns, community mobilisation, door-to-door enquiry in areas with a high burden of smear-positive TB, and screening of high-risk populations
Other progress made to improve TB case detection and notification
The number of TB diagnostic sites has increased to from 319 in 2012 to 364 in 2014. Out of these a
total of 75 sites are using Fluorescent Microscopy for TB diagnosis giving coverage of 21% of
laboratories using this technology for TB diagnosis.
Using the grant funds, 40 LED Microscopes, 15 Gene Xpert MTB/RIF machines and 1
Spoligotyping Machine have been procured and will be delivered before the end of March 2015.
With Global Fund resources, UNDP has also procured laboratory supplies and reagents to support
the national TB laboratory network through CDL. Some of the items that have been procured
and distributed across the country include weigh balances, water distillers, autoclave machines,
extractor fans etc
3.1.2 TB CASE MANAGEMENT TO IMPROVE TREATMENT SUCCESS RATE:
Zambia implements, universally, the DOTS strategy, and hence, the universal coverage of TB
services in all the public sector- with TB anti-drugs being provided free of charge. The Private
sector facilities also provide TB treatment.
The treatment Success Rate has increased to 90% IN 2014 from 88% recorded in 2013. The country
has so far met the 2015 target as set in the revised Global Plan to Stop TB 2011 - 2015. This
Globally, the number of TB cases diagnosed and notified per 100 000 population remained relatively stable between 2009 and 2014. According to preliminary results of TB prevalence survey 2013/14, (482/100,000) a clear gap exists between the numbers of notified cases and the estimated numbers of incident cases.
38
performance is largely attributed to uninterrupted supply of TB drugs and the wide coverage of
the TB DOTS treatment strategy in about 2,000 health facilities across the country.
Figure 17: Trends of TB cases enrolled, and patients successfully treated among the new smear positive TB cases registered on treatment 2014, by Provinces.
Source- MCDMCH/NTP Data, February 2015
Figure 18 :TB Treatment Outcomes of TB Patients - Cohort Notified in same quarter of last years
There is universal coverage of TB services in the public sector with TB anti-drugs being provided
free of charge to all patients.
EasternCopperb
eltNorther
nMuchin
gaLuapula
Southern
NorthWestern
Central Western Lusaka
Number of new smear positive TB patientssuccessfully treated
720 2,401 567 281 459 1,040 323 714 757 3,733
Total Enrolled 819 2,630 651 299 562 1,156 372 815 880 4,054
Treatment Success Rate 88% 91% 87% 94% 82% 90% 87% 88% 86% 92%
0
500
1000
1500
2000
2500
3000
3500
4000
4500
TB Mortality rate among the new Smear Positive:
The death rate among
the new smear positive
cases enrolled was
recorded at 4% . Same
rate was reported in
2013. Default rate is at
3%, while treatment
failure was reported at
1%.
39
With the support of the Global Fund and GRZ, there has been consistent supply of anti-TB drugs.
During the reporting period, there have been no reported cases of stock out of TB drugs. At the
time of reporting, the country had sufficient stocks of FLD at Medical Stores Limited (MSL)
warehouse. For the adult formulations, the NTP consumption data estimated that the country
has 21 months of the 2FDC; 16 months of the 3FDC; 21 months of the 4FDC; and 6 months of
streptomycin. For the paediatric formulations there are 15 months of both the 2FDC and the
3FDC.
The community based TB Treatment Adherence Supporters have played key role in supporting
patients adhere to the treatment prescribed thus sustaining the high levels of success in the
treatment outcomes over the years.
3.1.3 ADDRESSING MDR-TB AS A PUBLIC HEALTH CRISIS The numbers of MDR-TB cases on category IV enrolled for second line treatment were collected from the two functioning MDR-TB treatment facilities; Ndola Central Hospital (NCH) and the University Teaching Hospital (UTH). The two treatment facilities enrolled at total of 73 patients on treatment. 44 were enrolled from UTH while 29 were enrolled at NCH. The target for the year 2014 was to enrol 80 patients. In order to strengthen the program, the NTP now has a designated officer at central level who is the focal person for MDR-TB. The program has begun putting in place strategies to increase the enrolment and retention of patients on treatment. The current centralised treatment model where only UTH and NCH initiate and follow-up patients and also provide in-patient and out-patient care has not been very effective. In order to address this, the NTP is now moving towards implementation a decentralised model of care to the provincial level and district level. This will reduce the distances and will facilitate quick initiation on MDR-TB treatment and patient monitoring. Trainings have been done in 5 provinces (Southern Province, Central Province, Lusaka, North-western Province and Copperbelt) to equip the Provincial Clinical Expert Committees (CEC) which the knowledge and skills in the management of MDR-TB. It is expected that these committees will supervise and monitor all the patients who will be on treatment in their respective districts. Furthermore, the program will implement the ambulatory model of patients who qualify and only those who are critically ill will be enrolled on treatment through the in-patient model. The Xpert MTB RIF machines that have been installed in 24 health facilities will facilitate quick diagnosis of RIF resistance, hence start the MDR-TB cases without further delays..
3.1.4 ACCELERATING THE RESPONSE TO TB/HIV: TB screening of high-risk persons or groups may contribute to reduced deaths and TB transmission. The WHO recommends that people living with HIV are systematically screened for TB at each contact with the heath service, using a symptom screen. There has been improved collaboration between the NTP and the HIV/AIDS programmes which has reinforced the implementation of TB/HIV collaboration activities. The top priority is now to increase coverage of ART for HIV-positive TB patients towards the 100% target, as is to expand coverage of TB preventive treatment among people living with HIV.
40
Systematic HIV testing among the TB cases: HIV testing among the TB patients is done
systematically in all HIV counselling and testing centres in the country as provided for in the
standard care and treatment guidelines. The program has progressively made improvements
over the last three years increasing the HIV testing rate among TB patients from 87% in 2012, to
91% in 2013 and reached 93% in 2014.
Out of those who tested for HIV, 61% were HIV positive and 73% of all the HIV/TB co-mobility cases
were enrolled into HIV care, and increase from 66% reported in 2013.
Figure 19: The HIV prevalence in the general population compared to prevalence among the TB
patients, by Provinces 2014
Source- MCDMCH/NTP Data, February 2015; ZDHS 2013-14 (March,2015)
During the year under review, the country did not record any stock outs of HIV test kits and, the
HIV and TB programs collaborated to ensure that HIV testing services were available at both the
static and outreach sites.
The NTP in collaboration with partners have provided training and mentorship to health care
workers on the management of TB/HIV co-infected patients. The trained adherence counsellors
also played an important role in supporting patients during TB treatment by counselling and
providing information on the importance of knowing ones HIV status and providing support after
a client undergoes the HIV test
During this year, 2014, the program started implementation of the new integrated ART
Treatment Guidelines, which provide for systematic antiretroviral treatment of TB/HIV co-
infected patients regardless of CD4 count and monitored during the course of the dual therapy.
