z pct model program report hv 1

Family Health International4401 Wilson Blvd., Suite 700Arlington, VA 22203 USAtel +1.703.516.9779fax +1.703.516.9781

www.fhi.org [email protected]

The Zambia Prevention, Care and Treatment Partnership (ZPCT), funded by the US President’s Emergency Plan for AIDS Relief through the US Agency for International Development, has achieved high levels of performance in technical and program management areas, and its staff are sought after to provide national, regional, and even global technical assistance to grantees, partners, and peers. With this publication, Family Health International (FHI) presents ZPCT as an example of a high-quality country program in HIV/AIDS whose lessons need to be shared across the organization.

FAMILY HEALTH INTERNATIONAL 2008

The Zambia Prevention, Care and Treatment Partnership: A Model Program

ZAMBIANS AND AMERICANSIN PARTNERSHIP TO FIGHT HIV/AIDS

The Zambia Prevention, Care and Treatment Partnership: A Model Program2008

Table of ConTenTsAcknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Background: ZPTC and HIV/AIDS in Zambia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ZPCT Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ZPCT Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

ZPCT as a Technical Model: Key Areas and Innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Counseling and Testing • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Prevention of Mother-to-Child Transmission • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Clinical Care and Antiretroviral Therapy • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Laboratory and Pharmacy • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Referral Network • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Monitoring and Evaluation • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Human Resources • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ZPCT as a Program Management Model: Key Areas and Innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Decentralization of Decisionmaking • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Infrastructure Refurbishing and Procurement • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Lessons Learned and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Appendix: Services in 97 Facilities Receiving ZPCT Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

2 The Zambia Prevention, Care and Treatment Partnership: A Model Program

aCknowledgmenTsThe Zambia Prevention, Care and Treatment Partnership (ZPCT), funded by the US President’s Emergency Plan for AIDS Relief through the US Agency for International Development, has achieved high levels of performance in technical and program management areas, and its staff are sought after to provide national, regional, and even global technical assistance to grantees, partners, and peers. With this publication, Family Health International (FHI) presents ZPCT as an example of a high-quality country program in HIV/AIDS whose lessons need to be shared across the organization.

ZPCT provincial and technical teams and Zambia Ministry of Health staff at all levels provided invaluable input for this document, which was drafted by consultant Mannasseh Phiri, MD, with the assistance of the following FHI/Zambia staff:

• Kwasi Torpey, MD, ZPCT Director of Technical Support

• Catherine Thompson, Country Director and ZPCT Chief of Party

• Asha Basnyat, ZPCT Director of Programs and Deputy Chief of Party

• Prisca Kasonde, MD, ZPCT Associate Director of Technical Support

• Parsa Sanjana, ZPCT Senior Program Coordinator

• Mushota Kabaso, Monitoring and Evaluation Advisor

• Jonathan Mukundu, Monitoring and Evaluation Officer

The Zambia Prevention, Care and Treatment Partnership: A Model Program 3

aCronymsADCH Arthur Davison Children’s HospitalAIDS Acquired immune deficiency syndromeARV Antiretroviral drugART Antiretroviral therapyARTIS ART Information SystemASW Adherence support workerCHAZ Churches Health Association of ZambiaCT Counseling and testingDATF District AIDS Task ForceDHMT District Health Management TeamECR Expanded Church ResponseEMS Expedited mail serviceFHI Family Health InternationalGRZ Government of the Republic of ZambiaHAART Highly active antiretroviral therapyHIV Human immunodeficiency virusJHU/HCP Johns Hopkins University/Health Communication PartnershipM&E Monitoring and evaluationMSH Management Services for HealthMSL Medical Stores LimitedMoH Ministry of HealthNAC National AIDS Council of ZambiaOI Opportunistic infectionPCR Polymerase chain reactionPEPFAR US President’s Emergency Plan for AIDS ReliefPHO Provincial Health OfficePLHA People living with HIV/AIDSPMTCT Prevention of mother-to-child transmissionQA/QI Quality assurance/quality improvementSTI Sexually transmitted infectionTB TuberculosisUSAID US Agency for International DevelopmentZPCT Zambia Prevention, Care and Treatment Partnership


exeCuTive summaryThe Zambia Prevention, Care and Treatment Partnership (ZPCT) is a cooperative agreement between Family Health International (FHI) and the US Agency for International Development (USAID) through the President’s Emergency Plan for AIDS Relief (PEPFAR). ZPCT runs from 2004 to 2010, and works to strengthen and expand HIV and AIDS services in five of Zambia’s nine provinces, in partnership with the country’s Ministry of Health (MoH) and the National AIDS Council (NAC). ZPCT assists the MoH to implement its policies in program planning, implementation, and moni-toring by providing support to provincial health offices and district health management teams and at the health facilities.

The key to ZPCT’s success is its partnership with the Government of the Republic of Zambia (GRZ) and with NGOs, local communities, and workers at healthcare facilities. ZPCT’s activities and support avoid the creation of parallel structures and sys-tems, making use of and supporting MoH policies and guidelines that benefit patients, and integrating programs that are initiated or improved into exist-ing systems and at district and facility levels.

Since implementation began in May 2005, ZPCT has assisted the government to initiate, improve, strengthen, and scale up counseling and testing (CT), prevention of mother-to-child transmission (PMTCT) services, and clinical care, especially antiretroviral therapy (ART).

ZPCT initially supported the scale-up of services in 43 health facilities in 9 districts, expanding to 97 MoH facilities in 26 districts by September 2007. Further expansion is planned to reach 33 districts and 216 facilities. ZPCT-supported facilities have provided CT services to 162,433 persons and ART for 40,999 individuals, including 2,807 pediatric clients. The facilities have also delivered PMTCT services for 117,562 pregnant women. In addition, male attendance and involvement in antenatal clinics and HIV testing have increased signifi-cantly, especially in Luapula Province. To achieve these results, ZPCT supported and implemented

simple but effective technical, program, and man-agement strategies.

In all facilities, the hiring of data entry clerks and the introduction of regular audits improved the quality, handling, management, and appreciation of data as a management tool. To enhance knowledge levels and accurate data collection, data collected in each province are audited by ZPCT staff from a different province and the head office in Lusaka.

Day-to-day program functions have been decentral-ized to ZPCT provincial offices, where a provincial program manager is assisted by technical officers for clinical care, PMTCT services, laboratory and pharmacy services, and monitoring and evaluation (M&E). These officers receive technical assistance in their specialty from Lusaka, while they themselves provide training and technical assistance for local healthcare workers in ZPCT-supported facilities.

