Article Type : Research Article
Authors : Kooma EH, Cheelo M, Chisanga A, Chifwesa A, Wakunuma T, Nyirenda C, Mwansa B, Nsofwa F, Phiri E, Chirwa B, Zinyengere D, Hansende W, Banda R, Bwenje F, Mbanga L, Malawo O, Shabukali V, Chanda J, Sanka M and Munachilemba O
Keywords : Indoor residual spraying; success factors; lessons learnt; best practices; cholera; Zambia
Indoor Residual Spraying has been one of the most effective
malaria vector control interventions that play a key role in malaria
elimination. The effective use of the intervention has been found to require
strong program capacity structures and systems at all levels. The objective of
this paper has been to contribute and supplement to achievement of the national
malaria elimination targets set for Indoor Residual Spraying by making the
program more efficient, cost effective, ecologically sound and sustainable for
impact. Zambia`s cholera out-break has many successes, lessons learnt and best
practices to emulate. The best practices could be learnt from both the public
and the private sector for maximum impact. Connections have to be established
at all levels of delivery. The good quality delivery operations depend upon
strong program leadership and well monitored service delivery management
systems through good planning, commitment, rigorous implementation, strict
supervision, careful monitoring and evaluation. Motivation and retention of
staff and community engagement at the initial stage provide good feedback and
response. The reorientation from malaria control to elimination does not entail
changing the entire malaria vector control strategies or interventions but
rather refocusing and intensifying those already in use, for the purpose of
malaria elimination.
There are many
factors that influence Indoor Residual Spraying (IRS) success or failure. While
IRS may have clearly defined set of variable objectives of value,
implementation of activities alone might not be enough to ensure the program`s
success. There are many other factors that have been found to impact on the
development of IRS and these may vary depending on the program: nature,
context, size, complexity, formality and environmental factors. The successful
Indoor Residual Spraying Campaign depends upon well-organized planning and
proper monitoring and supervision at all levels; timely feedback through
monitoring allows appropriate corrective measures. The advocacy of political,
traditional/community leadership and sensitization (awareness raising) of the
community plays an important role in achieving the goal of the IRS activities.
This Indoor Residual Spraying Campaign document establishes a platform for
further improvement of the campaign program for the 2018/19 and beyond the
spraying period. The document also describes the challenges and opportunities
that need to be mitigated and exploited respectively to improve the Indoor
Residual Spraying program. It provides a strategic direction with full display
of applicable opportunities for 2018 and beyond. It establishes requirements
for improvement from the success factors, best practices and lessons learnt
from the field situational analysis feedback exercise that was undertaken from
stakeholders, partners and selected individuals and from eight (8) provinces of
Zambia [1].
Success factors
The Indoor Residual
Spraying success factors rely upon the ownership of the program by level
leadership with a clear understanding of the reasons for the existence of the
program; who is it for and what is it? What does the government say about
achieving the legacy goals. As this might be a factor influencing the tailoring
of program activities to better suit the IRS program environment. Different
ownership might translate in different stakeholders taking part in the decision
making process. There has been a need for support and participation of the
major stakeholders/interested parties to ensure a controlled development of the
Indoor Residual Spraying Campaign program. A clear and feasible planning of the
various management stages have been found essential to reduce the level of
risk. This will also avoid scope-creep; communication amongst all interested
parties and a clearly defined hierarchy within the IRS program management team
to help control the program and prevent or manage adverse events; the right
choice of people for the IRS team at every level in order to ensure that the
required skill has been set to deliver the program`s products is present.
Motivation of the parties involved in the program to foster better collaboration
and hence a greater awareness of each other’s responsibilities. The mentioned
success factors are usually accompanied by some sector specific aspects that
deal with the principle of sustainability. This includes the concept of a
program delivering a product with the potential for long term benefits that
continue to improve the social and economic wellbeing of the communities into
the future. These are not limited to the program as they promote a sustainable
environment where positive impact on the environment and local culture endures
in the long term, while the economy and employment opportunities for local
people are improved [2,3].
Lessons learned
It has been important
that vector control unit can learn from various experiences and pass on to the
future vector control programs from the lessons gathered during the vector
control program life cycle. Learning from experience the fundamental principle
and best practice of vector control programs are unique and challenging.
Therefore, vector control teams must seek to learn from the experience of
others and from previous and current events. Evaluating, what has gone
right/wrong within a particular activity or part of the program allow to
recreate/avoid that particular event in order to improve efficiency in current
vector control programs or projects [4].
Best practice
This could enhance
program-wide best practice related to program management and lead eventually to
the creation of Centres for Excellence that become the Focal Point for the
application of best practice. Stakeholder and partners must be clearly
represented within the program team thus improving and promoting a wider
understanding and support [5].
Collaborative approach
There have been twelve identified but related motives and reasons that could help vector control program implementation for multi-stakeholder collaboration and their associated benefits to the program excellent performance. In the context of sustainability, vector control program requires a strong process of collaboration at policy, program or community level to allow collective decisions taking and jointly agreed or collective actions [6].