52.7%
60.4%
37.3%
45.3%40.0%
65.7%
37.1%
71.5%
49.1%
68.9%
60.9%
9.3%
18.2%
10.5%6.4%
11.0% 12.8%
7.2%
12.5%15.4% 16.3%
13.3%
Eastern Copperbelt Northern Muchinga Luapula Southern NorthWestern
Central Western Lusaka 2014ZambiaResults
HIV prevalence among TB patients HIV prevalence among the general population
41
The 3Is project has been rolled-out in the high burden provinces (i.e. Copperbelt, Central, Lusaka
and Southern) , and the activities of the project has created additional awareness of dual therapy
in this group of patients.
Figure 20: Percentage of TB patients tested for HIV, the TB/HIV prevalence and eligible patients enrolled on ART, by Provinces 2014
Table 5: Provinces scorecard: Aacceleration of the response to TB/HIV collaborative services
The key factors affecting the performance of this indicator is the low number of accredited ART
health facilities compared to the number of facilities providing TB treatment services. Currently
there about 582 ART sites compared to approximately 2,000 TB treatment sites. This therefore
means that some co-infected clients have to cover long distances from their TB treatment sites to
access ART treatment at another facility leading to some not started ART, dropping out or not
being consistent on the treatment.
Testing HIV more than
90% and putting on ART
more than 80% of
TB/HIV co-infected
patients
Southern Province
Northern Province
Muchinga Province
Testing HIV above
90% but enrolling on
ART less than 80% of
TB/HIV co-infected
patients:
Eastern Province
Coperbelt Province
Luapula Province
Western Province
Enrolling on ART less
than 70% of TB/HIV co-
infected patients:
Lusaka Province
Central Province
North Western
Province
42
IMPROVING TB DATA MANAGEMENT
The World Health Organization (WHO) in 2013 revised standard case definitions for TB and drug-
resistant TB, the categories used to assign outcomes and the standard reporting framework for
TB. The revised recording and reporting tools will be printed with funding from the Global Fund
and are expected to be roll-out during the first quarter of 2015.
Prior to production of this report, on-site data quality and completeness review was conducted
by the joint teams, between 8th and 16th February 2015, with team comprising of MoH, MCDMCH
and UNDP in all the provinces, and targeted low performing Districts earlier assessed as lagging
behind in terms of completeness of data. Some of the challenges noted where the delays in
reporting by the health facilities due to the frequent staff changes at health facilities.
To support the Provincial TB/HIV Liaison Officers in their data management and supervisory
functions, UNDP has ordered laptops for these officers. With support from Global Fund
resources, the NTP was supported to develop its Monitoring and Evaluation Plan.
Zambia has made notable progress in improving TB control, but the burden of TB remains
enormous. This situation can be reversed. Ensuring high, sustained coverage of effective
interventions for TB and HIV, including in children and special populations, will substantially
reduce the burden of TB and result in the NTP - NSP targets being met
GLOBAL FUND SUPPORT TO SUPPLY OF TB DRUGS
The country has sustainable stocks of 1st line anti-TB drugs at the central warehouse, with an
average of 20 months of stock and approximately 3 months at service delivery points. This is
inclusive of buffer stocks. The pipeline for first line TB drugs is quite secure during this reporting
period. For second line drugs, the stocks are not adequately covered for Kanamycin 1g and
Levofloxacin 250mg tablets.
There is approximately 3 months of stock at the MDR TB sites. Kanamycin 1g vials and
Levofloxacin 250mg tablets have low stock levels at central level. There is currently 1596 packs of
Kanamycin at central level and this will last the country another 8 months according to
consumption data from the National TB Programme.
Global Fund – supported Procurement of TB drugs in 2014, costs in US$ First line TB drugs
ITEMS PLANNED FOR PROCUREMENT IN 2014 PACK QUANTITY
PLANNED
PLANNED
BUDGET
QUANTITIES
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
RIFAMPICIN + ISONIAZID + PYRAZINAMIDE + ETHAMBUTOL 672 13,271 541,590.00 17,664 748,070.40
RIFAMPICIN + ISONIAZID, TAB 150/75MG 672 23,816 458,463.00 31,709 622,447.67
RIFAMPICIN +ISONIAZID +ETHAMBUTOL TAB 150/75/275MG 672 4,991 255,552.00 6,655 209,299.75
RIFAMPICIN +ISONIAZID, TAB 60/30MG 90 0 14,000 20,860.00 20,860.00
RIFAMPICIN/ISONIAZID/PYRAZINAMIDE 60/30/150MG (RIM 84 0 7,179 15,363.06 15,363.06
Total Costs 1,616,040.88
43
Second line TB drugs
Source: UNDP – Global Fund Projects Management Unit, March 2015.
TB products on the pipeline
UNDP has placed an order for Kanamycin 1g (995 boxes of 50 vials). This will last the country for
another 4 months. NFM HIV/TB has committed funds of USD84,825 for Year 1 and these funds
will procure more Kanamycin 1g which will sustain the country for another 7 months (approx.
1855 packs to be procured). Levofloxacin 250mg is currently stocked out at central level,
however there is 3 months of stock at the respective MDR treatment sites. The quarterly needs
were issued to the sites at the beginning of February 2015. Levofloxacin 250mg (1600 bottles of
100 tablets) is also on order through UNDP. This order is expected to arrive in Zambia in April
2015.
Under the GF NFM, there are funds to boost the Levofloxacin 250mg stocks (USD45,447 has been
earmarked to procure 5,404 bottles). This will last the country for another 7 months. The second
line drugs have a short shelf life hence the gradual ordering strategy to manage the potential
expiries.
