Attachment_6_NMSP2011-2015_Final_(1).pdf

National Malaria Control Programme Ministry of Health Lusaka, Zambia

Republic of Zambia

Ministry of Health

NATIONAL MALARIA CONTROL

PROGRAMME STRATEGIC

PLAN FOR FY 2011‐2015

“Consolidating malaria gains for impact”

Government of the Republic of Zambia

MINISTRY OF HEALTH

DRAFT-2 (10March2012)

National Malaria Strategic Plan 2011-2015

Consolidating Malaria Gains for Impact Page i

CONTENTS PAGE

FOREWORD ............................................................................................................................................. III

ACKNOWLEDGEMENTS ........................................................................................................................ IV

LIST OF TABLES ...................................................................................................................................... V

LIST OF FIGURES .................................................................................................................................... V

ACRONYMS AND ABBREVIATIONS .................................................................................................... VI

DEFINITIONS OF SELECTED TERMS ................................................................................................. VII

1 EXECUTIVE SUMMARY

1.1 INTRODUCTION

1.2 SITUATION ANALYSIS

1.3 VISION, MISSION, AND GOALS

1.4 PROPOSED STRATEGIES

1.5 COSTING AND GAP ANALYSIS

1.6 IMPLEMENTATION FRAMEWORK

2 INTRODUCTION

2.1 CONTEXT

2.2 PURPOSE

2.3 STRUCTURE

2.4 CRITICAL LINKAGES

3 BACKGROUND

3.1 JUSTIFICATION

3.2 METHODOLOGY AND PROCESS

4 SITUATION ANALYSIS

4.1 COUNTRY PROFILE

4.2 MALARIA EPIDEMIOLOGY

4.3 MALARIA PROGRAMME PERFORMANCE

4.4 MAIN STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS

5 STRATEGIC FOCUS

5.1 VISION, MISSION, AND GOALS

5.2 OBJECTIVES AND MILESTONES

5.3 STRATEGIC PRIORITIES

5.4 KEY PRINCIPLES

6 PROPOSED STRATEGIES

6.1 OVERVIEW

6.2 HEALTH SERVICE DELIVERY

6.3 HEALTH WORKFORCE/HUMAN RESOURCES FOR HEALTH (HRH)

6.4 MEDICAL PRODUCTS, INFRASTRUCTURE, EQUIPMENT, AND TRANSPORT

6.5 HEALTH INFORMATION

6.6 HEALTH FINANCING

6.7 LEADERSHIP AND GOVERNANCE

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7 IMPLEMENTATION FRAMEWORK

7.1 OVERVIEW

7.2 POLICY AND REGULATORY FRAMEWORK

7.3 INSTITUTIONAL FRAMEWORK

7.4 PLANNING AND CAPACITY BUILDING

7.5 FINANCING ARRANGEMENTS

7.6 MONITORING AND EVALUATION

7.7 ANALYSIS OF RISKS AND PROPOSED MITIGATION

8 ANNEXES ....................................................................................... 7ERROR! BOOKMARK NOT DEFINED.

ANNEX 1:0 NMCC ORGANISATIONAL STRUCTURE

ANNEX 2:0 MONITORING AND EVALUATION FRAMEWORK

ANNEX 2.1: NATIONAL MALARIA PERFORMANCE MONITORING INDICATORS

ANNEX 3:0 COSTING AND GAP ANALYSIS

ANNEX 3.1: PROGRAMMATIC AND FINANCIAL GAP ANALYSIS ‐ MALARIA COMMODITIES

ANNEX 3.2: SUMMARIZED COSTING AND FINANCIAL GAP ANALYSIS

ANNEX 4: 0 ZAMBIA: HEALTH FACILITIES BY TYPE, SIZE, AND OWNERSHIP, 2010

ANNEX 5: 0 REFERENCES

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FOREWORD

Zambia’s overall development framework is guided by the Zambia Vision 2030 Strategy, which aims to transform Zambia into a prosperous middle-income nation by 2030. The Vision 2030 Strategy is being implemented through Five-Year National Development Plans, with the current one being the Sixth National Development Plan 2011–2015 (SNDP). At sector level, the Ministry of Health has developed the National Health Strategic Plan 2011– 2015, which is linked to, and forms part of the SNDP.

Malaria is a major driver of poverty and thus a major obstacle to socioeconomic development. In view of the foregoing, malaria has been prioritized in the national development agenda, particularly in the Vision 2030 Strategy and the SNDP.

Over the past five years, significant progress has been made in malaria control in Zambia and other parts of the African sub-region. However, significant challenges still remain. The lessons learned from the Malaria Indicator Survey 2010, which reported some resurgence of malaria incidence and impact in some parts of the country, calls for focused and sustained implementation of high impact malaria interventions, differentiated on the basis of evidence.

In this respect, the Malaria Program Review 2010 proposed to fine-tune the strategies by packaging the high impact malaria interventions according to the identified malaria epidemiological patterns.

This document presents the National Malaria Strategic Plan 2011–2015. It provides a strategic framework for comprehensive and coordinated delivery of targeted evidence-based packages of high impact malaria control interventions in order to achieve the national vision of “a malaria-free Zambia by 2030.”

In this respect, I wish to call upon all our partners, including the bilateral and multi-lateral partners, faith-based organizations, private sector, civil society, and community partners, to maintain their commitment and scale up their support in order to consolidate the gains and achieve the objectives of this new strategic plan.

I sincerely hope that this plan will lead our country closer to the 2030 vision of a malaria-free Zambia.

