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Evaluation database

Evaluation report

2000 ZAM: Review of UNICEF Support to Malaria Control in Zambia

Author: Hill, J.; Webster, J.; Basimike, M.; Malaria Consortium

Executive summary


The Community-based Malaria Prevention and Control Programme (CBMPCP) began as a pilot project in Samfya District, Luapula Province, in 1994 with support from UNICEF. In 1998-1999, implementation was expanded to the rest of the communities in Samfya and to communities in three more districts in Luapula Province -- Mansa, Mwense and Nchelenge. The focus of the program is on community-based sale of insecticide-treated mosquito nets (ITNs) through community health workers (CHWs), capacity building of health workers in malaria case management through Integrated Management of Childhood Illness (IMCI), training of CHWs in malaria case management and community-based information, education and communication (IEC).

Purpose / Objective

The Malaria Consortium was contracted by UNICEF to provide technical assistance to key areas of the national malaria control program in Zambia at a critical juncture. Firstly, the recently developed Zambia Roll Back Malaria strategy needs operationalizing and secondly, UNICEF support to community-based malaria prevention is undergoing rapid expansion. In addition, UNICEF Lusaka is preparing for a new country program cycle and there is a staffing gap within the Health Section.

Specific objectives in the Terms of Reference were:
- To conduct a rapid review of the progress and processes of implementation of the CBMPCP in the four initial districts in Luapula province (Samfya, Mansa, Mwense and Nchelenge) and make recommendations for the way forward
- To review UNICEF support to malaria control in Zambia in general, as well as the action plan for expansion of the CBMPCP to the 28 districts in Eastern, Western, North-Western and Northern provinces, and to make recommendations -- in the light of recommendations from objective 1 above. The recommendations should also feed into the planning/strategizing process for UNICEF programming for malaria for the new country program cycle
- To support the detailed action planning process to operationalize the national Roll Back Malaria strategy for Zambia (see attached document), in collaboration with key partners in Zambia (NMCC, the Central Board of Health (CBoH), WHO, USAID, etc). Priority areas include nationwide scaling up of the ITN component, changing the anti-malarial drug policy, capacity building (including scaling up IMCI implementation), advocacy and IEC. Review of the capacity building strategy and materials for the UNICEF-supported programs
- To assess monitoring and evaluation systems and mechanisms for malaria programs within the systems of the Central Board of Health/NMCC and make recommendations to strengthen this component. Conduct a review of current ITN program/revolving fund monitoring systems, identify constraints and modify, as necessary, to develop a user-friendly and workable reporting/monitoring system for district health management team (DHMT) and health center staff and community workers. Support NMCC to ensure its incorporation into the mandatory reporting systems of the CBoH
- To support NMCC and CBoH to develop detailed action plans for malaria prevention and control (with a focus on ITN access) for the following vulnerable groups: pregnant women, refugees, displaced populations, orphans and vulnerable children, including child-headed households, and the very poor.

This report covers objectives 1, 2 and 4 -- all of which relate to the community-based malaria prevention and control program. The reports on operationalizing RBM and on malaria in vulnerable groups are covered in separate reports.


The rapid review of the CBMCP was conducted through interviews with: staff of the National Malaria Control Centre and UNICEF; Luapula provincial level staff; the District Health Management Team (DHMT) of each of the four districts of Mansa, Mwense, Nchelenge and Samfya; the staff of 14 Rural Health Centres involved in the CBMCP (4 in Mansa, 2 in Mwense, 5 in Nchelenge and 3 in Samfya); a total of 59 members of 17 Malaria Control Committees (MCCs) (4 in Mansa, 3 in Mwense, 5 in Nchelenge and 5 in Samfya); the Society for Family Health (SFH) Project Coordinator; and several households in two districts (Mansa and Mwense).