To initiate and expand HIV and AIDS services, ZPCT obtained the agreement of local health authorities on needed infrastructure renovations, essential medical and laboratory equipment, and capacity building. ZPCT then signed recipient agreements with district health management teams (DHMTs) and hospital boards that spelled out the support to be provided. ZPCT then followed the GRZ tender process, working with the MoH and Ministry of Works to provide renovations, and cosigned contracts with the DHMTs. ZPCT thus facilitated renovations of outpatient departments

In remote areas, ZPCT provides motorcycles equipped with coolers, which are used to transport blood samples to labs and take results back to clinics and health centers.


and disused hospital outbuildings to create ART centers that provide comprehensive HIV and AIDS care or space for storing antiretroviral drugs (ARVs) and diagnostic items. The renovations needed to expand services helped to improve the environ-ments of health workers and their morale.

Sophisticated ZPCT-supported laboratories can now be found in low-level facilities such as health centers. HIV test results are available the same day, improving acceptance of testing and the collection of results. In more remote locations, lab samples and results are transferred by motorcycle to refer-ral labs, obviating the need for clients to travel long distances to a clinic and return to obtain their test results. In addition, parents and guardians of pedi-atric clients at the ART center at the Arthur Davison Children’s Hospital (ADCH) can now access adult HIV services instead of going to different—and per-haps distant—institutions on different days.

ZPCT also supported a new polymerase chain reaction (PCR) laboratory for the ADCH that pro-vides accurate HIV testing for children less than 18 months old to centers in the five provinces through an innovative sample referral system. From a wide catchment area, dried blood-spot samples drawn from children under 18 months are transported to the hospital by expedited mail. Results are relayed to the originating facilities by the same means, increasing service uptake and reducing inconve-nience for clients.

The need to increase uptake and expand ser-vices in the face of the country’s serious shortage of trained healthcare workers spurred innovative coping mechanisms to fill gaps. One such mechanism entails the training of community volunteers as lay counselors, adherence support workers (ASWs), and PMTCT motivators. The ASW volunteers are living with HIV/AIDS and are consumers of HIV services. They have helped to make these services sustainable and averted the suspension of programs.

In addition, ZPCT is supporting training for health-care workers on ART, pediatric ART, PMTCT, CT, and other technical areas. Where possible, this training is offered in the health facilities where they work during afternoons and evenings. This timing means that staff are not removed from their stations while they are most needed and clinics are open.

Improving access and addressing equity issues requires the design of HIV intervention strategies that are creative as well as practical. In addition, the program must work collaboratively with the GRZ to ensure sustainability without compromising the speed of implementation.

Working in close collaboration with the MoH, ZPCT has brought HIV-related care and treatment services as close to the community as possible. This has been achieved in spite of the human resource shortages and weak infrastructure capacity, mak-ing these intervention strategies a model for other programs. Bold innovations that address criti-cal shortages, overcome other obstacles, increase uptake, support adherence, and expand services are the program’s hallmark, but they owe their suc-cess to the strength of ZPCT’s partnerships and its adherence to existing systems.

Under the ZPCT initiative, male attendance and involvement in antenatal clinics and HIV testing have increased significantly, especially in Luapula Province.


Background: ZPCT and HIV/AIDS in Zambia

ZPCT’s objectives are to increase access to and use of CT •increase access to and use of PMTCT •interventionsincrease access to and strengthen delivery of •clinical care for HIV/AIDS, including diagnosis, prevention, and management of opportunistic infections (OIs), and prevention and management of other HIV-related conditions and symptomsincrease access to and strengthen delivery •of ART

ZPCT provides technical, program, and manage-ment support for national, provincial, and district structures and systems through a memorandum of understanding with the MoH and provincial health offices (PHOs). ZPCT provides national-level sup-port by participating in technical working groups to develop policies and national treatment guidelines with the MoH and the National AIDS Council. At district and facility levels—and in 26 districts and 97 health facilities in the five provinces—ZPCT sup-ports the implementation of HIV clinical services, including CT, PMTCT, ART, and related laboratory and pharmacy support services.

Working within the FHI global network, ZPCT developed unique innovations and an exceptional program. At the end of September 2007, ZPCT had supported the MoH in providing CT services to 162,433 persons; ART to 40,999 individuals, includ-ing 2,807 pediatric clients; and PMTCT services to 117,562 pregnant women.

The estimated HIV prevalence rate in Zambia for adults ages 15–49 is 16.5 percent, with more women infected (18 percent) than men (13 percent). The number of Zambians living with HIV and AIDS is estimated to be 1.2 million, and the number needing ART is estimated to be 370,000. As of September 2007, over 110,000 were receiving free ART in pub-lic sector health programs.

As in other resource-limited settings, Zambia is challenged to provide access to available, affordable, and acceptable CT, PMTCT, and ART interven-tions. Approximately 130,000 children in Zambia are infected with HIV, and 30,000 acquire the infec-tion vertically each year. Mitigating the impact of HIV/AIDS and preventing new infections require adequate human and material resources, as well as innovations that address this need. However, for all cadres of healthcare workers, the country’s current human resource capacity is far below rec-ommended levels.

ZPCT, a six-year cooperative agreement between FHI and USAID that is funded through PEPFAR, is strengthening GRZ programs in order to provide HIV clinical services in five of the nine provinces—Central, Copperbelt, Luapula, Northern, and North Western—and increase access to ART in public-sector health facilities. Management Sciences for Health (MSH) is a partner for laboratory and phar-macy technical areas; other partners are Churches Health Association of Zambia (CHAZ), Expanded Church Response (ECR), and Kara Counselling and Training Trust.


ZPCT Organizational Structure

AIDS services through district-wide referral net-works and coordinated mobile CT activities.

Managers of provincial offices represent their respective program teams and report to the direc-tor of programs in the Lusaka office. The managers supervise provincial office staff (program, finance, and technical), oversee ZPCT activities at the pro-vincial level, build relationships and work closely with district and provincial partners, and ensure that activities in targeted health facilities and com-munities are implemented in accordance with ZPCT technical strategies.

The director of technical support oversees technical staff and the technical direction of all areas of HIV/AIDS clinical care, including ART, CT, PMTCT, quality assurance/quality improvement (QA/QI), training, laboratory and pharmacy services, and M&E. The technical support team directs and sup-ports the work of provincial-level technical officers. Though they report to provincial managers, these technical officers receive guidance and direction from technical advisors in the Lusaka office.

The director of finance and administration over-sees all ZPCT’s financial operations and ensures compliance with the contractual requirements of USAID and other donors. From the Lusaka office, finance and administrative staff work with their provincial- counterparts on financial and account-ing functions, as well as on procurement and the distribution of equipment and supplies. They also work together to ensure that accounts are consis-tent with FHI policies and procedures and donor regulations, and they develop and submit financial reports that follow ZPCT procedures and conform to the regulations of USAID and other donors.

Much of ZPCT’s success can be attributed to its organizational structure. It has six offices: the main office is in the capital city, Lusaka, and it has an office in each of the five provincial capitals. Of the staff of 116, only four are expatriates. ZPCT is headed by a chief of party, who is assisted by a dep-uty chief of party/director of programs, a director of technical support, and a director of finance and administration.