Dr. Peter Mwaba Permanent Secretary

DRAFT-2(10March2012)

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ACKNOWLEDGEMENTS

I wish to acknowledge, with thanks, the participation and support of various stakeholders and partners including: government ministries and departments; the World Health Organization (WHO); the United Nations Children’s Fund (UNICEF); the United States President’s Malaria Initiative (PMI); the Malaria Control and Evaluation Partnership in Africa (MACEPA), a program at PATH; faith-based organizations, under the coordination of the Churches Health Association of Zambia (CHAZ); research and academic institutions; civil society organizations, including World Vision, and Malaria Consortium; and the private sector. All these partners participated in the process of developing this strategic plan, under the leadership and coordination of the Ministry of Health (MOH) Directorate of Public Health and Research.

I also wish to take this opportunity to thank all the members of staff at the National Malaria Control Programme (NMCP) of MOH, and officials from partner institutions who actively participated in the process of developing this strategic plan. Special mention goes to Dr.

Mulakwa Kamuliwo (NMCP), Dr. Chibesa S. Wamulume (NMCP), Dr. Emmanuel Chanda (NMCP), Busiku Hamainza (NMCP), Mercy Mwanza Ingwe (NMCP), Pauline Wamulume (NMCP), Chadwick Sikaala (NMCP), Kapelwa Wambinji, Cecilia Katebe (NMCP), Dr.

Freddie Masaninga (WHO), Nora Mweemba (WHO), Dr. Rodgers Mwale (UNICEF), Dr.

Richard Steketee (MACEPA), Dr. Boniface Mutombo (MACEPA), Dr. John Miller (MACEPA), Bertha Simwaka (MACEPA), Kafula Silumbe (MACEPA), Todd Jennings (MACEPA), Dr. Anna Winters (Akros Research), Benjamin Winters (Akros Research), Drs.

Allen Craig and Oliver Lulembo (PMI), and Mr. Boniface Chiluba (CHAZ). I also wish to thank the two consultants who provided technical support at different stages of the planning process, Bonah Chitah (at the early stages) and Alex Nondo Chikwese (at finalization).

May I also acknowledge the significant contributions from the representatives of all the nine Provinces and selected districts representing the three main malaria epidemiological transmission zones (Mansa, Luapula, Katete, Mongu, Lufwanyama, Ndola, Samfya, Lukulu, and Lusaka) for the invaluable technical inputs provided at the two stakeholders' meetings held on 9 January 2011, and 21 February 2011, respectively.

The strategy significantly benefited from the rich and diverse technical expertise and guidance from the NMCP Technical Working Groups and was financed with resources from MOH, MACEPA, and the Southern Africa Roll Back Malaria Network. We are most grateful for their support.

I thank you all.

Dr. Elizabeth Chizema Kawesha Director, Public Health and Research

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LIST OF TABLES

Table 1 Selected Demographic Indicators Table 2 Changes in all-cause child mortality rates 2001, 2002, and 2007, Zambia

Table 3 Clinical Staff Per 1,000 Population, as of December 2009 Table 4 Health Facilities in Zambia by type, ownership and provincial distribution, 2010 Table 5 Health Policies and Legislation relevant to malaria control in Zambia Table 6 Zambia NMCP Partners Table 7 Zambia NMCP Strengths, Weaknesses, Opportunities, and Threats Table 8 Zambia NMSP 2011–2015 Objectives and Milestones Table 9 Zambia National Malaria Control Priorities, 2011–2015 Table 10 Zambia NMSP 2011–2015: Analysis of Risks and Proposed Mitigations

LIST OF FIGURES

Figure 1 Trends in In-patient Malaria Cases and Deaths Among Children Under Five

Years of Age, by Quarter, 2001–2010 Figure 2 Epidemiologic Strata for Malaria Transmission in Zambia as Determined by

Child Parasitemia Prevalence, 2010 Figure 3 Trends in Reported Inpatient Malaria and Non-malaria, Non-anemia Cases, 2001–2008 Figure 4 Trends in Inpatient/Out-patient Cases in Public Health Facilities, 2001–2008 Figure 5 Health System Building Blocks – Conceptual Framework Figure 6 External funding (US$ million) received by the Zambia Malaria Control

Programme, 2003–2010 Figure 7 Levels of organization and coordination of the Zambia NMCP Figure 8 Health Sector Strategic Planning Framework

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ACRONYMS AND ABBREVIATIONS

ACT Artemisinin-based combination therapy AIDS Acquired Immune Deficiency Syndrome AL Artemether-Lumefantrine BCC Behaviour Change Communication CBO Community-based organization CHAZ Churches Health Association of Zambia CHI Church Health Institutions CHW Community Health Worker CSO Central Statistics Office DfID Department for International Development (United Kingdom) DMO District Health Offices EPR Epidemic Preparedness and Response GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HC Health centers HIV Human Immunodeficiency Virus HMIS Health Management Information System HP Health Posts IEC Information Education, Communication EPR Epidemic preparedness and response MDGs Millennium Development Goals MACEPA Malaria Control and Evaluation Partnership in Africa MIS Malaria Indicator Survey MOH Ministry of Health MPR Malaria Programme Review NGO Nongovernmental organizations NHC Neighborhood Health Committee NHSP National Health Strategic Plan NMCC National Malaria Control Centre NMCP National Malaria Control Programme NMSP National Malaria Strategic Plan PHC Primary health care PHO Provincial Health Office PMI President’s Malaria Initiative PRA Pharmacy Regulatory Authority PMU Programme Management Unit RBM Roll Back Malaria RDT Rapid diagnostic test SADC Southern African Development Community SAG Sector Advisory Group SM&E Surveillance, monitoring, and evaluation SNDP Sixth National Development Plan TWG Technical Working Groups WHO World Health Organization ZDHS Zambia Demographic and Health Survey

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DEFINITIONS OF SELECTED TERMS

Activity An action or series of inter-related actions, necessary to deliver a service implemented to achieve an objective.