The review of monitoring and evaluation systems was conducted by interviews with key actors in the malaria project implementation at all levels (national, provincial/district and community levels). At the national level, interviews were conducted with the NMCC Programme Manager, who is responsible for the overall coordination of the monitoring activities, and with the Health Information System Specialist and Malaria Control Officer, responsible for all ITN activities. In Nchelenge, Mansa and Samfya districts, interviews were conducted with the DHMT officers responsible for ITN/malaria control activities in the district. At UNICEF level, interviews were held with the Child Survival Project Officer in which program the malaria control activities fell. Meetings with relevant staff from UNICEF, government and other partners involved in malaria control in Zambia were arranged.

The review of UNICEF support to malaria control in Zambia focused on the findings of the rapid review of CBMPCP in the context of the new RBM strategy and within the context of other resources available for malaria control in the country. Interviews focused on NMCP, CBoH and the main partners supporting malaria (UNICEF, WHO, USAID, SFH, CMAZ) and other health sector initiatives.

Program documentation was reviewed from UNICEF, NMCC, the DHMTs and the MCCs. This documentation included the mid-term review, the evaluation, action plans, proposals and reports including previous Malaria Consortium reports and those that have been provided by UNICEF. A wide range of documents were reviewed, including internal program and project reports, CBoH strategy and policy papers, reports commissioned by NMCC and reports provided by other agencies; these are cited in the footnotes of the report.

Key Findings and Conclusions

Essential findings are that the program has succeeded in developing significant capacity at community level, such that some communities have been empowered to make important, innovative decisions regarding management of the project. The program has even succeeded in serving as a pathfinder for district-based management structures within the reforms in projects where the relationship between the community (community agents, Neighborhood Health Committees and Malaria Control Committees), staff at rural health centers and at district level (DHMTs) is working well. Two examples are Mambila community in Mwense District and Kambuali community in Nchelenge District.

In general, however, supervision and monitoring of the project was found to be poor at all levels. Management of the revolving fund, in particular, appears to be weak in almost all the projects for a variety of reasons, some of which can be improved through the redistribution of tasks within the community structure. Suggestions to improve the management and supervision of the projects include involving a wider group of partners at district level, and improved monitoring and supervision at central level.

The sustainability of the revolving fund was threatened when the barter system was in place, due to the inability of communities to convert goods into cash. However, a removal of this system from the projects may be a major factor in the poor sales of nets among the target population, ranging from 15.4% in Samfya District (the original pilot district, initiated in 1994) to 2.5% in Nchelenge, and net re-treatment rates are less than 1%. This, and an independent review of CBMPCP, reveal that most of the nets that have been purchased and used by men. A small, rapid household survey is recommended in order to determine barriers to purchasing nets, net use among target populations and to net re-treatment. The cost recovery rate for the program, as a whole, is poor, estimated at around 10%.

The emphasis of the program has been on net sales and management of revenue from the sale of nets at the expense of IEC (for ITNS, including net re-treatment, and home-based management of malaria) and the case management arm of the project. It is recommended that malaria agents are retrained as community health workers, some of whom focus on IEC and handle basic drug kits. This should be implemented as part of the ongoing community-based IMCI initiative, which receives support from USAID's Zambia Integrated Health Programme. Also within the framework of IMCI, health workers in rural health centers serving CBMPCP communities should receive training in IMCI and associated support.


Recommendations have been made to strengthen all aspects of the existing framework for CBMPCP, covering technical and management issues at all levels of the program. A number of tools have been developed and field tested to streamline the monitoring of program activities (annexed to the report). Finally, a number of key outcome indicators, which are essential to the evaluation of RBM in Zambia as a whole, are proposed for evaluating program impact.

In the light of the above findings, it is essential that NMCC and its partners, including UNICEF, review the strategy for ITNs in Zambia. Already, a number of objectives and approaches have been developed in the RBM strategy but, given the scale of the proposed UNICEF support for ITNs and a number of new potential partners in the ITN arena, it is time to review the RBM strategy for ITNs. A prerequisite would be to establish a national ITN steering committee, which carried representatives of all the major players in ITNs in Zambia, including the private sector. The proposed UNICEF support ($1 million) should be used to support a national ITN strategic plan, focusing on vulnerable groups.

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