Open ended questionnaire
was used to dig deeper in the experiences of the field staff at provincial
health offices, district health offices and partners; the way they felt indoor
residual Spraying campaign could be improved in Zambia. Nine out of the 10
provinces responded to the questionnaire in exception of Eastern and Copper
belt provinces who did not respond. The questions and responses per province
have been put in the tables. Literature review was from published articles,
vector control handbooks, indoor residual spraying manuals for malaria
elimination, a hand book on a Frame Work for Malaria Elimination were reviewed
to give insights and compare and contrast the position of implementing indoor
residual spraying during the campaign seasons. Comparisons of success factors,
lessons learnt and practices during cholera out-break of 2017/18 were emulated
for best practice and impact. The thematic areas were support supervision,
community engagement, capacity building of both technical and community based
health workers, collaboration with partners and government sectors, social and
resource mobilization and areas that can make Indoor Residual Spraying fail
including operational research for decision making.
The following questions were used to obtain insight into the current Indoor Residual Spraying status in Zambia, its awareness, and the possibility of successful implementation of the program for malaria elimination.
The findings on improving the implementation
of Indoor Residual Spraying in Zambia are presented in the tables below. There
were a total of 20 participants and out of these 17 males and 3 females. All
interviewees agreed that Indoor Residual Spraying was a good intervention that could
significantly contribute to malaria elimination agenda for Zambia. The
participant’s opinions on the magnitude of issues surrounding failures, best
practices, lessons learned and successful implementation of Indoor Residual Spraying
are summarized in tables.
Success factors,
lessons learned and best practices from 2017/2018 cholera out-break
The Table 1
summarizes the success factors as: Quality leadership with a focus, community
engagement, resource availability, implementer commitment and capacity building
of staff (ongoing). Lessons learnt were stakeholder involvement and other
government sectors. Strengthened supervision, quality monitoring, thematic
working groups, communication and reviewing of the program with feedback. The
best practices were stratification of problem areas, existence of communication
plan, engagement of relevant stakeholders and civil society. Technical
guidelines were also available for reference by field staff including the need
for community engagement as one of the principal basis to implement activities
in the community (Table 1).
Situational analysis
and recommendations by the provincial health offices on improving IRS campaign
program in Zambia
Table 2 provides a
situational analysis from the provinces. Two provinces did not provide a
feedback to the situational analysis however weak community engagement by
levels was observed across all the provinces. The logistics for indoor residual
spraying were inadequate at all levels and included inadequate partnership
engagement. The remuneration for Spray operators was found not to commensurate
to the work involved by the spray operators. There was no strict following of
the indoor residual spraying calendars. The campaign most of the time lacked
adequate quality spray. There has been a need for strengthened community
mobilization with adequate number of sensitization days to the communities.
Operational research was not conducted to understand the views of the
community. Community indoor residual spraying was recommended by all provinces
to be the next intervention that can make impact towards malaria elimination
agenda. The financial resources were also another area that needed to be
decentralized to the provinces with strict monitoring of its use (Table 2).
Table 3 Effective
implementation of Indoor Residual Spraying has to be central part of malaria
control strategies where IRS is appropriate. IRS is implemented with the
objective of reducing morbidity and mortality and accelerating progress towards
global and community malaria agents. The important considerations surround the
need to strengthen social mobilization and community engagement, regular
performance review meetings, strong involvement of provincial supervisor’s
capacity building, improvement of storage facilities and working bays. Adequate
transport, strengthened monitoring and evaluation and supervision itself,
number of spray days has to be increased including mapping and strengthened
HMIs (Table 3).
The supervisory
skills at all levels are an integral factor in how well a supervisor relates to
his subordinates. Supervision for quality performance was found lacking
especially at all levels. Regular review meetings to improve supervision were
cited and need to be implemented during, before and after spraying campaign.
The training of TOTS period of training to have more and must include
Provincial Health Staff as first step to engage provincial leadership. The
storage facilities at all levels to be adequate to accommodate material
logistics. Monitoring and supervision was to be strengthened at all levels. The
supervision has to be extended to assess adequacy of changing rooms and
operations of the Malaria Task Forces (MATFs) (Table 4).
It shows the
critical areas for strengthened community engagement in order to get people
better connected into community and for ensuring that services designed next.
The concept of community involvement in improving health outcomes has its roots
in the action that communities have always taken to protect and support their
members. Roles of key affected populations with malaria, community
organizations and networks and public or private sector that work in
partnership with civil society at community level in design delivery,
monitoring and evaluation and supervise its self. Number of spray days has to
be increased including mapping and strengthening Health management information
system. Capacity building helps identify obstacles, gaps and opportunities as
identified by all provinces. Capacity building has been known for strengthening
capacities in IRS and entomological surveillance system for staff data
collection, analysis and management especially for monitoring insecticide
resistance. Capacity building has opportunities for strengthening infrastructure
for IRS and laboratory and insectaries. There are also opportunities to use
information. Building community capacity has been foundation to both prevention
and treatment of malaria from creating demand for IRS and LLINs to increase
trust between health worker and community volunteer (Table 5).