Goal A statement of the medium or long-term result that the organization or institution will achieve in pursuit of its mission.

Impact Long-term or medium-term effects produced by the implementation of a specific programme or intervention. This could be positive or negative.

Indicator A prior agreed or prescribed measure of programme performance in specific areas over prescribed timelines (may be a numeric value, a ratio, or a rate).

Milestone An activity or event that marks significant progress in delivering a product or service.

Mission statement A broad description of what the organization does, and with, for whom, and why the organization exists, i.e., has a sense of “fundamental purpose.”

Monitoring Continuous follow-up and assessment of activities and programme delivery to ensure that they proceed according to plan and meet the established goals, objectives, and targets.

Objective A statement of specific shorter-term results which contributes to the achievement of a goal. It should be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound).

Operational Plan An annual, semi-annual, or quarterly based plan aimed at achieving short and medium-term goals and objectives that are in turn related to the longer term strategic plans and objectives.

Output The immediate result of activities.

Strategic Plan A plan providing information on where the organization should be in the future.

Strategy A course of action or an approach (usually involving a group of activities) adopted by an organization to achieve its goals to fulfill its mission, in the face of existing and anticipated strengths, weaknesses, opportunities, and threats.

Values statement Description of the fundamental principles on which the organization is founded. This statement describe how an organization intends to operate on a day-to-day basis as it implements its vision and mission, normally ethical considerations best expressed in terms of behaviour.

Vision statement A future-oriented statement of the “ideal,” it describes the future the organization intends to create. The Vision Statement also provides direction and inspiration for organizational goal-setting and conveys a sense of “future direction.”

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1 EXECUTIVE SUMMARY

1.1 Introduction

This document presents the National Malaria Strategic Plan for 2011 to 2015 (NMSP 2011– 2015). It seeks to provide the strategic framework for the National Malaria Control Programme (NMCP), for the next five years, ending in 2015.

The plan is linked to, and forms a part of, the National Health Strategic Plan 2011 to 2015 (NHSP 2011-2015), and through it, to the Sixth National Development Plan 2011 to 2015 (SNDP), and the Vision 2030 strategy for Zambia, which provide the broader national development agenda. It is also linked to global health and malaria control initiatives, particularly the Roll-Back Malaria (RBM) strategy, and the Millennium Development Goals (MDGs).

1.2 Situation Analysis

1.2.1 Malaria Epidemiology

Malaria remains one of the leading causes of morbidity and mortality in Zambia. However, over the past 5 years, based on the available evidence, significant reductions in the malaria burden have been achieved. This was demonstrated by the substantial declines in in-patient malaria cases, deaths (more than a 60% decline) and anemia in under-five children, reported in the 2001-2008 analysis of routine surveillance data. However, during the period from 2009 and 2010, an upsurge in malaria cases and deaths was observed in some provinces, particularly the Northern and Luapula provinces.

Over the past 5 years, ending in 2010, emerging evidence from routine information systems, national surveys, and focused studies consistently reported declining malaria trends, evident in three malaria epidemiological zones in Zambia, which are as follows:

Zone 1: Areas where malaria control has markedly reduced transmission and parasite prevalence is <1% (Lusaka city and environs).

Zone 2: Areas where sustained malaria prevention and control have markedly reduced transmission and where parasite prevalence is between 1% and 14% in young children at the peak of transmission (Central, Copperbelt, North-Western, Southern, and Western Provinces).

Zone 3: Areas where progress in malaria control has been attained, but not sustained;

where lapses in prevention coverage have led to resurgence of infection and illness; and where parasite prevalence in young children is 15% or more at the peak of the transmission season (Eastern, Luapula, and Northern Provinces).

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1.2.2 Malaria Programme Performance

Malaria control has been prioritized in the national development agenda, and enjoys significant political will. The country’s vision is “a malaria-free Zambia by 2030.”

Over the past five years, significant success was achieved in scaling up high-impact, internationally proven malaria control interventions in prevention and malaria case management. As a result of these efforts, the percentage of homes with at least one long-lasting insecticide-treated net (LLIN) increased from 13.6% in 2001 to 38% in 2005 and to 64% in 2010, and over 6 million LLINs were distributed. As of 2010, indoor residual spraying (IRS) had been successfully implemented in 54 districts, an increase from 5 districts in 2003. The percentage of targeted homes actually sprayed remained above 85% (in most cases over 90%), meeting, and exceeding expectations. Households that either owned an LLIN or had been sprayed increased from 43% to 73%. Intermittent preventive treatment during pregnancy (IPTp) and diagnosis and treatment activities were also significantly scaled up.

Major challenges in this area included: the resurgence of malaria in Luapula, Northern, and Eastern Provinces; emergence of insecticide resistance; human resource challenges, including shortages of health workers, and skills gaps; inadequate resources for malaria control commodities and activities; data and information management gaps; and organizational challenges.