The chief of party is responsible for all program, financial, and technical activities, and is answerable to USAID on the progress of the program. The per-son in this position supervises directors; maintains relationships with the MoH, USAID, other part-ners, and programs; and sets the strategic direction of program activities.

The director of programs is responsible for overall management of program rollout and implemen-tation, with the assistance of the Lusaka-based program staff and five provincial management teams. The program team in Lusaka liaises with staff in the technical and finance departments on overall program design, implementation, monitor-ing, and deliverables. This team also takes the lead on developing annual work plans, quarterly reports, and other USAID deliverables.

Each provincial office takes the lead in developing its respective programs, recipient agreements, work plans, and monthly reports, with the support and assistance of the Lusaka program team. On the staff of each provincial office are one or more technical officers in the following categories: clinical care, CT/PMTCT, laboratory and pharmacy, community and referral, and M&E. Provincial staff also develop activities that mobilize communities to access HIV/


ZPCT Partnerships

pharmaceutical services. MSH technical staff report to ZPCT’s director of technical support, and they provide information to ensure the sustained supply of laboratory reagents, equipment, HIV testing kits, and pharmaceuticals (including ARVs) throughout all programs.

At the national level, as with all technical staff, the MSH/ZPCT pharmacy and technical staff par-ticipate in the development of MoH policy and guidelines. They also provide training and mentor-ing for laboratory and pharmacy staff in supported facilities and at provincial and district levels.

The Churches Health Association of Zambia (CHAZ) supports mission health facilities in North Western, Northern, and Luapula provinces through a subagreement with ZPCT. ZPCT provides fund-ing to CHAZ to identify and complete renovations and procure essential medical and laboratory equip-ment to expand HIV/AIDS services. These activities have been completed at four health facilities. ZPCT and CHAZ jointly identified three additional health facilities for support, which began in July 2007. ZPCT and CHAZ staff jointly monitor implementa-tion progress at the selected mission health facilities, with ZPCT taking the lead on technical assistance.

Kara Counseling and Training Trust, the best known and longest-serving HIV and AIDS coun-seling training service in Zambia, is responsible for training counselor supervisors at ZPCT-supported health facilities and at the district level. As of September 2007, Kara had trained and certified 171 counselor supervisors.

The Expanded Church Response (ECR) is respon-sible for working through church communities to increase knowledge and demand for HIV/AIDS ser-vices at ZPCT-supported facilities. To accomplish this, ECR set up coordinating committees that focus on selected health centers in two provinces—Cen-tral and Copperbelt. Church members requiring HIV services are mobilized and referred appropri-ately, whether for services in the community or in the district. In addition, the ECR has implemented a few mobile CT activities at their churches.

Partnership is the cornerstone of ZPCT operations and of their success. Partnerships are at the central-government level, with the MoH and the National AIDS Council, and have been developed with in-ternational organizations, local and national faith-based organizations, and community-based NGOs.

At the inception of ZPCT, FHI signed memoranda of understanding with the MoH and each of the five PHOs.1 Each of these offices was consulted to determine which districts to assist, then each district was consulted to identify which facilities to support. ZPCT then collaborated with district health offices and selected hospitals to assess their needs, in terms of training, infrastructure, labora-tory, and equipment.

ZPCT’s level of support for a given health facility depends on the level of health services the facil-ity provides, the state of its infrastructure, and the extent to which it needs services that ZPCT pro-vides or supports. For each supported facility, an implementation plan is used to develop a recipient agreement. Such agreements are signed by DHMTs or hospital boards and the FHI country director, who is also the ZPCT chief of party. The agreements outline all the proposed support from ZPCT for a given facility, including ongoing expenses, items to be procured, infrastructure improvements, and training activities planned.

By signing recipient agreements, the parties consent to their roles and responsibilities in implementing activities under the partnership. The agreements provide detailed technical information on what is required to improve HIV/AIDS services in each health facility, taking into account staffing, infra-structure, client load, catchment area, and other services available in the district. ZPCT manages the funds on behalf of the recipients and in accordance with the recipient agreements, since USAID rules and regulations make it difficult to provide funds directly to a government entity.

MSH, a subpartner in the cooperative agreement, is responsible for technical support for laboratory and

1. The memoranda of understanding were signed with the MoH and the Central Board of Health. The latter has since been consolidated into the MoH.


COUnSeLIng AnD TeSTIng

By the end of September 2007, ZPCT had facilitated rapid expansion of CT services, extending them to 97 facilities in the five provinces and 162,433 people. Further expansion to a total of 216 facilities started in October 2007.

CT has been expanded byestablishing dedicated CT rooms within health •facilitiesproviding testing corners in clinical areas, such as •in hospital wards, STI and TB clinics, and general outpatient departmentsproviding testing through the Ndola Catholic •Diocese home care programintegrating CT into antenatal services •using multidisciplinary mobile outreach counsel- •ing teamsensuring constant and uninterrupted supplies of •test kits and other supplies

To increase pediatric access to CT, ZPCT estab-lished it as a routine service in 10 pediatric inpatient

Fig. 1. Current and new Pediatric Clients on ART at ZPCT Sites, May 2005–September 2007

No. of children currently receiving ART No. of new pediatric clients initiating ART

Current and New Pediatric Clients on ART, ZPCT Sites, May 2005–September 2007

443

654

876

1,096

1,344

1,597

1,949

2,203

2,484

2,807

248294229240

17481

399 352403

331

0

500

1,000

1,500

2,000

2,500

3,000

May 05–Jun 05 Jul 05–Sep 05 Oct 05–Dec 05 Jan 06–Mar 06 Apr 06–Jun 06 Jul 06–Sep 06 Oct 06–Dec 06 Jan 07–Mar 07 Apr 07–Jun 07 Jul 07–Sep 07

Pers

ons

serv

ed

No. of persons currently receiving ART (children) No. of NEW clients initiating ART (including pregnant women)

wards and selected under-5 clinics. This service has helped increase the number of HIV-positive chil-dren who are diagnosed and linked to care and ART (fig. 1).

Task shifting and involvement of non-healthcare workers in provision of CT helped to expand ser-vices and address the limited number of trained workers in health facilities. To provide these ser-vices, ZPCT trained and placed lay counselors to work alongside healthcare workers.

PReVenTIOn OF MOTHeR-TO-CHILD

TRAnSMISSIOn

Between the inception of ZPCT and September 2007, 117,562 pregnant women accessed PMTCT services from 96 facilities in the five provinces. These women received CT services and their test results, and 10,680 also received full ART prophy-laxis. In addition, 439 providers (doctors, midwives, nurses, clinical officers, and laboratory and phar-macy staff) were trained to provide PMTCT services. Further expansion to a total of 196 facilities started in October 2007.

ZPCT as a Technical Model: Key Areas and Innovations


Innovations contributing to increased uptakeThe opt-out approach to CT at antenatal clinics in health facilities was MoH policy when ZPCT began implementation. Since then, ZPCT has operation-alized routine CT, with same-day results for all pregnant women attending antenatal care. This has led to sustained high uptake—over 95 percent—of PMTCT services in antenatal clinics, which includes CT and clients receiving their results (fig. 2).