ITEMS PLANNED FOR PROCUREMENT IN 2014 PACK QUANTITY
PLANNED
PLANNED
BUDGET
QUANTITIES
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
CAPREOMYCIN 1GM VIAL INJECTION 1 50 277.00 2,400 13,392.00
D-CYCLOSERINE POWDER 5G 1 6 2,959.93 6 2,959.93
ETHIONAMIDE POWDER, 500G 1 6 6,300.22 6 6,300.22
KANAMYCIN MONOSULPHATE POWDER, 500G 1 6 2,993.01 6 2,993.01
OFLOXACIN POWDER, 500G 1 6 2,166.18 6 2,166.18
STREPTOMYCIN POWDER, 500G 1 8 8 1,565.39 1,565.39
KANAMYCIN, DRY PWD FOR INJ, 1G VIAL 10 600 15,480.00 1,680 43,344.00
Total cost 72,720.74
44
Global Fund – supported Procurement of Laboratory reagents and supplies in 2014, costs in US$
ITEMS PLANNED FOR PROCUREMENT IN 2014 PACK QUANTITY
PLANNED
PLANNED
BUDGET
QUANTITIES
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
BD BACTEC MGIT: 960 SIRE KIT (40 TESTS) 1 4 269.78 4 269.78
BD BACTEC MGIT: 960-CALIBRATORS KIT 1 5 584.84 5 584.84
BD BACTEC MGIT: SUPPLEMENT TESTE KIT 1 33 2,166.18 33 2,166.18
BD BACTEC MGIT:MYCOBACTERIA GROWTH INDICATOR, 7ML 100 83 15,015.76 83 15,015.76
BD MGIT: TBC IDENTIFICATION KIT 1 70 4,869.59 70 4,869.59
BD TAXO - TB NIACIN TEST STRIP 25 73 859.28 73 859.28
POTASSIUM PERMANGANATE, ANALYTICAL GRAD,100G 1 270 1,288.45 270 1,288.45
RIFAMPICIN ANALYTICAL GRADE, 500G 1 8 8 4,431.66 4,431.66
BASIC FUCHSIN POWDER, BIOLOGICAL STAIN, ANALYTICAL 1 21,264 165,859.00 1,000 1,972.44
BD BACTEC MGIT: 960 SIRE KIT (40 TESTS) 1 24 1,544.61 24 1,544.61
BD BACTEC MGIT: 960-CALIBRATORS KIT 1 5 2,239.03 5 2,239.03
BD BACTEC MGIT: SUPPLEMENT TESTE KIT 1 180 11,281.07 180 11,281.07
BD BACTEC MGIT:MYCOBACTERIA GROWTH INDICATOR, 7ML 100 250 43,152.36 250 43,152.36
BD MGIT: TBC IDENTIFICATION KIT 1 200 13,276.83 200 13,276.83
BD TAXO - TB NIACIN TEST STRIP 25 440 5,706.49 440 5,706.49
BITREX FIT TEST KIT WITH HOOD, PUMP & TEST SOLUTIO 1 10 3,307.23 10 3,307.23
BUFFER TABLETS PH 7.2 50 10 2,280.00 32 396.69
CENTRIFUGE TUBES - STERILE FALCON PLASTIC TUBES 50 1,000 3,605.53 1,000 3,605.53
DISPOSAL BAG FOR BIOHAZARDOUS WASTE 30CMX50CM 500 1 97.19 1 97.19
ETHAMBUTOL POWDER, 25G 1 8 3,990.69 8 3,990.69
FILTER PAPER ROUND DIAMETER 11CM MN 615 100 400 1,874.88 400 1,874.88
IMMERSION OIL, TROPICAL GRADE, CP 1 100 530.00 250 1,611.88
INNOCULATING LOOP, 10UL PLASTIC STERILE 2,000 13 618.71 13 618.71
ISONIAZIDE 500G 1 8 3,329.22 8 3,329.22
L-ASPARAGINE-1-WATER GRG 1 20 1,554.41 20 1,554.41
LENS CLEANING TISSUE PAPER 50 3,000 8,685.09 3,000 8,685.09
MAGNESIUM CITRATE, 2.5KG 1 6 735.91 6 735.91
MAGNESIUM SULPHATE, 500G 1 8 26.47 8 26.47
MEDIUM SLANT 1 880 12,150.21 880 12,150.21
MEDIUM SLANT W/P NITROBENZOIC ACID 500UG/M 1 220 6,469.38 220 6,469.38
METHYLENE BLUE POWDER, BIOLOGICAL STAIN, ANALYTICA 1 2,500 6,750.00 1,000 2,714.75
MICROSCOPE SLIDE, SINGLE FROSTED,PRECLEANED,76.2MM 50 5,000 20,000.00 4,000 2,375.41
N-ACETYL-L-CYSTEINE GRG 25G 1 12 409.12 12 409.12
PLASTIC PASTURE PIPETTE,3ML GRADUATED 500 30 312.41 30 312.41
POTASSIUM DIHYDROGEN PHOSPHATE POWDER, GPR 1 30 302.55 30 302.55
SODIUM CITRATE, 500G 1 20 119.19 20 119.19
SPUTUM CONTAINER, 40ML WITH SCREW CAP POLYPROPYLNE 500 500 33,700.00 240 7,121.13
Total Cost 170,466.41
45
Global Fund – supported Procurement of Laboratory Equipments in 2014, costs in US$
Source: UNDP – Global Fund Projects Management Unit, March 2015. These commodities are managed by the Medical Stores Limited (MSL) and the Chest Diseases Laboratory (CDL) which is the National Reference Laboratory for TB. The remaining consignments are expected in May 2014.
ANNEX 2: SHOWS THE OVERALL FINANCIAL PERFORMANCE OF TB GRANTS (cumulative to December 2014), IN US$
ITEMS PLANNED FOR PROCUREMENT IN 2014 PACK QUANTITY
PLANNED
PLANNED
BUDGET
QUANTITIES
ACTUALLY
PROCURED
COST OF
RROCURED
PRODUCTS
AUTOCLAVE SHELVES AH-75 1 6 6 197.14 197.14
FORCEPS 10.5CM POINTED ANTI-MAGNETIC WITH PIN 1 30 30 100.21 100.21
MM/PIPPETE STERILIZING CILINDRE 1 4 4 613.96 613.96
PERFORATED BASKET FOR STEAM STERILIZER, 380X260MM 1 6 6 1,155.28 1,155.28
ANALYTICAL BALANCE 1 300 267,524.00 30 28,788.99
AUTOCLAVE STERICLAV HORIZONTAL 75 LITROS 1 2 9,875.21 2 9,875.21
AUTOCLAVE STERICLAY-S OF 110 LITRES 1 2 12,691.02 2 12,691.02
PHILIPS HALOGEN BULB, 30W 1 125 125 1,004.78
STANDARD WEIGHT SET OF 11 1 30 22,010.81 30 22,010.81
STERILIZATION INDICATION TAPE 1 130 256.31 130 256.31
SURGICAL GOWN (DISPOSABLE APRONS) SIZE 115X140CM 10 30 242.83 30 242.83
WATER DISTILLER WITH STORAGE TANK 1 300 399,900.00 15 22,123.74
WEIGHING BOAT 1,000 1 41.68 1 41.68
WEIGHING BOAT, BOROSILIC GL SIZE C 1 1 41.68 1 41.68
WRILING DIAMONDS WOODEN HANDLE 1 75 10,830.00 600 7,024.42
Total Costs in $ 106,168.04
46
SUPPORTING NATIONAL RESPONSE TO MALARIA CONTROL PROGRAM :
The Scope of Malaria Grant 2014
The Scope: The main and only activity under this grant is procurement and distribution of LLITNs to contribute towards the country target of universal coverage of LLITNs. This grant is a continuation of Round 7 grant Phase 2 funding, which was implemented from December 2011 with a portfolio of US$ 12, 931,024 came to a close in June 2013. In May 2013, additional funding of US$ 24,362,218 was signed, through the GF Transitional Funding Mechanisms to continue key malaria interventions from the Phase 2 of the Round 7 Grant. This grant now has a total budget of US$ 37,293,242 and is expected to end in June 2015.