1.3 Vision, Mission, and Goals

The vision, mission, and goals for the National Malaria Control Program (NMCP) for the period of 2011 to 2015 are as follows:

Theme: To consolidate malaria control gains, for higher impact.

Vision: A malaria-free Zambia by 2030.

Mission: To facilitate equity of access to quality-assured, cost-effective malaria prevention and control interventions, close to the household.

Goals: To reduce malaria incidence by 75% of the 2010 baseline by 2015.

To reduce malaria deaths to near zero by 2015 To reduce all-cause child mortality by 20% of the 2010 baseline by 2015.

To establish and maintain five “malaria-free areas” in Zambia by 2015.

1.4 Proposed Strategies

The proposed strategies have been aligned to, and structured along, the “Six Health Systems Building Blocks” framework in order to facilitate a comprehensive analysis. These building blocks include: health service delivery; health workforce; medical products, infrastructure, and equipment; health information; healthcare financing; and leadership and governance.

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1.4.1 Health Service Delivery

The following are the proposed strategies in each of the main malaria service delivery areas.

1. Integrated Vector Management (IVM)

By 2015 achieve 100% coverage of households with access to vector control interventions and 80% coverage of people living in malaria-risk areas using appropriate vector control interventions.

Ensure IRS coverage of at least 85% of all the targeted structures/households in low to high transmission epidemiological zones, and focused application of surveillance-driven IRS in very low transmission zones by the end of 2011, and maintain through 2015.

Achieve universal coverage (100%) of targeted households and 80% utilization of LLINs by 2015.

2. Malaria Case Management

Ensure 100% of all malaria suspected cases in all districts receive parasitological

(microscopy or rapid diagnostic test [RDT]) analysis, and 100% of parasitologically confirmed malaria cases receive prompt, effective antimalarial treatment by 2015.

3. Information, Education and Communication/Behaviour Change Communication

(IEC/BCC)

Increase public awareness and knowledge on malaria prevention and control, and improve uptake and correct use of interventions.

4. Epidemic Preparedness and Response

Ensure that all districts have the capacity and preparedness to respond to malaria epidemics by 2015.

1.4.2 Health Workforce

Improve the availability and distribution of qualified health workers in the country.

Significantly increase the annual outputs of the health training institutions in order to mitigate the critical shortages of qualified health workers.

1.4.3 Medical Products, Infrastructure, Equipment and Transport

Ensure availability of adequate, quality, efficacious, safe, and affordable malaria commodities and consumables at all levels of service delivery through efficient and effective procurement and logistics management.

Ensure availability and equitable distribution of essential infrastructure in order to facilitate equity of access to essential health services.

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Improve on the availability and condition of transport and communication equipment, in order to facilitate efficient and effective implementation of malaria control activities at all levels.

1.4.4 Health Information and Monitoring and Evaluation

Strengthen surveillance, monitoring, and evaluation systems in order to ensure timely availability of quality, consistent, and relevant data on malaria control performance to guide policy and decision-making, during the course of this strategic plan.

Strengthen operations research to generate evidence to support informed decision-making on policy and implementation of the malaria programme.

1.4.5 Leadership and Governance

Significantly strengthen the leadership and governance frameworks in order to improve organization, coordination, partnerships, transparency, and accountability for efficient and effective management of the NMCP.

1.5 Costing and Gap Analysis

A detailed costing of the NMSP 2011–2015 has been done. The indicative total cost of the strategies is US$291,668,539. The total financing gap, after considering the projected funding from the Ministry of Health (MOH) and pledges from Cooperating Partners (CPs), is

US$184,021,465.

1.6 Implementation Framework

The plan will be implemented within the existing policy, legal, institutional, planning, financing, and monitoring and evaluation frameworks, which will be periodically reviewed and strengthened. The interventions proposed in this plan will be integrated into the Primary Health Care (PHC) systems and implemented through the established MOH structures and partnerships at national, provincial, district, facility, and community levels. MOH, through the National Malaria Control Centre (NMCC), will be responsible for overall coordination of the implementation of this plan. Deliberate efforts will be made to continuously review capacity needs and take appropriate capacity building measures during the course of implementing this plan.

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2 INTRODUCTION

2.1 Context

Malaria is a major public health concern in Zambia, and fighting the disease is a national priority that requires a focused, comprehensive, and consistent approach in order to achieve the vision of “a malaria-free Zambia by 2030.” Even though significant reductions in the malaria burden have been recorded over the past ten years, the disease is still among the major causes of morbidity and mortality in the country, particularly in high-endemic areas and among the vulnerable population groups, which include pregnant women and children less than five years of age. In 2009, malaria incidence per 1,000 populations was reported at 246, a reduction from the 358 recorded in 2006. However, in 2010 it increased to 330 due to resurgence experienced in some parts of the country, particularly the Eastern, Northern, and Luapula provinces1. In 2010, 4.2 million clinical and laboratory-confirmed cases were reported, representing an increase of 31% from 20082.

From 2006 to 2010, Zambia implemented a comprehensive five-year National Malaria Strategic Plan (NMSP 2006–2010), which provided the overall strategic framework for the fight against malaria in the country. Following the end of this plan, in 2010, the MOH, together with the NMCC and partners, identified the need to develop a new malaria strategic plan.

