I. EXECUTIVE SUMMARY
When it was launched in 2005, the goal of the President’s Malaria Initiative (PMI) was to reduce malariarelated mortality by 50% across 15 high-burden countries in sub-Saharan Africa through a rapid scale-up of four proven and highly effective malaria prevention and treatment measures: insecticide-treated mosquito nets (ITNs); indoor residual spraying (IRS); accurate diagnosis and prompt treatment with artemisinin-based combination therapies (ACTs); and intermittent preventive treatment of pregnant women (IPTp). With the passage of the Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act in 2008, PMI developed a U.S. Government Malaria Strategy for 2009–2014. This strategy included a long-term vision for malaria control in which sustained high coverage with malaria prevention and treatment interventions would progressively lead to malaria-free zones in Africa, with the ultimate goal of worldwide malaria eradication by 2040-2050. Consistent with this strategy and the increase in annual appropriations supporting PMI, four new sub-Saharan African countries and one regional program in the Greater Mekong Subregion of Southeast Asia were added in 2011. The contributions of PMI, together with those of other partners, have led to dramatic improvements in the coverage of malaria control interventions in PMI-supported countries, and all 15 original countries have documented substantial declines in all-cause mortality rates among children less than five years of age.
In 2015, PMI launched the next six-year strategy, setting forth a bold and ambitious goal and objectives. The PMI Strategy for 2015-2020 takes into account the progress over the past decade and the new challenges that have arisen. Malaria prevention and control remains a major U.S. foreign assistance objective and PMI’s Strategy fully aligns with the U.S. Government’s vision of ending preventable child and maternal deaths and ending extreme poverty. It is also in line with the goals articulated in the RBM Partnership’s second generation global malaria action plan, Action and Investment to defeat Malaria (AIM) 2016-2030: for a Malaria-Free World and WHO’s updated Global Technical Strategy: 2016-2030. Under the PMI Strategy 2015-2020, the U.S. Government’s goal is to work with PMI-supported countries and partners to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.
Zimbabwe was selected as a PMI focus country in FY 2011.
This FY 2017 Malaria Operational Plan presents a detailed implementation plan for Zimbabwe based on the strategies of PMI and the National Malaria Control Program (NMCP). It was developed in consultation with the NMCP and with the participation of national and international partners involved in malaria prevention and control in the country. The activities that PMI is proposing to support fit in well with the NMCP strategy and plan and build on investments made by PMI and other partners to improve and expand malaria-related services, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) malaria grants. This document briefly reviews the current status of malaria control policies and interventions in Zimbabwe, describes progress to date, identifies challenges and unmet needs to achieving the targets of the NMCP and PMI, and provides a description of activities that are planned with FY 2017 funding.
The proposed FY 2017 PMI budget for Zimbabwe is $15 million. PMI will support the following intervention areas with these funds:
Entomologic monitoring and insecticide resistance management: PMI will support NMCP planning for IRS through entomological monitoring in target districts, validating the residual efficacy of insecticides, and collecting data on insecticide resistance and vector behavior, species composition, and density nationwide. PMI will continue training and post-training follow-up visits to ensure quality improvement. Technical assistance will be continued to the two NIHR laboratories and at Africa University. PMI will support one entomological officer position at the NMCP to consolidate nationwide entomological surveillance.
Insecticide-treated nets (ITNs): PMI will support ITN procurement of 811,675 rectangular ITNs and distribution for the ongoing continuous distribution approach designed to ensure high coverage of new cohorts of pregnant women and children, and to replace worn out ITNs distributed through previous campaigns to all Zimbabweans that need ITN protection. PMI will conduct the third and final year of monitoring of the performance and durability of ITNs, and will support external expertise to advise on ongoing refinement of policies to balance IRS and ITN coverage in Zimbabwe, based upon the epidemiological context.
Indoor residual spraying (IRS): PMI will support a robust, full package of IRS implementation in the highest burden province of Manicaland, spraying 171,736 structures and protecting 375,324 persons in the targeted districts. PMI will support an external evaluation of environmental compliance and environmental management plans associated with the IRS project. PMI’s contributions to environmental compliance and other cross-cutting efforts, such as entomological monitoring, including insecticide susceptibility monitoring, surveillance, monitoring, and evaluation, and social and behavior change communication (SBCC), will continue nationwide. PMI will work with the NMCP to identify priority districts based on the most recent entomological and epidemiological data.