The main activity under this grant was the procurement and distribution of LLITNs to contribute
towards the country target of universal coverage (100%) of LLITNs, according to the national
malaria control strategic plan 2011-2016.
3.1 MALARIA GRANTS: FINANCE OVERVIEW AS AT END OF DECEMBER 2014
Table 6. Approved budget, Actual Expenditure, and absorption capacity.
Status of Active Grant Portfolio by end of December 2014 Total US$ Mobilizes 2011-2014 TB grant Malaria grant HIV/AIDS SSF
Approved Budget 15,174,213 37,123,387 156,509,071
387,918,261
Disbursed from GFATM
12,855,382 35,446,881 130,099,401
350,736,730
% Already disbursed in-country by end of December 2014
95%
Cumulative expenditure, by end of December 2014
32,687,584.33
Source: UNDP/PMU, March 2015
47
3.2 OVERALL PERFORMANCE OF THE MALARIA PROGRAMS
The overall performance of the Transitional Funding Mechanism (TFM) Malaria grant has been
quite good.
Figure 21 : Total Number of ITNs committed by GRZ and partners and actual number distributed in
2014
Actual number of ITNs distributed, 2014 Number of ITNs committed 2014
Source: MOH/NMCC (February 2015) UNDP/PMU (February 2015)
Out of 4,810,300 nets procured by UNDP, a total of 4,725,357 were distributed by MoH and CHAZ,
and the GRZ distributed 16,400, while USG/PMI distributed 1,627,630 nets.
3.2.1 Procurement of Insecticide Treated Mosquito Nets by UNDP Between mid-April and June 2014, 100 percent of the 4,810,300 nets procured by UNDP, through UNICEF in Tanzania, and were transported by the UNICEF forwarder DAMCO to Zambia. UNDP benefitted from volume discount of unit cost for an ITNs as a result of long term agreement it has with UNICEF, and nets were able to arrive on time. By end of June 2014, the ITNs had been delivered in all targeted districts of Central Province (937,500 Nets); Eastern Province (1,080,400 Nets); Southern Province (1,038,300 Nets); Northern Province ( 774,900 Nets); Muchinga Province (493,700 Nets) and North Western Province (485,500 Nets);
Global Fund,
4,810,300
USG/PMI, 1,690,000
GRZ, 200,000
48
3.2.2 Planning for and implementation of ITNs distribution to homes of end users Setting the stage for distribution, monitoring and reporting on the number of nets reaching the beneficiaries. UNDP in collaboration with MoH, CHAZ and partners jointly elaborated the LLITNs mass distribution
plan which was approved by the Global Fund in December 2013.
Elaboration of this plan was driven by the desire to synchronize the processes with timing of LLITNs procurement and distribution by the GRZ, USG/PMI, DFID and other partners. Evidently, planning for procurement and distribution of 4.8million nets was a comprehensive activity in nature, as set of activities would take place in 6 provinces and involving different stakeholders and partners. Between April and June 2014, UNDP procured a total of 4,810,300 through UNICEF in Tanzania,
and were transported by the UNICEF forwarder DAMCO to Zambia. UNDP benefitted from
volume discount of unit cost for a net as a result of long term agreement (LTA) it has with
UNICEF, and nets were able to arrive on time.
By end of June 2014, the LLINs had been delivered in all targeted districts of Central Province;
Eastern Province; Southern Province; Northern Province; Muchinga Province and North Western
Province.
Engaging key stakeholders in planning meetings and training of HCWs and CHWs in ITNs distribution. In order to ensure ownership, smooth management of the distribution processes and in line with
the approved distribution plan; planning meetings were conducted at provincial and districts
levels.
The plan outlined the processes and operational plan to guide continuous steps from the procurement of LLINs, to storage, quality assurance, distribution to end users and monitoring and reporting of all the LLINs distributed. The plan further outlined the road-map and timing of each step, as well as roles and responsibilities of all actors involved in this activity.
49
District level training of Health care workers and training of CHWs
A total of 64 people were trained at the Provincial level as ToT to districts, and at the District level
1,161 were trained- drawn from centre in charge, a clinical officer, nurse, environmental health
technician, community health assistant or classified daily employee- , who in turn cascaded the
training to about 6000 community health workers (CHWs) that were involved in the actual
distribution of nets into beneficiaries’ households.
Annex 2 and 3 show the summary of the provinces, districts and number of people who
attended the training as TOT during the provincial planning meetings.
3.2.3 Transportation, Storage and Handling of Insecticide Treated Mosquito Nets
Guided by the national micro-planning
guidelines developed by the National
Malaria Control Program, these
workshop enabled key stakeholders in
the ITNs distribution process to take
part, and that their respective provinces
and districts had comprehensive
distribution plan and understood what
was required to have ensure a
coordinated ITNs distribution and
accounting for ITNs distributed using
the report format approved by the
MoH/NMCC.
Pictured is a section of participants attending
Provincial Planning meeting in Northern
Province
Drawing on their logistical strength, WFP was
engaged by UNDP to transport the nets to
974 health centres, close to beneficiary target
population. It took only eleven weeks to
complete the dispatches from the Provincial
Hubs to all 974 Health Centres in the six
Provinces. Over 95% of all deliveries in each
province were completed within a period of
three weeks. Reaching remote health centres
and communities was difficult due to
challenging road conditions.
50
Table 1: LLINs Delivered by WFP from Provincial Hubs to Health Facilities
Source: MoH and CHAZ Progress Reports, December 2014
Figure 21. A copy of a delivery notes that WFP transporters were using in delivery the LLINs to health facilities.
Figure 22: ITNs Delivery Timeline by WFP from the Provincial Hubs to Health Centres:
Source: WFP Final Project Report, August, 2014.
Provinces
LLITNs offloaded by UNICEF at Hubs
Delivered by WFP at Health facilities Differences Comments
Central Province 1,038,180 937,520 100,660 The nets were redistributed to Eastern Province
Southern Province 1,080,160 1,038,000 42,160 The nets were redistributed to Eastern Province
Eastern Province
937,520 1,079,340 (141,820)
Additional nets were redistributed from Central and Southern Province to Eastern Province due to high demand.
Northern Province 773,240 773,180 60
North Western Province 485,400 485,400 -
Muchinga Province 493,720 493,220 500
Totals
4,808,200 4,806,660 1,560 The loss to be recovered from WFP
Mosquito net deliveries were completed
within the agreed time frame. The overall
losses were minimal, resulting in 99.92%
successfully delivered from Tanzania by
UNICEF, as well as WFP storage and
deliveries to health centres.
51
3.2.4 Actual distribution of ITNs to end users The distribution of the nets from the health facility to households was done by Trained
Community Workers (CHWs), between May and December 2014- both by the MOH in Muchinga,
Eastern, Northern and Central provinces, and by CHAZ in Southern and North western province.
Collection of bed space information prior to actual distribution : Prior to the arrival of the nets,
the CHWs collected bed space registration information in the community to determine numbers
of sleeping places.