This document presents the National Malaria Strategic Plan 2011 – 2015 (NMSP 2011– 2015). It seeks to provide the strategic focus and framework for malaria control in Zambia for the next five years, ending in 2015. The plan was developed through a broad-based consultative process, involving all the key stakeholder groups, including MOH, NMCC, relevant government line ministries and departments, the faith-based health sector under the coordination of the Churches Health Association of Zambia (CHAZ), the private sector, civil society and communities, and the international CPs. The plan is linked to, and will be implemented within, the existing policy, regulatory, institutional, and monitoring and evaluation (M&E) frameworks, which will be further strengthened as proposed in the implementation framework. The plan is complemented by the National Malaria Operational Plan 2011–2013 and the National Malaria Monitoring and Evaluation Plan 2011–2015, which will guide implementation.

2.2 Purpose

The purpose of this plan is to provide, for the period of 2011 to 2015, a comprehensive strategic framework for the fight against malaria that contributes to the attainment of the national vision of “a malaria-free Zambia by 2030.” The plan seeks to:

1. Provide a comprehensive situation analysis highlighting the performance trends and status of the malaria programme against the objectives and targets of the NMSP 2006–2010.

2. Identify the strengths, weaknesses, opportunities, and threats for the national malaria programme in Zambia.

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3. Develop an appropriate strategic direction and framework that is evidence-based and aimed at significantly contributing to the attainment of the national vision of a “malaria-free Zambia.”

4. Carry out comprehensive programmatic and financial gap analyses and costing of the strategy.

5. Propose an implementation framework aimed at ensuring efficient and effective coordination of the implementation of the plan.

The plan provides a strategic focus and comprehensive framework for moving from “Scale-up for impact,” which was the main focus for the NMSP 2006–2010, to “Consolidated delivery of malaria prevention and control services,” based on the available evidence.

2.3 Structure

The plan is divided into the following chapters: executive summary, introduction, background, situation analysis, strategic focus, proposed strategies implementation framework, and annexes. The detailed structure of the plan is presented in the table of contents.

2.4 Critical Linkages

The NMSP 2011–2015 is linked to other important and relevant policy and strategic frameworks at sector, national, regional, and international levels. The implementation of this strategic plan will therefore be influenced by, and have an impact on, such frameworks.

At the national level, the plan is directly linked to, and forms a chapter of, the NHSP 2011– 2015, through which the plan is also linked to the SNDP and Vision 2030, which form the overall national development agenda. Vision 2030 is the country’s long-term development strategy, whose goal is to transform Zambia into a “prosperous middle-income nation by 2030.” The NMSP 2011–2015 is also linked to other disease-specific strategies and programmes within the health sector, including the maternal and child health strategies, the School Health and Nutrition strategy, and other relevant programmes.

At regional and international levels, the plan is linked to the MDGs3, the RBM strategy, the Southern African Development Community (SADC) Malaria Strategy, and other international frameworks relevant to malaria, to which Zambia is a signatory. The plan is also closely linked to, and significantly dependent on the technical and financial support, and active participation of various local and international partners, who have continued to significantly contribute to the fight against malaria in Zambia.

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3 BACKGROUND

3.1 Justification

From 2006 to 2010, Zambia implemented the NMSP 2006–2010, whose theme was “Scale--up for Impact”. While the implementation of this strategic plan resulted in significant progress and impact on malaria burden, morbidity, and mortality in Zambia, the plan came to an end in 2010. Considering the foregoing, it became necessary to develop a new strategic plan to provide the strategic framework for the next five years, from 2011 to 2015.

The NMSP 2011–2015 seeks to build upon previous successes and address current and emerging challenges in the fight against malaria. It is therefore focused on sustaining impact, delivering an integrated package of high impact malaria control interventions by epidemiologic strata, strengthening provincial and district capacities for delivery of key malaria control interventions, scaling up expanded use of malaria diagnosis for effective case management, and improved targeting of interventions through strengthening of surveillance, monitoring, and evaluation (SM&E).

3.2 Methodology and Process

The NMSP 2011–2015 was developed through a broad-based and highly consultative process, which aimed at achieving consensus and promoting ownership of both the process and the plan by all the key stakeholders. In this respect, all key stakeholder groups, including NMCC/MOH, other relevant government line ministries and departments, CHAZ, the private sector, civil society, community health partners, the communities, and CPs participated and contributed to the development of this plan. The planning process was coordinated by the Directorate of Public Health and Research of MOH, with strong technical back-up from the Directorate of Policy and Planning at MOH, with NMCC playing the role of secretariat for development. The process included the following main stages: preparation/inception, data collection and analysis, preparation of the draft, review of the draft, and finalization.

3.2.1 Preparation/Inception Phase

In order to ensure coordination, a roadmap for the preparation of the NMSP 2011–2015 was developed and a technical team was established to support the process. The technical team comprised members from various agencies, including NMCC/MOH; the World Health Organization (WHO); the Zambia Integrated Systems Support Program; the Malaria Control and Evaluation Partnership in Africa (MACEPA), a program at PATH; and the United States President’s Malaria Initiative (PMI). This team was intended to provide technical leadership, support, and coordination to the strategic planning process. The technical team worked closely with the existing National Malaria Control Programme (NMCP) technical working groups (TWGs) in the following thematic areas: programme management; integrated vector management (IVM); insecticide-treated nets (ITNs); IRS; malaria case management;

information, education, and communication (IEC); behaviour change communication (BCC);

epidemic preparedness and response (EPR); operational research; and SM&E.

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3.2.2 Data Collection and Analysis

Data collection and analysis formed a critical component of the strategic planning process.

Relevant data were collected mainly through desk review of relevant literature and reports, strategic planning meetings/workshops, and detailed analysis.

