Matabeleland South Province
In Matabeleland South, implementation of activities took place over 2 years, from August 2016 – September 2018. In the two intervention districts (Beitbridge and Gwanda), most challenges from Year 1 were carried into Year 2 (Table 2). One challenge from the first year (liquidation of funds and implementation of activities) was resolved sufficiently for the Task Team to take on new challenges in the second year, which are outlined in Table 2.
Table 2. Matabeleland South Province Year 1 and 2 Challenges
Challenge
|
Solution
|
Year 1 Change from Baseline to Midline
|
Year 2 Change from Midline to Endline
|
Malaria register availability by health facilities
|
Audit conducted and supportive supervision visits to health facilities. Training on use of the malaria register provided to health care workers
|
Beitbridge: -23% (90% to 67%). Stockouts of registers occurred during a malaria outbreak period.
|
-39% (67% to 28%)
District needs to scale up printing during an outbreak.
|
Gwanda: 10% (83% to 93% or 25/30 to 28/30 health facilities)
|
7% (93% to 100%)
|
Drug stockouts
|
Continuous monitoring of medicine stocks by pharmacy manager
|
ACTs: -16% (22% to 6%)
PQ: -4% (6% to 2%)
|
ACTs: 0% (6% to 6%)
PQ: 0% (2% to 2%)
|
Case investigation rate within 3 days
|
Mobilize additional human resources (contract workers, students, military) for high risk areas, implement a tracker system, monitor during monthly meetings, weekly feedback to districts
|
10% (55% to 65% or 65/119 to 821/1265 cases investigated of cases reported)
|
Beitbridge: 19% (65% to 84%)
|
Gwanda: 35% (65% to 100%)
|
Incorrect or delayed liquidation of funds and implementation of activities
|
Review of financial and reporting regulations, creation of planning tools, and supportive supervision visits by managers
|
71% (29% to 100%)
|
N/A
|
Table 3. New Year 2 Challenges for Matabeleland South Province
Challenge
|
Solution
|
Year 2 Change from Baseline to Endline
|
Village health worker (VHW) recruitment and retention
|
Lowered qualification requirements for VHW recruitment and provided VHWs with training and support to retain them
|
Beitbridge: 3% (87% to 90%)
|
Gwanda: 5% (83% to 88%)
|
Lack of inter-provincial collaboration
|
Use available funding from the Elimination 8’s Global Fund grant to conduct a minimum of two peer to peer province and district learning visits. The meetings will enable harmonization of surveillance and response activities between provinces and create cross-border and inter-provincial linkages.
|
Target achieved through initiation of inter-provincial (Matabeleland South-Masvingo) and cross border meetings (Zimbabwe- Botswana) and exchange visits).
|
Low IRS coverage in Beitbridge district
|
Conducted operational research and analysed results
|
Planned to implement recommendations* in the 2018/19 IRS campaign.
|
Failure to conduct entomological activities
|
Engage the national entomologist, conduct training on larval source management (LSM) to build the capacity of the EHTs
|
Beitbridge achieved target of 2 entomological activities (malaria vector bionomics investigation, bioassays for testing insecticide susceptibility and training of EHTs on LSM). Gwanda had not yet initiated entomological activities.
|
Slow uptake of Public Finance Management System (PFMS) funds
|
Provided on the job training and telephone consultations
|
Efforts to improve use of the finance system despite internet connectivity challenges resulted in improvement in fund utilization.
|
Failure to update slide results of RDT+ cases in case-based surveillance records
|
Developed tool to track slides received from health facilities which will allow the microscopy center to update results on case-based surveillance and relay results back to health facility
|
Feedback loop between lab and health facilities will be closed with the introduction and training on this tool at health facilities.
|
*Recommendations from the operational research conducted to address low IRS coverage included increased community sensitization, development of IEC material in local languages, including radio programs in local languages, recruitment of community mobilizers, early engagement and partnership of stakeholders, and better planning for IRS timing, resources, and supplies.
Matabeleland North
In Matabeleland North, implementation of activities took place over the course of 10 months from November 2017 to September 2018. Although all 7 districts participated, only 5 of the districts have oriented towards malaria elimination.
Table 4. Matabeleland North Year 1 Challenges
Challenge
|
Solution
|
Year 1 Change from Baseline to Endline
|
Regular review of malaria case investigation data and data management
|
Identify focal persons to be point of contact and follow up for surveillance related work, provide mentoring and supportive supervision visits on how to use DHIS2 tracker (malaria elimination surveillance system) to the focal persons, regular onsite data verification and data cleaning, initiation of regular surveillance meetings
|
8% increase in malaria slide examination rates of confirmed cases (81% to 89% or 115/142 to 90/101 slides examined out of total positive cases).