The creation of testing corners within maternal and child health clinics and the training of healthcare workers also contributed to increased uptake. So did hands-on mentoring and task shifting: nurses are conducting the HIV tests, and trained lay coun-selors provide some components of service delivery, such as motivational talks and HIV testing.

ZPCT is also working with PMTCT motivators—lay female volunteers who are trained to encourage pregnant women to access these services. Originally trained through the Academy for Educational Development’s Linkages Project, the cadre was incorporated into ZPCT after that program ended.

CD4 estimations and a systematic follow-up systemCD4 evaluations are conducted for all HIV-positive pregnant women to ensure provision of more effi-cacious ARVs, including HAART, for women

whose levels warrant full ART. This is done through a sample referral system that allows blood samples from HIV-positive pregnant women to be sent to a lab with CD4 capability, with results returned to the originating facility.

Within existing maternal and child health struc-tures, ZPCT established a systematic mother-baby follow-up system and early infant HIV diagnosis. The systematic follow up of HIV-positive women after they give birth ensures early infant diagnosis and continuity of care. ZPCT also facilitated initia-tion of cotrimoxazole prophylaxis and HIV testing for infants through the PCR technology. The newly established system is used to collect dried blood spots from infants for analysis and to offer linkages to appropriate HIV services.

Male involvement in PMTCTIn Luapula and North Western provinces, male involvement is higher than in other parts of Zambia. This is due to work of US government partners, such as Johns Hopkins University/ Health Communication Partnership (JHU/HCP), and innovative approaches with traditional leaders. In Luapula Province, for example, women who attend antenatal clinics with their husbands are given pri-ority and seen first. This encourages other women

Percentage of Pregnant Women Accepting Testing, ZPCT Sites, May 2005–September 2007

29%

49%

59%

75%

84%

93% 93%95% 96% 98%

0%

20%

40%

60%

80%

100%

120%


Pers

ons

serv

ed

Fig. 2. Percentage of Pregnant Women Accepting Testing at ZPCT Sites, May 2005–September 2007


who wish to avoid long queues to come to the clinic with their husbands.

The community sensitization conducted by JHU/HCP in the Chembe area (bordering the Democratic Republic of Congo) led to the creation of “Safe Motherhood Action” groups that promote male involvement in antenatal care, including PMTCT. Now, when women come for antenatal services, Chembe Clinic also caters to the health needs of their partners.

These activities have led to a significant increase in male participation in PMTCT. Before sensitiza-tion, male attendance at antenatal clinic was zero. Within five months of starting sensitization activi-ties, 75–100 percent of antenatal clients arrived with their male partners, and acceptance of HIV testing by women also increased.

CLInICAL CARe AnD AnTIReTROVIRAL THeRAPy

As of September 2007, 40,999 people were receiv-ing ART through ZPCT-supported government facilities (fig. 3).

ART clinicsTo scale up ART services, ZPCT initiated the pro-vision of ART in the outpatient departments of all

central, general, and district hospitals in the five provinces and several urban and rural health cen-ters. The ART services are provided as static or outreach services.

Setting up ART clinics required healthcare worker training and the development of job aids and standard operating procedures. In some cases, ren-ovations of sections of outpatient departments or hospital outbuildings were also required. The ART clinics set up include waiting areas that are also used for group counseling and education; counsel-ing rooms used by psychosocial counselors, ASWs, and lay counselors; and dedicated ART pharmacies for dispensing ARVs and other ART-related medi-cations. Laboratory services are either at the sites or nearby.

The new ART clinics facilitated the flow of clients and made access to services much more conve-nient. Previously, clients attended clinics that were held one day a week, in single rooms in outpatient departments. They had to go from there to hospital laboratories for blood tests, return to the clinics to have their results interpreted, and then go to the general hospital pharmacy to collect medications. Now all services are in one location.

Current and New Clients on ART, ZPCT Sites, May 2005–September 2007

6,729

8,994

12,893

16,914

21,111

25,003

28,743

32,950

36,464

40,999

4,896

9812,217

3,555 4,062 4,628 4,276 5,150 5,068 4,786

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000


Pers

ons

serv

ed

No. of persons currently receiving ART (including pregnant women)No. of NEW clients initiating ART (including pregnant women)

Fig. 3. Current and new Clients on ART at ZPCT Sites, May 2005–September 2007

No. of persons currently receiving ART (including pregnant women) No. of new clients initiating ART (including pregnant women)


Family-centered careThe family-centered ART clinic created at the ADCH provides ART services for children and their parents in a renovated building and serves as a referral center for the five provinces. Parents of HIV-positive children receiving ART can access CT and ART for themselves at the same center, saving them from the inconvenience of going to different health facilities on different appointment dates. Instead, under the same roof, the same caregiver provides continuous HIV clinical care, treatment, and monitoring for parents and their children.

Pediatric HIV servicesThe commissioning of the PCR testing laboratory at the ADCH in August 2007 means that infant HIV diagnosis is now available to all districts.2 A dried blood-spot sample referral system is used to meet infant diagnostic requirements and make available PCR testing—and thus early, accurate diagnosis of HIV infection in infants—in all government health facilities in the five provinces.

Dried blood-spot samples, collected on filter paper in hospitals, clinics, and health centers in all districts, are delivered to the laboratory within 24–48 hours

2. This is the third such facility in Zambia; the other two are in Lusaka.

through the expedited mail service (EMS) system of Zambia’s National Postal Services Corporation. After the samples are processed, tested, and read, results are delivered by the EMS to originating districts and conveyed to the appropriate facility within two weeks. The distribution network and the rapid expansion and accessibility of this service are unprecedented, both in Zambia and within the FHI global network.

The introduction of routine HIV testing of all chil-dren admitted into children’s wards, regardless of their admission diagnosis, has also enhanced pedi-atric HIV diagnosis and treatment. Appropriate pediatric formulations of ARVs are available throughout the five provinces to initiate HIV-infected children on treatment and facilitate smooth scale-up of pediatric ART.

One of ZPCT’s goals is that children constitute 10–15 percent of all ART clients. As of September 2007, 2,807 pediatric patients were receiving ART—7 percent of all clients.

Outreach ART activitiesTo broaden the scope and availability of ART ser-vices, DHMTs and other trained health workers travel from static sites to more remote facilities to

Fig. 4. Percent of Current and new ART Clients Receiving Services at ZPCT Outreach Sites, May 2005–September 2007

No. of persons currently receiving ART (including pregnant women) No. of new clients initiating ART (including pregnant women)

Percentage Current and New ART Clients Receiving Services, ZPCT Outreach Sites,

May 2005–September 2007

25%24%

22%

20%

17%16%

13%

10%

7%

5%

13% 13%

17%

21%

25%

27%28%

30%

33%

30%

0%

5%

10%

15%

20%

25%

30%

35%


Pers

ons

serv

ed

Percent outreach current clients Percent outreach new clients


initiate and monitor clients on ART. For this out-reach, the DHMT typically comprises a medical doctor trained on ART, a laboratory technician, and/or pharmacy staff. Because clients no longer have to make long and costly trips to access ART, uptake has improved tremendously, as has compli-ance and adherence (fig. 4).