3.2.2.1 Desk Reviews

The desk reviews and analysis involved the identification, collection, and analysis of critical literature and reports relevant to malaria control in Zambia. The main documents reviewed included:

National Malaria Control Programme Reports. These included the NMSP 2006–2010, National Malaria Monitoring and Evaluation Plan 2006–2010, National Malaria Annual Action/Operational Plans for the period of 2006 to 2010, the Zambia Malaria Programme Review 2010 (MPR 2010) report, Malaria Indicators Survey (MIS) reports for 2006, 2008, and 2010, national malaria progress reports, and other relevant reports and surveys.

Health sector level documents. These included the National Health Strategic Plan 2006– 2010 (NHSP 2006–2010); Human Resource for Health (HRH) Strategic Plan 2006– 20104; Medium-Term Expenditure Framework Plans (MTEF); annual action plans and budgets, Health Management Information System (HMIS) reports; Sector Advisory Group (SAG) reports; the Health Sector Mid-Term Review 2008 report; Zambia Demographic and Health Survey (ZDHS)5; successful proposals and progress reports from the Global Fund to Fight AIDS, Tuberculosis and Malaria6; regulatory instruments and frameworks on the use and disposal of chemicals; and other relevant reports.

National level documents. These included Vision 20307, the Fifth National Development Plan 2006–2010 (FNDP), health-related legislation, FNDP Performance Assessment Framework, annual budget speeches by the Minister of Finance and National Planning, annual budget allocations/yellow book, and annual economic reports for the period 2006 to 2010.

International level documents. These included the MDGs8, RBM strategy and progress reports, WHO policy guidelines and reports on malaria control, SADC Malaria Strategy, Human Development Index reports, and other relevant documents.

3.2.2.2 Strategic Planning Meetings/Workshops

In order to provide for broader participation of stakeholders at all levels, a participatory “bottom up” consultative process was adopted.

The SAG is the highest policy making and coordination body under the Sector-wide Approaches (SWAPs) in Zambia. It comprises MOH, other government line ministries and departments, the faith-based health sector, represented by the Churches Health Association of Zambia (CHAZ), the civil society, and Cooperating Partners (CPs).

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This was largely facilitated through the holding of strategic planning meetings/workshops, which drew participants from all the key stakeholder groups. The draft strategic documents were also widely circulated to obtain feedback from all the key stakeholders at national, provincial, district, and community levels.

3.2.3 Preparation of the Draft NMSP 2011–2015

Following the strategic planning workshops, a consolidated draft NMSP 2011–2015 and the associated documents were developed, which were then widely circulated to stakeholders at different levels (i.e., national, provincial, district, and community levels) for review and comments. Circulation of the draft strategic documents was through a combination of methods, including hand deliveries, by post, by emails, and via the NMCC Website.

Communication with the communities was facilitated through the District Health Offices (DHOs) and Neighborhood Health Committees (NHCs).

3.2.4 Review of the Draft NMSP 2011–2015

The draft NMSP 2011–2015 was subjected to comprehensive internal and external reviews before being finalized. In this respect, the review was guided by the Joint Assessment of National Strategies (JANS) guidelines and tools, which is a comprehensive tool developed by the International Health Partnerships and related initiatives (IHP+) team at WHO used for assessing national-and programme-level health strategies9. This approach was also a requirement for countries intending to apply for GFATM support through the National Strategy Application route, which Zambia intended to do.

3.2.5 Finalization of the NMSP 2011–2015

Following receipt of the JANS Report from the external reviewers, a two-day national malaria stakeholders’ workshop was held to analyse and respond to the issues raised by the external JANS review team and finalize the strategic plan1. Participants at this workshop were drawn from a wide range of stakeholders at national, provincial, district, and community levels. NMSP-TWGs provided the necessary technical leadership and coordination in their respective thematic areas.

The final consolidation and editing of the strategic plan was carried out by the Joint Assessment Organising Body with technical support from a local consultant. The final version of the plan was also presented to MOH Senior Management and SAG meetings for consideration and approval. The plan was also presented to the Country Coordinating Mechanisms of the GFATM.

4 SITUATION ANALYSIS

4.1 Country Profile

4.1.1 Geography

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Zambia is a land-locked country located in Sub-Saharan Africa. It covers a surface area of approximately 752,612 square kilometers, and shares borders with the Democratic Republic of Congo and Tanzania in the north, Malawi and Mozambique in the east, Zimbabwe and Botswana in the south, Namibia in the South-West, and Angola in the West.

Administratively, the country is now divided into 10 provinces and 80 districts, following the recent reorganization. Lusaka and Copperbelt provinces are predominantly urban, while the rest of the provinces are predominantly rural. The capital city is Lusaka.

4.1.2 Political Overview

Since its independence in 1964, Zambia has remained among the most peaceful and politically stable countries in Africa. The country has also prioritized the fight against malaria, which has continued to receive significant political will and support at all the levels within the Government structures.

4.1.3 Demography

The country has experienced a rapid population increase, from 5.7 million people in 1980 to

13.05 million people in 2010. Population density increased from 7.5 people per km in 1980 to

13.1 in 2000, and 17.3 in 2010. Table 1 presents selected demographic indicators derived from previous Central Statistics Office (CSO) census reports and ZDHS reports.