Under the supervision of the health facility staff, the volunteers registered all households in their
NHCs, locations of the households, number of people in each household and the numbers of
each household, names and ID numbers of the household heads. Following the registration, they
then collected the LLINs based on their needs and distributed the required LLINs in the
respective households and obtaining signatures or thumb prints of the household heads upon
accessing the LLINs using the community registers.
ITNs Distribution implemented by the MoH A total of 3,205,291 ITNs procured by UNDP were distributed by the MoH in the following
Districts:
In Central province: Chibombo (139,160), Chisamba (65,032), Itezi tezhi (50,640), Kabwe (130,
701), Kapiri mposhi (170, 240), Mkushi (102, 768), Mumbwa (151, 501), Serenje (111,419).
In Eastern province; Katete (163, 177), Chadiza (71,737), Chipata (301,760), Lundazi (261,363),
Mambwe (47,835), Nyimba (52,442), Petauke (208,260) – bring to a provincial total of (1,079,340)
nets distributed .
In Muchinga province; Mpika (142,120), Chama (56,990), Nakonde (81,075), Chinsali (47, 919),
Shiwang'andu (41,900), Isoka (47,778), Mafinga (48,160). Northern province; Chilubi (50,785),
Mbala (129,964), Kaputa (78,700), Kasama (164,440), Luwingu (96,918), Mporokoso (68,618),
Mpulungu (67,808), Mungwi (97,737
Province Estimated Population
Number of Sleeping spaces
ITNs delivered by WFP
Number of LLINs actually distributed
Under/ Over distributed)
% Coverage of sleeping spaces)
Central Province 1,781,292 1,099,057 937,520 921,461 16,059 84%
Province Estimated Population
Number of Sleeping spaces
ITNs Delivered by WFP
Number of LLINs actually Distributed
Under/(over distributed)
% Coverage of sleeping spaces)
Eastern Province 2,105,538 1,260,395 1,079,340 1,062,917 16,423 84%
Province Estimated Population
Number of Sleeping spaces
ITNs Delivered by WFP
Number of LLINs actually Distributed
Under/(over distributed)
% Coverage of sleeping spaces)
Muchinga Province 972,237 547,350 493,220 465,942 27,278 85%
52
In Northern province; Chilubi (50,785), Mbala (129,964), Kaputa (78,700), Kasama (164,440),
Luwingu (96,918), Mporokoso (68,618), Mpulungu (67,808), Mungwi (97,737)
ITNs Distribution implemented by the CHAZ A total of 1,320,066 ITNs procured by UNDP were distributed by the CHAZ in the following
Districts:
In Southern province: Sinazongwe (68,360), Siavonga (65,688), Choma (163,500), Livingstone
(96,480), Monze (125,048), Kazungula (75,480), Namwala (68, 600), Mazubuka (150,710,
Gweembe (35,513) and Kalomo (187,560) ) – bring to the provincial total of (1,038,000)nets
distributed.
In North western province; Chavuma (22,920), Ikelenge (20,507), Kabompo (60, 322), Kasempa
(47,920), Mufumbwe (39,720), Mwinilunga (68,660), Solwezi (169,678), Zambezi (53,400) – bring
to the provincial total of (485,400) nets distributed,
The figure below shows the total number of ITNs distributed in the 6 Provinces and percentage
coverage of sleeping places
Province Estimated Population
Number of Sleeping spaces
ITNs Delivered by WFP
Number of LLINs actually Distributed
Under/(over distributed)
% Coverage of sleeping spaces)
Northern 1,497,222 820,821 772,980 754,971 18,009 92%
Province Estimated Population
Number of Sleeping spaces
ITNs Delivered by WFP
Number of LLINs actually Distributed
Under/(over distributed)
% Coverage of sleeping spaces)
Southern 1,769,984 1,258,184 1,038,000 1,036,939 1,061 82%
Province Estimated Population
Number of Sleeping spaces
ITNs Delivered by WFP
Number of LLINs actually Distributed
Under/(over distributed)
% Coverage of sleeping spaces)
North Western 944,003 531,686 485,400 483,127 2,273 91%
53
Figure 23 The total number of ITNs distributed and percentage coverage of sleeping places, by
Provinces covered
Sources: Aggregations from MoH and CHAZ Progress Reports, December 2014
All the 46 districts who received nets submitted reports approved by the district health offices to
the central level- accounting to 4,725,357 actually distributed by end of December 2014.
A review of District reports at the Central level shows a shortfall of 81, 103 nets. Out of these
77,769 were distributed to under five children and pregnant women through the routine
distribution; and 3,334 nets were reportedly lost or could not be accounted for.
Accountability and reporting on the ITNs distributed
The reporting systems on the number of LLITNs distributed was envisaged to use the “bottom up data flows approach”. Data collection tools were elaborated to collect raw data at the community levels and, at the Health Facilities and Districts, the form provided aggregated information from the lower levels as follows:
1. The community data collection form was used at community level and collected information on household and bed space registration, LLINs actually distributed and indicated the beneficiary names and IDs. This information was recorded and reported by community volunteers and was passed on to the health facility.
2. The Health centre aggregation form was used for aggregating the number of nets required and the number of nets actually distributed in each of the health facility catchments; this was compiled by a designated officer at the health facility and passed on to the district.
3. The District aggregation form was used for aggregating data on ITNs distributed by all facilities in their respective districts and was passed on to the central level.
4. At central level, the focal person at National level who is the Principal ITN Officer at the National Malaria Control Program (NMCP) received all the district reports and entered the data into the NMCC’S ITN distribution database.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
Central Eastern Muchinga Northern Southern NorthWestern
Number of Sleeping spaces Number of LLINs actually Distributed
% Coverage of sleeping spaces
54
Since MoH and CHAZ had signed an SR agreement with UNDP to distribute and account for all
the nets received, the two SRs regularly conducted on-the site visits during and post LLTNs
distribution period and, received copies of Districts reports and aggregated information to
establish the actual number of LLITNs distributed in their respective Provinces.
Performance-Based Payment (PBP) for LLITNs distributed The successful distribution of huge sum of nets to end users, about 4.8 million in less than three
month, was largely attributed to the performance based payments made to key actors in the actual
distribution process as incentives.
The Community Health Workers (CHWs), Health Workers (HWs)at the Health facilities and Health
Workers at the District level were paid for the services rendered to reach out LLITNs to the
beneficiaries as follows:
The CHW was paid ZMK1 for every LLIN that was actually distributed and accounted for. The HW was paid 20 ngwee for every LLIN distributed and accounted for at the health facility. The District Malaria Focal Points was paid ZMK500 for supervision, reviewing the health facility report and preparing the District consolidated report. It was a requirement that the District reports are authenticated by the District Medical Officer by way of signing it and stamping it with an official District Stamp.
Lessons learnt that could inform future distribution
Delivery and hand-out of millions of nets to end users was made possible by health workers and
community volunteers.
Coordinated by the MoH, MCDMCH and
the NMCC, the ITNs distribution process
has registered significant success.