In Copperbelt Province, the outreach team works closely with the Catholic Diocese’s home-based care program, providing ART services through three home-based care centers in communities in Ndola, Chingola, and Kitwe districts. Home-based care teams, trained in HIV/AIDS management, assess and register clients and perform a prelimi-nary screening for ART by using the World Health Organization clinical staging system.

Clients reached by ZPCT-supported ART services are among the poorest members of a community. Patients in stages three and four are seen dur-ing weekly visits of the outreach ART team, who clinically assess and examine clients and perform pre-ART investigations, including taking blood samples for testing. The team initiates patients on ART, providing adherence counseling and dispens-ing ART drugs. Team members also review and manage clients already on ART, monitoring prog-ress and restocking their drug supplies.

The Catholic Diocese provides transportation to facilitate the outreach team’s travel from DHMT clinics to communities. The DHMT provides the staff of the outreach teams, as well as the drugs, equipment, and reagents, and ZPCT provides the allowances required for outreach activities. Eventually, all these clients will be referred to MoH facilities for ongoing services.

Laboratory-sample referral systemLaboratories in central and district hospitals — and, in some cases, in centrally located clinics and health centers — have been upgraded and equipped with the capacity to perform ART-related tests: CD4 counts, full blood counts, and blood chemistry. Staff have been trained and, where necessary, retrained to carry out these tests.

To make lab facilities available to all health centers and clinics in the districts, ZPCT provided motor-

cycles to DHMTs and to hospitals and clinics with laboratory facilities. This innovation has given clients, even those in remote areas, access to sophis-ticated laboratory tests. The motorcycles are used to transport blood samples to labs and take results back to clinics and health centers. They also carry infants’ dried blood spots to the PCR laboratory.

In addition, the use of motorcycles has greatly reduced client inconvenience. Many clients had to travel long distances to have their blood tested at laboratories, then needed to return within a few days for their results. Now they make short journeys to the nearest health center or clinic, where they have their blood drawn and later receive their results.

Technical assistance and mentorshipClinical care officers within the technical staff in ZPCT provincial offices are trained ART experts who provide supervision, training, technical assis-tance, and mentoring for all healthcare workers involved in ART in their respective provinces. Clinical care advisors in the technical support office in Lusaka train these officers on new trends and innovations and keep them up to date on revisions and changes to national guidelines. In turn, the offi-cers do the same for technical staff in government facilities in the provinces.

LABORATORy AnD PHARMACy

Laboratory servicesHigh-quality laboratory services are important for the diagnosis, treatment, and monitoring of HIV infections. As such, they are a crucial component of the effective scale-up of all HIV/AIDS services, especially for ART and PMTCT. To this end, ZPCT has refurbished laboratories to create adequate working and equipment space, and has provided standard state-of-the-art equipment and ongoing training of personnel on handling the new equip-ment. Modern laboratories have thus been created in facilities that were previously run-down town-ship clinics or health centers.

Each ZPCT-supported district now has at least one centralized laboratory that is capable of perform-ing ART-related blood tests. Several laboratories in each district have the capacity to perform full


blood counts and blood tests relating to liver and renal functions. In larger provincial centers (such as Ndola in Copperbelt Province and Kabwe in Central Province), the DHMT and ZPCT divided health facilities in the district into zones and linked them to a centralized laboratory that has a CD4 machine. Blood samples from health facilities in a particular zone are taken to a specified laboratory. This zoning system has been set up in all the prov-inces to ensure that a CD4 test is available within 100 kilometers.

In Ndola, two trained laboratory staff who are based at a clinic in a township health center spend one day a week in a centralized laboratory, performing CD4 count tests on samples from their own center and others. In this manner, skills are centralized on a periodic and regular basis.

A major logistic challenge is ensuring that a network of sophisticated laboratories is functional and well stocked with reagents, possesses serviced equip-ment, and maintains high standards and quality control. To this end, ZPCT procured HIV test kits until the MoH system was in place and continues to provide some reagents for laboratories.

To avoid stockouts, ensure uninterrupted supplies, and promote sustainability, all supplies are ordered by the district through Medical Stores Limited (MSL),3 the central stores for all medical supplies, which has a standard MoH supply system in place. Other US Government partners are working with MSL to improve this MoH supply logistic system and ensure that needed amounts of supplies are properly quantified.

ZPCT provides supervisory and technical assis-tance to laboratories to monitor quality and ensure timely performance of tests and release of results. An automated laboratory information system is being introduced in selected facilities to enhance accurate inventory management and patient test profiles. An internal quality control system for lab-oratory tests associated with HIV and ART is being

3. MSL, a private company based in Lusaka, is the MoH’s central supplier of drugs, reagents, and equipment, and distributes to all provinces, districts, and centers. ZPCT, in collaboration with a project of John Snow Inc., often communicates directly with MSL on stock levels and timely placement and delivery of orders.

piloted to monitor the quality of services provided, in collaboration with the MoH and other partners.

Pharmacy services Pharmacy support activities are integral to the ZPCT-supported comprehensive HIV prevention, care, and treatment program. Pharmacy services are cross-cutting and closely coordinated with CT, PMTCT, ART, and clinical care services.

ZPCT’s technical approach to pharmacy services includes

training facility staff to effectively forecast, quan- •tify, order, procure, and store ARVs, OI drugs, and other supplies and avoid stock outs and shortages

improving storage space at all health facilities •

providing appropriate equipment to support the •management of pharmaceuticals

strengthening inventory management systems, •logistics, and security, and improving the delivery of ARVs and other drugs to facilities

assisting the GRZ in its formulation and imple- •mentation of standard operating procedures for inventory management systems, recordkeeping, and good dispensing practices

It is also important to note that ZPCT obtains ARVs and test kits through the national drug sup-ply system, and that staff training provided helps to strengthen the system.

The ART pharmacy in ndola, Copperbelt Province, was refurbished by ZPCT. It is an important element of the comprehensive prevention, care, and treatment program.


Numbering among ZPCT innovations is the adoption, support, and scale up of the automated Zambia Pharmacy ART Program (also known as the ARTServ Dispensing Tool). Developed by MSH through the USAID-funded Rational Pharmaceutical Management Plus Program, the tool is now in use in all pharmacies with computer technology. ARTServ has simplified the monitor-ing of drug consumption by clients and improved patient care. Pharmacy staff have been trained to use it, and provincial laboratory technical officers provide supportive supervision and mentoring.

ZPCT has also improved pharmacy infrastructure and storage space, and has supported the installa-tion of air conditioners to maintain drugs at opti-mum temperatures.