Table 1: Selected Demographic Indicators Indicator Source Status Population CSO 2010 Census, interim results 13.05 million Sex ratio (males per female) CSO 0.99 Average annual population growth rate CSO projections 2.7% Life expectancy at birth CSO projections 51.3 years Population under the age of 15 years (%) CSO, 2000 Census 47% Urban population CSO, 2000 Census 34.7% Poverty levels ZDHS 2007 67% (overall)

4.1.4 Socio-economic Situation

Zambia is endowed with abundant mineral wealth, water resources, a varied biodiversity, arable land, and climate favourable to agriculture. The economy largely depends on mining and agriculture.

The country’s long-term development agenda is guided by the Vision 2030 Strategy, which aims at transforming the country into “a prosperous middle-income nation by 2030.” This national strategy is being implemented through successive five-year national development plans, with the current one being the SNDP. Malaria control was among the key priority areas identified in Vision 2030 and the FNDP for the period of 2006 to 201010.

Since 1991, Zambia has been implementing wide-ranging socio-economic reforms, aimed at attaining meaningful and sustainable socio-economic development. In 2010, the country

Consolidating Malaria Gains and Impact Page 11 graduated from the Highly Indebted Poor Countries category to that of a Low-to-Medium Income developing country.

4.1.5 Health Sector Development

Health sector development in Zambia is firmly linked to the overall national development agenda. During a five-year span ending in 2010, health sector development was guided by the NHSP 2006–2010, which was directly linked to the FNDP and Vision 2030. The health component of Vision 2030 seeks investments that will contribute to the attainment of health for all by 2030, with a mission of providing “equitable, cost-effective health services close to the household.”

Zambia is a country inundated with a huge burden of disease, leading to high morbidity and mortality levels among the population, with significant impact on socio-economic development. The disease burden is largely influenced by the high prevalence of preventable and treatable communicable diseases, such as malaria, HIV and AIDS, sexually transmitted infections, and tuberculosis (TB). Zambia is also among the countries with the highest levels of maternal and child mortality levels in the world, with a Maternal Mortality Ratio of 591 per 100,000 live births. The country is also experiencing a growing burden of non-communicable diseases, particularly hypertension, cardio-vascular diseases, diabetes mellitus, mental health, trauma, and various forms of cancer.

Even though major achievements have been made in malaria control, malaria still remains among the top 10 leading causes of morbidity and mortality in Zambia, particularly among pregnant mothers, children under five years of age, and other vulnerable population groups.

4.2 Malaria Epidemiology

The MPR 2010 reported a more than 60% decline in malaria morbidity and mortality in Zambia from 2001 to 200811. However, the review also observed that malaria still features among the top 10 diseases of public health concern and will therefore require continued investments and efforts to control.

4.2.1 Geographical Distribution of Malaria

The epidemiology of malaria in Zambia is a result of two major forces: the geographic, climatic, and social features of the country that establish factors conducive or restrictive to malaria; and the introduction and scaling up of malaria control interventions across the country, which alter transmission and the consequent infection, morbidity, and mortality rates associated with malaria.

4.2.2 Malaria Parasites

In Zambia there are four types of Plasmodium parasites that can cause malaria in humans: (1) Plasmodium falciparum, (2) Plasmodium malariae, (3) Plasmodium vivax, and (4)

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Plasmodium ovale. Out of these, P. falciparum constitutes the most predominant, causing the severest form of malaria. P. falciparum accounts for 98% of all malaria infections in the country, with low frequency of infections from P. malariae (>1%) and P. vivax (<1%), and little or no transmission of P. ovale.

4.2.3 Malaria Vectors

Malaria in Zambia is transmitted by the members of the Anopheles gambiae complex and of the Anopheles funestus group. The main vector species are Anopheles gambiae s.s., An.

Arabiensis, and An. funestus. Recent field research demonstrated the presence of An. nili in the An. nili complex, and An. funestus-like and An. Rivulorum within the Anopheles funestus group. However, their role in malaria transmission has yet to be established.

4.2.4 Vector Susceptibility to Insecticides

Currently, the insecticides used for IRS in Zambia include two classes, the organochlorines (DDT, for dichlorodiphenyltrichloroethane) and pyrethoids (Alphacypermethrin, lambdacyhalothrin, and deltamethrin). Insecticide resistance to DDT and pyrethroids has been detected in both An. gambiae s.l. and An. funestus. There is a great variation in the level of resistance between IRS and LLIN localities, with an exceptionally higher level resistance being detected in IRS areas. Knock-down resistance mutation has been detected in some parts of the country, particularly in the Copperbelt Province, with cross resistance between pyrethroids and DDT. Although larviciding is part of the IVM strategy, it has only been implemented in a few areas, by the private sector. Bacillus thuriengensis and Larvex 100, have been used or are currently being used for larviciding.

4.2.5 Efficacy of Antimalarial Medicines

Therapeutic efficacy testing has been conducted in Zambia since 1995 and provided policy direction. Based on such evidence, in 2003 the MOH adopted the use of artemisinin-based combination therapy (ACTs), using artemether-lumefantrine (AL), as a front line antimalarial medicine for uncomplicated malaria in all patients except children below 5 kg and pregnant women in the first trimester. Efficacy of AL is at 99%, as per a 2009 therapeutic efficacy study.

Quinine remains efficacious in the treatment of severe malaria in both children and adults.

The efficacy of Sulfadoxine-Pyrimethamine (SP) for use in IPTp is still being evaluated.

4.2.6 Disease Trends

Malaria remains one of the leading causes of morbidity and mortality in Zambia, and still remains among the top 10 major causes of visitation to health facilities. However, significant achievements have been made in malaria control in the last decade. Substantial declines in inpatient cases, deaths (more than a 60% decline), and anemia in children under five years of age have been reported in the 2001–2008 analysis of routine surveillance data. This is also

Consolidating Malaria Gains and Impact Page 13 evidenced in the 2006 and 2008 MIS reports. Figure 1 presents trends in annual reported malaria inpatient cases and deaths among children under the age of five.