Drawing on their logistical strength, WFP
has proved to have capacity to transport
ITNs to as far as close to beneficiaries.
The WFP was able to transport nets to 980
health centers, close to beneficiary target
population.
55
For the purpose of ensuring programmatic management and accountability of ITNs planned to
reach end users, the MoH and partners designed ITNs recording and reporting systems which
enabled operational data flows from communities where nets were distributed to the central
MoH and CHAZ, through the health facilities and Districts.
Information about the ITNs received was recorded and reported at each level during the
distribution; community, health centre, district and province and was submitted to the MoH and
CHAZ.
Quality Assurance of ITNs from production to prior distribution stages
Internal quality assurance during the LLTNs production process : The contracted manufacturing company “NET HEALTH LIMITED” has internal quality assessment during the production process where LLINs produced are assessed on conformity to standards. In addition, Crown Agents was contracted by UNICEF to facilitate physical checks in terms of quantities, stitching, dimensions, cleanliness, trimming, weights, labelling and sizes. The pre-shipment quality assessment revealed that the LLINs conformed to the WHO standards.
External quality assurance during the LLTNs distribution: In addition to the quality assurance process conducted on the nets at the factories, UNDP engaged external quality assurance, conducted during the distribution of the LLINs. Prior to distribution, samples of nets from different batches were sent for external quality assessment at Wallon Agricultural Research Centre in Gembloux, Belgium for both physical, chemical and stress analysis. The analysis assessed appearance, permethrin identity, content and isomer ratio, fabric weight, permethrin wash resistance index, netting mesh size, dimensional stability to washing and bursting strength of both the net fabric and seams. The report shows that all the 14 samples were in conformity to WHO standards in line with the purchase agreements.
Challenges experienced The major challenges in the ITNs distribution included impassable roads in hard- to- reach urban
villages, long distances covered by health workers, and the intensity of the field work done by
CHAZ and the MoH to review the distribution documentations at Districts, Health Facility and
conduct selected households physical verifications at community level to certify whether the
number of nets reportedly distributed actually reached the end beneficiaries.
The program also faced lack of adequate resources to conduct on-site monitoring during and
post-distribution, covering wider sample of ITNs mass distribution
56
4. PROGRESS IN IMPLENTATION OF CAPACITY DEVELOPMENT AND TRANSITIONAL PLAN, 2014
During the year 2014, UNDP in collaboration with the MoH have successfully completed the
implementation of Phase 1 of the MoH’s Capacity Development and Transitional Action Plan (
CDTP) which was jointly developed by UNDP and MOH in consultation with the key stakeholders.
This plan has brought about sustained positive change in the MOH’s ability to manage GF grants
and enabled the MoH to resume the Principal Recipient (PR). Since January 2015, the MoH has
taken over the PR-ship roles, and has since signed with the Global Fund, the NFM grant with the
portfolio of about $240 million to finance high impact HIV/TB and Malaria programmes for two
years period ending 2017.
Figure 23: MoH’s Capacity Development and Transition Plan – Functional areas and budget
allocations
4.1 The successful Capacity Development interventions which enables the transfer of PR-ship to the MoH.
The following the key milestone were achieved with support of CD Plan, funded by under the
Global Fund
$274,227
$994,593
$219,594
$1,581,719
Programme Management
Financial Management &Systems
Procurement and SupplyManagement
Monitoring & Evaluation
Total Budget $ 3,070,133
Establishment of a
Skilled and functional
Programme
Management Unit (
PMU) within the
Ministry of Health to
manage Global Fund
Grants with high
efficiency and
accountability.
57
2.Deployment and
Live go of the
Automated Financial
Management
Information System,
NAV Application at
PMU that ensures
timeliness and
accuracy in financial
data capture, morning
and reporting.
3.Procurement
Standard
Operating
Procedures
operationalized at
MOH that ensure
transparency and
value for money.
58
Subsequently, to determine whether the nominated PR and SR fulfils Global Fund minimum
standard, capacity assessment of MOH and MCDMCH was conducted by the Global Fund in
June, 2014. The assessment confirmed that MOH meets standard capacity criteria in all functional
areas to resume the PR role, except in sub-recipient management which was not part of the
Phase 1 of CDTP.
The assessment further recommended, the need for MOH to develop capacity of its sub
recipients (MCDMCH and MSL) in grants implementation whilst managing the HIV/TB and Malaria
grants as PR under NFM starting from January 2015 to December, 2017. The NFM grants for both
HIV/TB and Malaria were signed by the MOH in January, 2015
UNDP as an interim PR will continue to provide technical support to MOH on grants
implementation as well as developing capacity of its SRs MCDMCH and MSL until it exit fully as
a PR with the ending of HIV single Source Funding in August, 2016.
4.Health Management
Information Systems,
and M&E Strengthened
at MOH to generates
quality and complete
data on time to
influence
policy/strategic
decisions to improve
health of Zambians.
59
4.2 Phase 2 of Capacity Development Plan focusing on MoH’s SR Management, capacity of MDCMCH and MSL.
UNDP with funding from the Global Fund supported the development of detailed Sub Recipient
Management Manual for MOH, which outlines SR selection, monitoring, reporting and
supervision of implementing partners, and conducting in-depth capacity assessment of
MCDMCH and MSL with recommended strategy to address capacity gaps.
The findings from the in-depth capacity assessment of MCDMCH and MSL informed the
development of a detailed Costed Capacity Development Operational Plan for MCDMCH and
MSL respectively. This plan also incorporated the MoH’s SR management elements and few
other CD activities for MOH as recommended by the GF and the UNDP assessment.
The Phase II of the CD operational Plan of MCDMCH focuses on developing institutional and
program management , financial management and monitoring and evaluation capacity of
MCDMCH; while the plan for MLS is geared towards strengthening national storage and
distribution systems.
The exceptionally successful partnership between the Ministry of Health and UNDP Zambia has
been documented and published as a Global case study on UNDP’s works to strengthen national
capacity to manage Global Fund programmes and ensure sustainability of GF investment. This
model of success can be adopted as best practices by many other countries and consider national
capacity development as an on- going part of the Global Fund Grants.
5. Key Results, Changes and Success Stories across GF Functional Areas
Results and changes brought about by Implementation of Capacity Development and Transition Plan, 2014
- Successfully transitioning of the PR roles from the UNDP to the MoH, from January 2015 - An extensive consultations between UNDP, MoH, MCDMCH, MSL, the Global Fund and
cooperating partners to assess capacity gaps at MoH, MCDMCH, MSL, and subsequently elaborate operational plans to aggress the identified capacity gaps.
- Strong national political commitment by the MoH, high level support from the Global Fund, UNDP and other partners
- Good partnership between MOH and UNDP, joint planning and team work in grants and CD plan implementation
- CD efforts firmly grounded in strengthening existing systems rather than creating parallel systems
- The establishment of a dedicated PMU in the Ministry of Health. - An effective combination of applied technical assistance, training, development of policy
and procedures and upgrades to technology.