ReFeRRAL neT WORK

The needs of people living with HIV/AIDS (PLHA) are diverse: apart from ART, they need medical care and psychosocial, nutritional, and financial support. Among many community-level service providers that address these needs are the DHMT, the district AIDS task forces (DATFs), faith-based organizations, and local and international NGOs, including ZPCT.

ZPCT initiated a coordination process at the dis-trict level by working with DHMTs, DATFs, the Network of Zambian PLHA, health center com-mittees, community leaders, faith-based and home-based care organizations, and other commu-nity-level organizations. This led to the formation of a referral network in each district that includes a referral coordinating unit, selected through a par-ticipatory process by network members. The unit is responsible for convening meetings, coordinat-ing activities, mobilizing resources, and providing technical assistance to new members.

At the district level, the referral network is managed by the DHMT or DATF. At regularly held network meetings, issues of common interest relating to the welfare of PLHA are discussed. ZPCT and the network members in each district contribute to logistics for regular monthly meetings, such as sta-tionery, printing, and meeting venues. Indicators, targets, and mechanisms for gathering data are

agreed upon before implementation. ZPCT’s con-tribution focuses on referral activities at the health facilities it supports, where a referral focal-point person is responsible for documenting referrals.

ZPCT developed and disseminated standard tools to refer and monitor the movement of clients between ZPCT-supported health facilities and other HIV-related support services and commu-nity assistance. Health workers have been trained in the use of these referral tools. They comprise

a referral form to be returned to the referring •organization, with a detachable section that is retained by the receiving organization

a referral register, used by referral focal-point •persons to document all referrals

a directory of services with contact details of all •organizations providing HIV-related services for PLHA and their families within a district

a referral operations manual, developed by all •network members to define principles and pro-cesses that guide its functioning

MOnITORIng AnD eVALUATIOn

ZPCT is working with the MoH to implement an M&E system that guides the rapid scale-up of ser-vices, while responding to the information needs of the GRZ, PEPFAR, USAID/Zambia, and the NAC. To meet all these information needs, ZPCT works with its partners to harmonize information and data systems, avoid duplication, and adhere to the “three ones” principle for the M&E component. ZPCT is collaborating with the MoH and US Government partners in the design and implementation of the SmartCare ART patient-tracking system, which will be used in all MoH ART sites.

SmartCare, a computerized system with a paper backup, can capture patient characteristics and simplify follow-up. Reports generated are in line with MoH and PEPFAR indicators. The prototype patient-tracking system was first introduced by the DHMT in Lusaka, with the support of Center for Infectious Disease Research in Zambia and the US Centers for Disease Control and Prevention. SmartCare is being rolled out by ZPCT in sites


the program supports to replace the manual- and paper-based ART information system (ARTIS).

In the five provinces, the M&E system focuses on activities and results at facility, district, and provin-cial levels. These provide the basis for

monitoring performance in achieving rapid scale- •up of quality HIV-related services

ensuring best practices for ART, clinical care, CT, •and PMTCT are documented and shared

ensuring that best practices for ART are devel- •oped through evidence-based approaches and are implemented by monitoring adherence and immunologic and clinical responses and applying results

measuring the contribution of program efforts •toward achievement of the objectives of the MoH, PEPFAR, USAID/Zambia, and the NAC

strengthening M&E capacity at national, provin- •cial, and district levels

The M&E system depends on the recruitment, train-ing, and placement of data entry clerks, the training of healthcare and health information staff in ARTIS and the CT and PMTCT information system, and onsite technical assistance and mentoring for staff at all levels.

Data entry clerksZPCT recognized that the collection, maintenance, and management of good-quality data are vital to the success of the scale-up effort, and that budget constraints have led to a dearth of health facility staff who can perform these functions. Thus, as of September 2007, ZPCT had recruited and trained 55 data entry clerks for the ART sites and facilities it supports.

These clerks, directly and fully funded by ZPCT, are placed in ZPTC-supported health facilities through the DHMTs. Initially hired through con-sultancy agreements, the clerks were transitioned by ZPCT to full-time contracts at rates equivalent to other GRZ employees at the same level. Funds for their salaries and benefits are included in recipi-ent agreements.

Since their introduction, the timeliness and qual-ity of data have greatly improved—so much so that the government is considering including data entry clerks in their district establishments. To further improve data quality, data entry clerks are attached to additional non-ART sites and health facilities in their districts, where they spend one day in a month to compile and collect data for MoH and PEPFAR reports.

EquipmentZPCT has supplied essential computer equipment for data storage and ART reporting to all health facil-ities it supports. SmartCare, a standardized patient tracking system developed by US Government partners and the MoH, is being installed in all ART clinics and centers, in collaboration with the MoH and other partners.

Data auditsZPCT instituted data audits at all sites to ensure that data collected are standardized and of high quality. So far, five audits have been conducted covering the period October 2005 to March 2007. These data audits are carried out by ZPCT M&E staff from Lusaka and provincial offices, with staff from one province assisting with data audits in other provinces.

The quality of data collection in MoH facilities at the onset of ZPCT was limited. The recruitment and placement of data entry clerks, the provision of equipment and data collection tools, and the data audit process have greatly improved management, collection, and quality of data from all provinces.

HUMAn ReSOURCeS

Maintaining trained and experienced staff in ZPCT-supported sites is a formidable challenge. ZPCT developed innovative approaches to counter severe staff shortages and high attrition rates due to trans-fers, resignations, and deaths. These have resulted in the retention and training of human resources essential for the successful scale-up of HIV services. However, the human resource shortage continues to be an issue in Zambia.

TrainingBecause the shortage of healthcare workers has reached crisis proportions, staff at facilities are


stretched to the limit when their colleagues are away from their stations for training. ZPCT devised alter-native training approaches to address this problem. Staff numbers are maintained at the highest possible levels when the workload is heaviest, but essential training is provided onsite, where possible, and in the late afternoon, after the day’s work is finished. The onsite training at Ndola Central Hospital pro-duced no significant difference in scores, compared with the conventional two-week residential training. Significant reductions in training cost also allow more health workers to be trained with this approach.

ZPCT is assisting the GRZ and other partners to train healthcare workers in CT, PMTCT, care of OIs, ART, and laboratory and pharmacy services. Where available, national training packages and national trainers are used, and ZPCT is working with the MoH to develop trainers and adapt pack-ages in areas where they are not.

The following table shows courses offered and num-bers trained by ZPCT, as of September 2007:

Training Number trained

Counseling and testing 395

Counseling and testing refresher 82

Counseling supervision 171

Couple counseling 24

Lay counselors 206

HIV testing for lay counselors 141

PMTCT 460

PMTCT refresher 39

ART/OIs 663

ART/OIs refresher 72

ART/pediatric 364

ASW training 273

Adherence counseling (healthcare workers) 348

Laboratory and pharmacy 243

M&E for data entry clerks 36

M&E for health information officers 16

M&E for healthcare workers 1,220

Staff retentionRetaining healthcare workers and other staff mem-bers who have been trained continues to be a challenge because conditions of service in the pub-lic sector are beyond the scope of ZPCT. Within these limitations, ZPCT continues to put in place innovations that reduce workloads for healthcare workers and motivate and retain staff in ZPCT-supported facilities.