Figure 1: Trends in In-patient Malaria Cases and Deaths Among Children Under Five Years of Age, by Quarter, 2001–2010

Deaths Cases

Source: Zambia, Malaria Programme Review 2010 (MPR 2010)

4.2.7 Risk Groups

The entire population of Zambia is at risk of malaria. However, children under the age of five years, pregnant women, the chronically ill, and immuno-compromised persons, such as those living with HIV and AIDS, are considered to be among the highest risk groups for malaria infection in Zambia.

4.2.8 Stratification and Risk Maps

In the past, the malaria endemicity map showed relatively uniform endemicity across the country and malaria transmission, illness, and mortality was determined by existing climate, geographic, and biological features of the vectors, humans, and parasites. However, in a five-year span, ending in 2010, emerging evidence from routine information systems, national surveys—particularly the MIS—and focused studies have consistently shown declining malaria trends evident in three malaria epidemiological zones in Zambia, which are as follows:

Zone 1: Areas where malaria control has markedly reduced transmission and parasite prevalence is less than 1% (Lusaka city and environs).

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Zone 2: Areas where sustained malaria prevention and control has markedly reduced transmission and parasite prevalence is between 1% and 14% in young children at the peak of transmission (Central, Copperbelt, North-Western, Southern, and Western Provinces).

Zone 3: Areas where progress in malaria control has been attained, but not sustained;

where lapses in prevention coverage have led to resurgence of infection and illness; and where parasite prevalence in young children of 15% or more at the peak of the transmission season (Eastern, Luapula, and Northern Provinces).

These zones are presented in Figure 2 and are reflective of the population-based survey estimates of malaria parasitemia among children under five years of age. Children under five represent approximately 20% of the total population. By strata, this categorization represents approximately 17% of the estimated 2010 population in Zone 1, 49% in Zone 2, and 34% in Zone 3.

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Figure 2: Epidemiologic Strata for Malaria Transmission in Zambia as Determined by Child Parasitemia Prevalence, 2010

Source: Zambia Malaria Programme Review 2010

4.2.9 Malaria and Child Survival in Zambia

Malaria is known to contribute substantially to child mortality, particularly to infant mortality and mortality for one- to four-year-old children. With the recent progress in malaria intervention coverage, Zambia has seen an improvement in health indicators for children (see Table 2). For example, there has been a 29% decrease in all-cause under-five mortality, including 38% and 36% reductions in infant mortality and child (one to four years of age) mortality, respectively.

Table 2: Changes in all-cause child mortality rates 2001, 2002, and 2007, Zambia Indicator 2001/02 ZDHS 2007 ZDHS Percent change

Infant mortality 95 70 -26% Neonatal mortality 37 34 -8% Post neonatal mortality 58 36 -38% Child mortality (1-4yrs) 81 52 -36% Under-5 mortality 168 119 -29% Source: Zambia Demographic Health Surveys. Mortality calculated as deaths per 1,000 live births except for child mortality which is calculated as deaths per 1,000 children surviving to 12 months of age.

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The Lives Saved Tool was used to estimate the impact of malaria control on under-five mortality. From 2001 to 2010, it is estimated that 33,000 deaths were averted in children less than five years of age, with most of this attributed to vector control (i.e., IRS and LLINs).

Figures 3 and 4 below present the trends in malaria and non-malaria, non-anemia cases from 2001 to 2008.

Figure 3. Trends in Reported Inpatient Malaria and Non-malaria, Non-anemia Cases, 2001–2008

Source: Zambia Malaria Programme Review 2010

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Figure 4: Trends in Inpatient/Out-patient Cases in Public Health Facilities, 2001–2008

Source: HMIS Reports 2001-2008, Zambia

4.3 Malaria Programme Performance

In order to provide for a comprehensive and systematic analysis of malaria programme performance and proposed strategies the “Health System Building Blocks” approach was adopted as the appropriate framework for this strategic plan. This framework, considered as an appropriate framework for comprehensive analysis and understanding of a health system, is comprised of the following system building blocks:

Health service delivery.

Health workforce/Human Resources for Health (HRH).

Medical products, infrastructure, and equipment.

Health information.

Health financing.

Leadership and governance.

This framework was also adopted by MOH for the NHSP 2011–2015. It also presents opportunities for easier and standardized inter-country comparisons and bench-marking.

Figure 5 presents the conceptual framework of this model.

To read about this approach, go to: http://www.eldis.org/go/topics/dossiers/health-and-fragile-states/who-health-systems-building-blocks

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Figure 5: Health System Building Blocks - Conceptual Framework

Source: National Health Strategic Plan 2011–2015, Ministry of Health, Zambia

4.3.1 Health Service Delivery

4.3.1.1 Context

Malaria is a disease of high national priority in Zambia and is adequately placed within the health sector and national development agenda. Malaria is prioritized in the national health policies and strategies, and the national development plans, including the NHSP 2011–2015, SNDP, and Vision 2030.

The overall goal of the NMSP 2006–2010 was to attain a 75% reduction (of the 2005 baseline) in malaria incidence and a 20% reduction in all-cause mortality in children under five years of age by 2010. These targets were in line with the Abuja and RBM target of reducing malaria mortality for Africa’s people by half by 2010.