Key operational results under Procurement and supply chain Management
- With support from the GRZ and the GF TB Grant, the country has had a stable supply of both first line and second line anti TB drugs during the year with no reported stock outs at the
60
health facilities. - Preferential treatment from the UNDP Long term agreements with suppliers, including
volume discounts for ARV drugs thereby stretching the dollar to procure more products in the country, and shorter lead times for lab reagents and consumables.
- Direct deliveries to services delivery points for medical equipment thereby reducing double handling and related costs.
- Improvement in forecasting and quantification of products (particularly ARV drugs and TB drugs), thereby improving the supply chain management by bringing consignments when they are needed to avoid overstocking and potential expiries.
- Supporting operations at Medical Stores, including provision of vehicles for transportation, forklifts for improved handling and computer equipment for warehouse management activities, support setting up of hubs by providing equipment to last mile distribution.
- Support the implementation of the national supply chain strategy at MSL. - The QA team together with their MoH counterparts conducted regular verifications of
assets procured under the Global Fund project. The teams conducted the verification exercises in all provinces, ensuring that the assets were delivered, appropriately recorded and used for the intended purpose.
- In the year 2014, regular sampling of pharmaceutical products were collected and permits obtained from Zambia Medicines Regulatory Authority (ZAMRA) to export the sampled for external QA. Certificates of Analysis have all indicated compliance with required standards for each product analysed.
Results and operational changes in the Financial Management, 2014
- Implementation of Direct Cash Transfer (DCT) for SR’s activities (MoH, CHAZ and WFP) as the new modality of transactions from a full Direct Payment system. As a result of DCT, MoH produces SR financial settlement report for management of Advances in ZMW and SR financial report in USD.
- Set up a new company for each grant as project in NAVISION to manage project transactions per grant (budget, income, payment, payroll, imprest and asset register)
- Fixed asset module in Navision has been activated and is now operational, making recording and keeping of disaggregated records a lot easier.
- MoH completed recruitment of a full finance and internal audit unit with a staff compliment of 8 members of staff (5 finance staff, 2 Internal audit unit and 1 compliance officer)
Key results under Programme management, M&E and reporting. - Regular coordination meetings, and amongst technical staff from MoH and MCDMCH
have enhanced coordination, buy-in and timely implementation of program activities - Improved planning and monitoring of the SR work plan: During the year 2014, UNDP
began transferring funds to MoH under the Direct Cash Transfer Modality. The close monitoring of programmatic and financial accountability ensured that only activities that can be realistically implemented are included in the work plan for the following implementation period- bearing in mind the human resource capacity to deliver programmes, financial and technical capacities).
- Financing and supporting finalization of key strategic plans, including NTP National Strategic Plan and M&E Plan (2011-2016); NMCP – NSP (2011-2016); Contributing to finding the MTR of the NSF, and revising the NSF(2011-2016)
61
- Procured of 4,810,300 LLITNs and fund the distribution in 6 Provinces: Northern (754,971), Muchinga (465,942), Southern (1,036,939, North western (483,127), Central (921,461) and Eastern provinces (1,062, 917).
- Completed the roll-out of the Primary Health care DHIS a web-based data base, and
commenced the creation of Hospital DHIS with support from the Global Fund.
- By end of February 2014, the reporting completion rate for the period January to December 2014 was reported at 95%.
- Conducting training to all the Provincial and Districts in HMIS/DHIS.2, and funding training of 125 Health Information Officers in M&E of Health Programmes, certified by the University of Zambia
- Support MoH and MCDMCH to conducting on-site data quality and completeness review in all the provinces, and targeted low performing Districts earlier assessed
as lagging behind in terms of completeness of data. Conducting joint workshops to review and validate the quality and completeness of data submitted to the Global Fund and into the Annual Reports.
6. Challenges experienced in Implementation of the Grants, and Responses
Inadequate funding: The country experienced resource gaps to ensure a balanced match between prevention, care and treatment of the three diseases. While the GRZ tripled its annual contribution for ARVs from USD 12 Million in 2011 to USD 35 Million from 2013, the in-country partner support did not increase from the 2013 levels, hence there is still financial gap based on the needs between 2014 and 2017.
Forecasting and quantification of health items: The country experienced problems of forecasting reliable quantities of health products (ARVs, test kits, ACTs, RDTs, TB drugs… etc.) largely due to non-availability of accurate data on consumption levels at Health facilities. This is, indeed, due to the fact the national supply chain systems, managed by MSL, ends at the District level.
Regular changes in treatment Guidelines: The evolution of clinical services, especially around PMTCT and ART, has resulted into changes in treatment protocols. This has, and will continue to require alterations of orders placed (ARV drugs, HIV test kits, etc.).
Existing Therapeutic committees within the MOH are being strengthened while the capacity to monitor the quality of commodities coming into the country, both by the PRA, through the National Quality Assurance Laboratory and MSL at facility level.
62
Programmatic/M&E risks: While commendable progress was made to upgrade the functioning of health management information systems (HMIS), including revision and printing of HMIS tools, DHIS.2 roll-out and training of all Health Information Officers at central MoH, Provincial and Districts; Data sources for the outcome and impact indicators rely heavily on donor supported resources. These include the DHS, PMTCT study, Sentinel Surveillance Survey and other operational programme-specific studies.
Lack of resources and sometimes failure by the partners to honour commitments has hindered the completeness of these surveys and, subsequently delays in release of results/findings - when they are needed to inform policy orientation and strategic planning.
Human Resources for Health: Inadequate levels of HRH (trained and quantity) at different levels, particularly in rural services delivery points. Low staffing levels in the main implementing units at MoH and MCDMCH, coupled with competing priorities, is the major cause of slow rate of some program implementation
The MOH in collaboration with partners are working together to improve the capacity of health care workers at different levels, through training.
Financial Management of Cash and Imprest under GF grants: The MoH will need to reinforce full function of NAVISION for all grants directly managed by MoH, and improve cash and imprest management.
63
ANNEXES ________________________________________________________
ANNEX 1: OVERALL FINANCIAL PERFORMANCE OF HIV/AIDS GRANTS (2013 -2014)
Expenditure Categories Cumulative Budget
Cumulative Expenditure
Variance Reasons for Variance
PMTCT 787,952.44 254,221.49 533,730.95 Delays in implementation of activities, lack of disbursement modalities to sub-national levels
VMMC 361,990.43 45,162.49 316,827.94 Delay in procurement process of MC equipment, kits and surgical consumables. Lower procurement costs of motor vehicle against initial budget- servings realized.
Testing and Counselling 2,649,107.91 4,063,991.14 -1,414,883.23 Temporal overspend as the procurement of HIV test kits for 2 years was done in the previous period due to the needs on the ground.
Blood safety and universal precaution
960,052.00 987,009.24 -26,957.24 The variance is due to higher unit cost of the Blood Bank item and transport equipment for Blood bank procured.