Transport reimbursementsZPCT works with facilities to determine how many extra shifts are needed to provide services and provides transport reimbursement funds to the DHMT for those approved shifts. The amount of the reimbursement is determined by the districts, in accordance with their policies.

This initiative has been implemented in most health facilities where ZPCT-supported activities have been introduced. It has helped to alleviate staff shortages, served to maintain high staff morale, and ensured continuity and sustainability of new and old services.

Lay counselorsTo relieve pressure on HIV psychosocial counsel-ors who are also health workers, ZPCT is training volunteer lay counselors to provide CT services at health facilities. Selected by the facility and the DHMT, these volunteers are primarily community members who have been engaged in some com-munity-based service, perhaps as a member of a neighborhood health committee.

Prospective lay counselors are interviewed to assess if they have previous HIV/AIDS training, can read and write in English, and are motivated to become counselors. Volunteers selected undergo training that is based on the national CT curricu-lum. Recently, after a change in national guidelines allowing non-medical persons to perform HIV tests, ZPCT began training lay counselors in the use of rapid tests for HIV testing.

As volunteers, lay counselors receive a monthly stipend of 100,000 kwacha (about US$25), the standard volunteer stipend of partners of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. These payments are included in recipient agreements.


Adherence support workersAnother ZPCT innovation is the new volunteer cadre of ASWs. They are PLHA who are on ART, drawn from the community and trained in adher-ence counseling. ZPCT developed the curriculum for training ASWs, which has been published and made available, both within Zambia and globally.

ASWs work three days a week: two days in a health facility and the third in a nearby community, where they visit patients to support their adherence to treatment and track down defaulters and try to reengage them. To facilitate this work, ZPCT pur-

chased one or two bicycles per facility that the ASWs share.

ASW counseling rooms are available in each facil-ity, adjacent to or near health workers’ consulting rooms. There, ASWs provide adherence counsel-ing for clients before they receive their ARVs. Such counseling is provided at the first prescription visit and when clients return for further supplies.

Interviews to select ASWs are conducted jointly by ZPCT and the DHMT, with the participation of facility staff and members of nearby communities. The major requirement is that ASWs be on ART themselves and exhibit a penchant for volunteerism and a willingness to model their own experiences as PLHAs. They also need to be able to read and write in English.

Retention of ASWs is good. They receive the same incentives as the lay counselors (100,000 kwacha per month), and these payments are included in recipient agreements. Currently, only 22 of the 273 trained ASWs have stopped offering the service.

The involvement on the HIV services team of peo-ple openly living with HIV and on ARVs is unique, and it has been well accepted by health workers, clients, and PLHA alike.

Another ZPCT innovation is the new volunteer cadre of ASWs. They are PLHA who are on ART, drawn from the community and trained in adherence counseling.


ZPCT as a Program Management Model: Key Areas and Innovations

DeCenTRALIZATIOn OF DeCISIOnMAKIng

Lusaka-based program staff provide assistance and support for program design, implementation, mon-itoring, and deliverables. They also take the lead on developing annual work plans, quarterly reports, and other deliverables for submission to USAID, but the overall management of program rollout and implementation has devolved to the five provincial management teams.

In each province, the ZPCT office takes the lead in developing programs, recipient agreements, work plans, and monthly reports, with assistance from the Lusaka program team. Within provincial offices are staff who are tasked with M&E and pharmacy and laboratory services. Technical staff in these offices also develop activities to mobilize commu-nities to access HIV/AIDS service in the facilities through district-wide referral networks and coor-dination of mobile CT activities.

Each provincial program team is headed by a pro-vincial manager, who supervises all provincial office staff (program, financial, and technical), and over-sees all ZPCT activities at the provincial level. The provincial manager builds relationships and works closely with district and provincial partners, ensur-ing that activities in targeted health facilities and communities are implemented according to ZPCT technical strategies. Provincial managers report to the director of programs in Lusaka.

new counseling rooms at the Kasanda Clinic, Kabwe, Central Province, were converted from a disused garage.

InFRASTRUCTURe ReFURBISHIng AnD PROCUReMenT

Infrastructure renovations to accommodate the delivery of HIV/AIDS services have been made in nearly all ZPCT-supported health facilities that provide CT, ART, and PMTCT services. Renovations have varied by site, depending on the condition of existing infrastructure and services to be provided. USAID-mandated environmental site assessments, commissioned by ZPCT, precede all renovation work.

USAID regulations governing ZPCT activities do not allow for the construction of new build-ings; they permit only the renovation or refurbish-ment of existing structures. Despite this challenge, some innovative and functional renovations have been accomplished, including the conversion of a dilapidated and abandoned garage into two counseling rooms at the Kasanda Clinic in Kabwe, Central Province.

An old, disused outbuilding at Kabwe General Hos-pital was renovated to create a center that provides ART services and has convenient patient flow, wait-ing space, and adequate furniture. Two water tanks installed at Pollen Clinic in Kabwe have ensured continuous availability of clean running water for

The post-delivery room in the Pollen Maternity Clinic in Kabwe is now supplied with clean running water.


all services and have improved PMTCT services in the middle of a high-density township.

At Pollen Clinic, the introduction of PMTCT ser-vices was accompanied by provider-initiated HIV testing for all children at the under-5 clinic. This model is being piloted in five ZPCT-supported clinics in Kabwe, Ndola, Kitwe, and Mansa. With ZPCT support, Pollen Clinic has started an ART clinic that provides services solely for pregnant women requiring ART—the first of its kind.

At the ADCH, the pharmacy department was relo-cated from the third floor to a more spacious and accessible location on the first floor. The ultramod-ern laboratory now houses DNA PCR equipment for early diagnosis of HIV infection in infants.

Renovations undertaken by ZPCT and hospital authorities at Liteta District Hospital in Central Province to accommodate new ART services cre-ated ample space for storage of pharmaceuticals and dispensing of drugs.

All renovations are agreed upon and executed jointly by ZPCT provincial office staff, district health authorities, and health facility staff. Certifications of quality, issued when renovations are complete, are undertaken by ZPCT-hired architects and GRZ

public works and supply departments, since the buildings are GRZ property.

Hand-in-hand with renovations that improve ser-vices is the training or retraining of staff to provide these services. For example, pharmacists and phar-macy technicians must be trained in counseling and the dispensing of new ARV and OI drugs that the expanded pharmacy can now provide, and labora-tory staff must be trained to handle new laboratory equipment before it is commissioned.