Malaria in pregnancy (MIP): PMI will procure 870,000 treatments of sulfadoxine-pyrimethamine (SP) plus 3,300 treatments of clindamycin, and will provide support to the MIP implementing districts for the training and supportive supervision of district, health facility, and community level staff on the revised IPTp and MIP implementation guidelines, including ITN promotion and treatment of malaria for pregnant women as well as data recording and reporting. PMI will promote the use of data from the assessment of barriers and facilitators to IPTp uptake and other evidence to guide the development of SBCC plans for prevention of MIP and knowledge of and adherence to updated treatment guidelines for malaria in pregnant women. PMI will engage with the NMCP regarding opportunities to update facility records, registers, and the health management information system (HMIS) to capture the total number of doses of SP given to women.
Case management: PMI will procure rapid diagnostic tests (RDTs) and medicines for severe malaria, and will train approximately 1,000 facility-based health workers and 1,300 village health workers (VHWs) in 15 districts. PMI will expand direct training support beyond Manicaland to Mashonaland East, Mashonaland Central, and Matabeleland North Provinces, which have moderate to high burden malarious areas. PMI’s continued support of workforce development will include mop-up and refresher training of facility-based workers, along with quarterly supportive supervision and the piloting of a mentoring program in a few districts. PMI will support the reinstitution and improvement of death audits and documentation through training and stakeholder consultations. Support will be provided to the NMCP Case Management Advisory Subcommittee to develop a prioritized multiyear training plan.
PMI will support the establishment of university laboratory capacity for both epidemiologic and entomologic surveillance sample analysis. In rural districts and urban referral centers, PMI will prioritize support for health worker training and supportive supervision to develop and maintain proficiency in microscopy, starting out in the 15 districts in Mashonaland East, Mashonaland Central, and Matabeleland North Provinces with a pilot in 20 health facilities.
PMI will continue to ensure that malaria commodities, such as ACTs, RDTs, severe malaria medicines, and SP, are available in health facilities through the Zimbabwe Assisted Pull System (ZAPS). A focus will be placed on stock management and the ordering system in an attempt to address overstock issues.
Support will also be given to strengthen and expand supervision and quality assurance.
Health systems strengthening and capacity building: PMI will support the secondment of an entomological officer to the NMCP who will provide technical assistance on entomological and vector control issues and support entomological surveillance in the remaining sites that PMI is not supporting.
PMI will also support the secondment of a Malaria Logistics Focal Person at the Ministry of Health and Child Care (MoHCC) Directorate of Pharmacy Services (DPS) to conduct quarterly support and supervision visits, manage the end-use verification activities, lead the quantification process for malaria products, keep the project informed on changes needed in the procurement plan, and otherwise manage and coordinate malaria commodity logistics issues at the central and lower levels of the system.
Social and behavior change communication (SBCC): PMI will support VHWs and school and community leaders to conduct interpersonal communication on key malaria messages around ITNs, malaria in pregnancy, RDTs, and ACTs in the 47 districts with the highest malaria transmission. The school and community leaders’ SBCC activities will be complemented by printed materials that accompany packaged ITNs, RDTs and ACTs, radio spots, and drama skits. The primary focus for all activities will be to support the launch of ITN distribution expansion, improve MIP uptake, and promote IRS and appropriate case management. PMI will continue to support malaria advocacy and commemoration events and the SBCC Working Group quarterly meetings.
Surveillance, monitoring and evaluation (SM&E): PMI will continue work with the NMCP to monitor the quality of malaria data collected through the HMIS and to improve data use to ensure that the programmatic needs of the NMCP are met. PMI will support malaria routine system strengthening with a focus on continued and expanded supportive supervision at the facility level. Support for improving epidemic detection algorithms, health worker capacity to analyze and monitor the malaria trends, and preparedness for epidemic detection and response will also be a focus of PMI activities in “moderate” (annual malaria incidence 6-100 cases/1,000 population) to “high burden” (annual malaria incidence >100 cases/1,000 population) areas such as Manicaland.
PMI will continue support for SM&E trainings at all levels, including VHWs as well as supervisory and district health facility trainings. In addition, PMI support will be used to facilitate quarterly meetings for district, provincial, national level, and cross-border representatives to meet and discuss surveillance and SM&E-related issues. PMI will conduct quarterly surveys to assess the availability of malaria commodities in health facilities and warehouses.