STI diagnosis and treatment
334,095.66 0.00 334,095.66 Delays in finalization/agreement of implementation arrangement between MoH and UNDP on implementation of STI Prevalence and Validation Study.
ART 50,617,926.67 48,722,334.15 1,895,592.52 Lower unit cost of ARVs from the Year 1 budget, delays in procurement of some items;
M&E - Information Systems and Operational research
2,923,592.49 339,248.14 2,584,344.35 Delays finalization of papers based HMIS Tools and printing, and delays in training of HCWs in Hospital HMIS and SmartCare.
Procurement & Supply Management (PSM) Strengthening
494,816.29 87,726.20 407,090.09 Delays in receiving specifications, leading to delayed printing and procurement processes.
Public Financial Management (PFM)
289,880.86 0.00 289,880.86 Postponement of the plan activities to the next quarter or semester
Institutional Capacity Development
580,963.02 9,183.28 571,779.74 Delay in approval of the proposal budget for the 2nd phase of CD plan
64
Expenditure Categories Cumulative Budget
Cumulative Expenditure
Variance Reasons for Variance
Procurement Supply Management
10,296,092.33 6,002,529.75 4,293,562.58 Overall delay in procurement process for both health and non-health items Lower unit costs than budgeted, hence realizing servings.
Institutional Capacity Development
742,813.75 516,463.06 226,350.69 Overestimate in the budget and, some activities were dropped
MoH, UNDP Programme Management and Administration
10,563,488.67 8,501,191.98 2,062,296.69
This variance will be off-set once budget review and re-allocation is approved by the Global Fund
Totals 81,602,772.52 69,529,060.92 12,073,711.60
ANNEX 2: TRENDS OF FINANCIAL PERFORMANCE AS AT END OF 2014 ( BUDGETS VIS A VIS DISBURSEMENTS AND EXPENDITURE) IN MILLION US$
1.29
69.58 74.15 78.57
81.60 78.57 78.57 78.57 78.57
130.10
49.94 51.79 58.26 61.16
69.30
-
20
40
60
80
100
120
140
Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014
Original Budget Disb to UNDP Actual Exp
65
ANNEX 4: THE OVERALL FINANCIAL PERFORMANCE OF TB GRANTS (cumulative to December 2014), IN US$
Expenditure Categories Cumulative Budget
Cumulative Expenditure
Variance Reasons for Variance
Phase 2 Round 7: Activities, budget and expenditure
Improving diagnosis 78,242.86 78,242.86
Standardized treatment, patient support and patient charter
3,709,401.10 3,709,401.10
M&E and External Quality Assurance
45,311.26 45,311.26
Procurement Supply Management
696,086.39 722,910.22
-26,823.83
Extra payments to MSL for storage and distribution of both pharmaceutical and lab supplies.
MDR-TB 230,176.80 230,176.80
To address TB/HIV, MDR-TB and other challenges
27,883.27 29,083.27
To contribute to health systems strengthening- HSS
837,521.86 791,924.54 45,597.32 Delayed procurement activity under phase 2, variance will be addressed.
Human Resource 589,418.32 454,620.14 134,798.18
This variance represents forecast for the closure plan after 30 June 2015
Program Management and Administration 1,232,859.49 1,169,784.92 63,074.57
Outstanding salary for Provincial TB/HIV liaison officers
Transitional funding Mechanisms – Activities , budget and expenditure
TFM related Procurement and Supply Management
2,112,500.69 1,890,596.54 221,904.15
Lower unit of the items procured, hence realized servings . Delays in waving the CP to procure 2nd line TB drug
Improving diagnosis and treatment
105,931.32 19,333.14 86,598.18
Pursue high-quality DOTS expansion and enhancement, M&E and EQA
352,302.05 59,463.33 292,838.72
Some Provincial and District level activities were not implemented
To contribute to health systems strengthening- HSS
823,630.98 19,604.50 804,026.48 Same explanations as above
Procurement Supply Management
82,363.10 28,876.61 53,486.49 Same explanations as above
Programme management and Administration
374,487.99 242,900.60 131,587.39
All TB-specific supervisory were conducted as cross-cutting and funded by SSF HIV. There were overall lower expenses in comparison with
66
Expenditure Categories Cumulative Budget
Cumulative Expenditure
Variance Reasons for Variance
Phase 2 Round 7: Activities, budget and expenditure
the approved budget
New Financing Model Grant – Activities, budget and expenditure
Improving Diagnosis 1,361,606.73 0.00 1,361,606.73
EQA supervisory visits to the provinces 102,280.18 42,860.00 59,420.18
Some Provincial and District level activities were not implemented
Procurement Supply Management
234,877.16 0.00 234,877.16
Programme Management and Administration
741,658.95 526,808.13 214,850.82
170,829.59 18,151.64 152,677.95
Totals 14,553,462.67 10,689,407.74 3,864,054.93
Annex 4: MoH, MCDMCH and UNDP personnel who took part in the production of 2014 Annual Report.
Name Position Organisation Contributions in disease Component (s)
1. Dr. Blaise Karibushi GF Project Manager UNDP All
2. Dr. Dean Phiri Grants Manager MoH All
1. Edmond Mwakalombe Chief Planning and M&E MCDMCD All
3. Mr. Trust Mfune Principal M&E Officer MoH HIV/AIDS
4. Mr. Japhet Taratibu M&E Specialist UNDP All
5. Mr. Boniface Mwanza M&E Specialist MoH All
6. Mr. Patrick Amanzi M&E Officer UNDP All
7. Dr. Henry Phiri Program Officer – HIV/TB MoH HIV/TB
8. Ms. Mercy Ingwe M&E Officer MoH/NMCC Malaria
9. Ms. Chali Selisho M&E Officer UNDP TB
10. Mr. Calvin Kalombo Senior M&E Officer MoH HIV/AIDS
11. Mr. Clifford Munyandi M&E Officer MoH TB
12. Ms. Nalukui Kazilimani M&E Officer UNDP Malaria
13. Dr. James Zulu Principle TB Programme Officer
MCDMCD TB
14. Clara Kasapo TB M&E Officer MCDMCD TB
15. Mr. Peter Funsani M&E Officer MoH Malaria, HIV
16. Mr. Sitali Mukube M&E Officer MoH TB
17. Dr. Nawa Mukumbuta Program Officer - Malaria UNDP Malaria
18. Dr. John Banda Program Officer - Malaria MoH Malaria
19. Mr. Paul Chitengi Program Officer - HIV UNDP HIV
20. Ms. Veronica Muntanga VCT/HCT - Officer MCDMCH HIV
21. Mr. Kazuhisa Yokomizo Finance Manager UNDP All (Finances)
22. Ms. Mildred Mushamba PSM Specialist UNDP All (Procurement)
23. Ms. Muyaka Ngwira Quality Assurance Officer UNDP All (QA)
24. Mr. Dungani Cheembo Logistics Associate UNDP All (Logistics)
67
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