Training staff to run renovated facilities and addi-tional services is an ongoing activity, as buildings are renovated and ZPCT-supported activities expand and are rolled out. All training is planned and con-ducted jointly by ZPCT and health authorities at provincial, district, and facility levels. Candidates for training are selected in consultation with the MoH.

Procurement ProceduresWhen ZPCT started, FHI procedures and regu-lations governed the procurement of goods and services. The program thus had parallel procedures in government-run health facilities, and this was found to be unworkable. As a result, ZPCT adopted GRZ tender procedures and incorporated them into its own procurement guidelines. These pro-cedures, now used for all goods and services, have made procurement much easier.

These tanks are the source of the Pollen Maternity Clinic’s new water supply.

general and ARV stocks at the newly refurbished Liteta District Hospital Pharmacy, Central Province.


Lessons Learned and Conclusion

Engaging the Ministry of Health. From the inception of ZPCT, the MOH has been engaged at all levels, and involved in the planning, implementation, and monitoring of all programs. PHOs, DHMTs, and facility-level management run these programs, and ZPCT provides support. This has ensured that own-ership remains within the GRZ and government facilities.

Integrating activities into existing systems. All pro-grams initiated, improved, or enhanced by ZPCT are integrated into existing MoH systems. For example, procurement for ZPCT programs became much easier when MoH procedures were integrated into the FHI procurement system.

Implementing policies and guidelines. In several instances, national policies and guidelines were not being implemented at the district or facility level. For example, routine CT at antenatal clinics was policy, but was not implemented until ZPCT provided technical assistance. ZPCT activities sup-ported the implementation of such policies and guidelines, to the benefit of the health of patients. New policies are not always needed; instead, what is often required is assistance in implementing exist-ing plans, policies, or guidelines.

Combining multiple strategies. The family-centered approach at the ART center at the ADCH in Ndola is an example of how multiple strategies increase uptake and use of services. The ART center is in a children’s hospital, but it also provides full ART ser-vices to the children’s parents and caregivers, saving them from the inconvenience of attending a differ-ent facility.

Using community volunteers. Sustainable HIV ser-vices would not have been possible without the ZPCT volunteer program. The training of com-munity volunteers as lay counselors, ASWs, and PMTCT motivators served to avert suspension of programs caused by the critical shortage of trained healthcare workers.

Introducing data audits. Regular data audits have improved the management, quality, and apprecia-tion of data. The use of staff from different provinces

to audit data from other provinces enhances knowl-edge levels and appreciation of the need for accurate data collection.

Instituting same-day results. The availability of HIV test results the day the test is done has improved the acceptance of testing and the collection of test results. Previously, many clients who were counseled and tested did not return to the clinic on another day to get results. This was a serious problem for pregnant women attending antenatal clinics.

Using a sample referral system. The sample referral system increased the uptake of services. It reduced the burden for patients who previously needed to travel long distances to laboratories to be tested and then return to obtain their results.

Improving the work environment. ZPCT programs demonstrate that ensuring the availability of reagents, drugs, and diagnostic equipment is as essential in motivating healthcare workers as improving the physical environment in which they work. Such environments improve staff performance.

Co-signing contracts. All contracts for infrastruc-ture renovations or for the supply of services are co-signed by the DHMT, ZPCT, and the contractor, thus giving joint ownership of contracts to health facility managers or the DHMT and to ZPCT/FHI.

ConclusionIn the five provinces where ZPCT operates, the part-nership has had a remarkable impact on HIV/AIDS clinical services. ZPCT support, combined with the GRZ policy of free ART services, has resulted in greatly expanded delivery of ART. Within a relatively short time, HIV/AIDS services have been scaled up and free ART made available to thousands, in rural as well as urban areas. The partnership’s innovative strategies have reduced the burden of traveling long distances for many and brought HIV/AIDS clinical services closer to remote communities.

By operating at all levels, integrating new activities into GRZ systems, and supporting the implementa-tion of its existing policies and guidelines, ZPCT is making a real difference in the lives of Zambians.


Services in 97 Facilities Receiving ZPCT Support

Indicator

Achievements (May 1, 2005–September 30, 2007)

Workplan(1 Apr 06– 30 Sep 07)

Quarterly Achievements(1 Apr 07–30 Sept 07)

Achievements(1 Apr 06–

30 Sept 07)Percent

Achievement

Cumulative LOP Achievements

(1 May 05– 30 Sept 07 )

TARGET FEMALE MALE TOTAL

CT

Service outlets providing CT 97

Persons trained in CT 402 125 594 148% 974

Persons receiving CT services 52,512 13,945 13,301 27,246 129,050 246% 162,433

PMTCT

Service outlets providing PMTCT 96

Persons trained in PMTCT 200 21 212 106% 460

Pregnant women provided with PMTCT services, including CT 35,851 16,799 16,799 90,758 253% 117,562

Pregnant women provided with a complete course of ART prophylaxis 8,963 2,015 2,015 8,817 98% 10,680

BASIC HeALTHC Are And SuPPOrT

Service outlets providing clinical palliative care services 97

Service outlets providing general HIV-related palliative care 97

Persons provided with OI management and/or prophylaxis 34,547 22,895 57,442 62,474

Persons provided with general HIV-related palliative care 34,547 22,895 57,442 62,474

Persons trained to provide general HIV- related care 100 32 280 280% 663

TreATMenT

Service outlets providing ART services 60

Health workers trained in ART 100 32 280 280% 663

New clients receiving ART 16,300 2,769 2,017 4,786 28,804 177% 39,619

Total clients receiving ART 28,410 24,366 16,633 40,999 40,999 144% 40,999

PedIATrIC TreATMenT

Health workers trained in pediatric care 150 17 364 243% 364

New pediatric clients receiving ART 660 156 175 331 2,027 307% 2,751

Total pediatric clients receiving ART 1,151 1,408 1,399 2,807 2,807 244% 2,807

TB And C Are

TB-infected clients receiving CT services 5,000 440 499 939 6,210 124% 6,210

HIV-infected clients attending HIV care/treatment services who are receiving treatment for TB disease (new cases)

2,188 537 569 1,106 3,515 161% 3,515

Appendix

Family Health International4401 Wilson Blvd., Suite 700Arlington, VA 22203 USAtel +1.703.516.9779fax +1.703.516.9781

www.fhi.org [email protected]

The Zambia Prevention, Care and Treatment Partnership (ZPCT), funded by the US President’s Emergency Plan for AIDS Relief through the US Agency for International Development, has achieved high levels of performance in technical and program management areas, and its staff are sought after to provide national, regional, and even global technical assistance to grantees, partners, and peers. With this publication, Family Health International (FHI) presents ZPCT as an example of a high-quality country program in HIV/AIDS whose lessons need to be shared across the organization.

FAMILY HEALTH INTERNATIONAL 2008

The Zambia Prevention, Care and Treatment Partnership: A Model Program

ZAMBIANS AND AMERICANSIN PARTNERSHIP TO FIGHT HIV/AIDS

z pct model program report hv 1

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