10% increase in fully investigated cases (88% to 98% or 125 cases investigated out of 142 RDT+ cases to 99/101).
Weekly disease surveillance reports shared with province: 1 out of 5 districts; quarterly district review meetings conducted: 2 out of 5 districts; quarterly provincial meetings conducted: 2.
Improvements to data discrepancies and timeliness (no quantitative data available to support).
|
Implementation of new treatment guidelines
|
Mentoring of health workers and VHWs, refresher trainings, setting up a help line
|
12% increase in the administration of primaquine (63% to 75% or 90/142 to 76/101 cases administered PQ/total positive cases).
Refresher trainings ongoing but all five eliminating districts have conducted post-training follow-up visits and VHWs now trained.
|
Coordination across departments
|
Map stakeholders, attend district and provincial social services and local governance meetings, develop service improvement plan
|
Target achieved at district level for external coordination. See Box 2. Improvements to internal coordination were in progress.
|
Lack of ownership and accountability
|
Conduct team building, award best performing district, provide peer support visits.
|
Peer support visits implemented in 2 of 5 districts. Other activities were in progress.
|
Malaria commodity stockouts
|
Create reporting template for tracer commodities, supportive supervision visits to improve stock management, redistributing excess commodities to other districts, supply VHWs with essential commodities.
|
20% improvement in medicine stock status (50% to 70%)
|
Larval source management
|
Order biolarvicide, map active breeding sites, train environmental health practitioners in LSM, use standardized bio larviciding reporting form
|
1 of 5 districts have completed mapping. Training in 2 of 5 districts conducted.
|
Poor quality IEC materials, unknown effectiveness of SBCC activities
|
Identify translators and correct malaria messages, evaluate impact of activities
|
Work in progress.
|
Box 2. District level multi-sectorial collaborations achieved through OD/QI activities
District
|
Organizations
|
Relevant Activities or Resources
|
Binga
|
Save the Children, Binga Rural Development Committee, Anglican Diocese of Matabeleland, Wild4Life, ActionAid
|
IRS support, food for IRS teams, fuel
|
Bubi
|
Plan International, Mary Ellen, Bubi Rural Development Committee, Isabella Mine, Streak Farm, Joe Trading, Inyathi Training Institute
|
Fuel, mosquito nets, food for IRS teams, allowances, IRS truck maintenance, storage facilities for LLINs before distribution
|
Hwange
|
ZAPMI, Hwange Colliery, Global Fund, World Vision, Wild4Life Health, Dept of National Parks and Wildlife
|
IRS support, support for mentorship visits to health facilities, protective clothing, food for IRS teams
|
Lupane
|
World Vision, Plan International, Sizimele, I-TECH, Africa Project, Lead and COSV
|
IRS support, entomology activities, SBCC activities, transportation, human resources, food for IRS teams
|
Nkayi
|
World Vision, Mbuma Mission Hospital, ZRP-Nkayi, HEFO
|
Food for IRS teams, transportation, servicing IRS vehicles, fuel
|
Tsholotsho
|
Plan International, DDF, TRDC, Global Fund, I-TECH
|
IRS and LLIN distribution, net storage, transportation, mentorship and training
|
Umguza
|
Plan International, DDF, URDC, I-TECH
|
IRS and LLIN distribution, storage storage facilities for LLINs before distribution, transportation
|
Midlands Province
Implementation of activities in Midlands Province in two districts, Chirumhanzu and Kwekwe, took place over 8 months from February to September 2018.
Table 5. Midlands Year 1 Challenges
Challenge
|
Solution
|
Year 1 Change from Baseline to Endline
|
|
Treatment of confirmed malaria cases with ACTs
|
Supportive supervision, community training
|
Chirumhanzu: 7% (93% to 100%)
|
|
Kwekwe: 11% (89% to 100%)
|
|
Case investigation rates
|
Submission of weekly disease surveillance meeting reports with action taken
|
Chirumhanzu: 0% (100% to 100%)
|
|
Kwekwe: 19% (80% to 99%)
|
|
Poor data quality
|
Implemented a weekly surveillance meeting and bulletin
|
Improvements to data quality, completeness, and timeliness with weekly review of data in 72% of facilities in Chirumhanzu and 100% of facilities in Kwekwe
|
|
|
Inadequate LSM
|
Identify and map breeding sites, train locals on scooping and environmental modification
|
Chirumhanzu: 78% of sites identified and mapped (1/73 sites to 58/73 sites)
|
|
Lack of knowledge about foci management
|
Train EHPs, identify and map foci, conduct contact screening and treatment
|
2 contacts identified, screened, and treated during initiation of foci investigation activities
|
|
Additional Qualitative Results
Feedback from workshop participants was collected with a qualitative instrument for all provinces with an average completion rate of 70%. Workshop participants in Matabeleland South reported an improvement in data management, with the development of a data collection tool, the initiation of data reporting from district to province on a weekly basis, and the establishment of a data focal point in each district. In Matabeleland North, motivation among nurses improved as they gained confidence in case management from training, and overall staff morale was impacted positively. There was also an improvement in data quality and the frequency with which data was shared via weekly bulletins. In Midlands, the poorly performing district was motivated to improve, and both participating districts became more goal-oriented. They also became more focused on monitoring their data regularly and learned how to develop indicators to measure the process improvement changes they were making. Participants from all provinces reported having a better appreciation of the value of communication, teamwork, planning, continuous monitoring of data, and adjustment of work plans and gained skills in listening, communicating, facilitating discussions, and making presentations.
More importantly, participation in the intervention changed the mindset of malaria program staff, increasing ownership and accountability, and empowering them to identify and solve problems, make decisions, and act within their sphere of influence, elevating challenges when appropriate. These changes were demonstrated by the following comments:
“We don’t think outside the box; we create the box.”
Senior Environmental Health Officer
“Significant improvement (was) seen on malaria elimination indicators for both Kwekwe and Chirumhanzu. The districts became more aware of their performance and actively made efforts to improve.”
Senior provincial-level clinician
“(In Zimbabwe), we found that participants really appreciated the opportunity to get in a room together to discuss challenges and identify their own solutions to these challenges … the act of getting people together in one place to discuss their challenges was seen as a major accomplishment in itself.”
Southern Africa regional malaria program officer
"Soon enough, people get it. By giving them autonomy, peers to reflect with, and experts to advise them on their planning, they gain confidence. The conversations change. No longer am I confronted with challenges like "we can only achieve this if we have more money". Instead the teams work on practical solutions by reviewing together and coming up with solutions that are feasible to execute, and within their control."
Senior provincial-level clinician
There was also a desire to continue the work beyond the funded implementation period:
“We have to continue this project because in Matabeleland North and Midlands, we saw the difference we made when we used the principles of Organization Development for Malaria Elimination. Let’s keep up the good teamwork, let’s communicate, let’s keep the good coordination because we can implement this project and integrate it into other activities.”
Senior provincial-level clinician
An indirect effect of the OD/QI program was the use of learned techniques in other areas of challenge within the health system. Box 3 describes how one trainee used change leadership skills to overcome transportation challenges in her province.
Costs of the program
We separated out the cost for training within-program facilitators. All costs were calculated in USD standardized to 2019. The breakdown of costs are shown in Table 6. The total cost of the 2-year program was $381,134, with the average cost per district in Year 2 being $26,450. Depending on what level of outside support is needed costing estimates per district for implementation range from approximately $30,000 using non-accredited local staff within Zimbabwe and as much as $50,000 using international consultants. The average cost of $26,450 is derived over the 2-year period where in the second year most facilitation and mentoring was supported by local trained team members. Costs of training and certifying 6 trainees is shown in Table 7.
Table 6. Costs of two-year program
|
Year 1 (2016-17)
1 province, 2 districts
|
Year 2 (2017-18)
3 provinces, 11 districts
|
Total (%)
|
Workshop costs (hotel, per diems)
|
$22,176
|
$100,007
|
$122,183 (32%)
|
Task Team costs (hotel, per diems)
|
$6,608
|
$30,183
|
$36,791 (10%)
|
Consultant costs
|
$32,715
|
$106,259
|
$138,974 (36%)
|
Travel
|
$14,195
|
$9,163
|
$23,358 (6%)
|
Project management, M&E
|
$14,485
|
$45,343
|
$59,828 (16%)
|
Total
|
$90,179
|
$290,955
|
$381,134
|
Table 7. Costs of change leadership program
|
Year 2 (2017-18)
|
(%)
|
Workshop costs (hotel, per diems)
|
$2,752
|
8%
|
Consultant costs
|
$19,725
|
61%
|
Certificate costs*
|
$10,000
|
31%
|
Total
|
$32,477
|
100%
|
* Costs for certification from University of West of England, UK
[Please see the supplementary files section to view box 3.]