Collaboration in IRS
implementation remains cardinal to achieve sustained malaria elimination. The
health system at all levels must assume its stewardship and leadership role and
exercise its mandate to coordinate efforts related to malaria elimination.
Technical capacity also needs to exist among competing technical needs. PMATF,
DMATF and CATF and national MATFs must exist for coordinated efforts. Intra and
Intersect oral collaboration with adequate representations from various policy
actors and strengthened channels of communication must exist at all levels of
the health system (Table 6).
Resource
mobilization has been described as: giving people the opportunity to give. It
is not an end in itself but rather the process whereby resources are
transferred from those who are able to give to those who have the need to
receive. The mobilization of resources facilitates this process. Resources are
the enablers of an activity that not only satisfies the need, but also satisfies
the giver that their contribution has been wisely and effectively used. This
term is used to be more comprehensive than the usual “fundraising”. Fundraising
suggests that someone else has funds and approaches need to be devised to
access their funds. Resource mobilization includes two other concepts; first,
that non?financial resources are also important; and second, that certain
resources can be generated by the NGO rather than accessed from other sources.
Resource mobilization is asking. While most people are willing to give to
obvious and needy causes, only on rare occasions will people give without first
being asked. No matter what the communication methods we use to convey the
message of need, if this does not include an ASK, effective response will not
take place. How can an organisation raise the income needed to carry out its
mission? Where are the required resources? How do you sustain your organisation
and work? These are the key questions confronting organizations when they
consider how to maintain their work and strengthen organizational
sustainability. Developing a plan or strategy for resource mobilization can
lead to creative efforts in using your own local assets to gain support for
your organisation. Multiple sources of funding can increase your independence
and flexibility to implement programs and reduce reliance on external (or
foreign) funding. With increased competition for scarce grant resources,
thinking of, and creating options for new, diverse, and multiple funding
streams will help your DHMTs manage their own programs (Table 7).
Operational research
has been known to improve public health evidence- based decision making.
Districts are encouraged to further start researching on vector control
activities and publish papers (Table 8).
Shows the gaps for
IRS that make it to some extent fail to make an impact. Late implementation
shows lack of seriousness at national level as IRS logistics have never been
adequate and the program always starting late, lack of engagement of key stakeholders,
inadequate funds, storage facilities, weak coordination of IRS activities, weak
social mobilization, inadequate structures and implementation levels, weak
monitoring and evaluation have made IRS fail year in and year out (Table 9).
Experiences across
provinces has shown that stakeholder commitment, leadership engagement,
advocacy, capacity building, operational research and political commitment
including social acceptance of Indoor Residual Spraying and information
management remain critical to improvement of IRS supplemented by intensified
monitoring and supervision (Table 10).
All the thematic
areas mentioned by partners are very cardinal to the successful implementation
of IRS at all levels of implementation. Implementers have to spend time to
learn the thematic areas. The thematic areas are systemic and managerial in
nature (Table 11).
Capacity building
helps to identify obstacles. The gaps and opportunities have been provided by
all provinces for capacity building. Capacity building has been known for
strengthening capacities in IRS and entomological surveillance system for staff
data collection analysis and management especially for monitoring insecticide
resistance. Capacity building has opportunities for strengthening
infrastructure for IRS and laboratories including insectaries. There are also
opportunities to use information, communication technology to more effectively
collect and respond to epidemiological and entomological data and to the
planning and implementation of vector control interventions like IRS.
Malaria control
remains a leading health challenge everywhere in Zambia. Indoor residual
spraying (IRS) has been an effective strategy to control malaria transmission,
but there are often barriers to reaching the coverage necessary for attaining
maximum community protective effect of IRS. Community engagement has been
recognized as one of the key components for successful health interventions
including malaria control [7,8]. However, in practice community engagement has
often played a marginal role within malaria control and elimination program.
Community engagement increases knowledge among families and communities
concerning malaria, its transmission and understanding that the mosquito is the
only vector of malaria. It further promotes communities’ uptake of malaria
prevention methods including the collect and consistent use of vector control
interventions in their homes and uptake of other interventions. Community
groups and CBVs play a key role in improving the demand for health services and
bringing positive changes in individual health practices and social norms [9].
It is quite important to recognize the vital role of community structures such
as Health Neighbourhood Committees & community based agents in generating
community involvement and ownership of malaria control and prevention
ultimately malaria elimination efforts. There has been a need to build capacity
to the structures to develop locally relevant malaria awareness, education and
mobilization activities within their own communities (Table 12).
Community capacity
building principally expands, diversifies and promotes community participation,
expanding community leadership base while at the same time strengthens
individual skills. It encourages a shared understanding and vision promotion
and provides a strategic community agenda. It further facilitates consistence
and tangible progress towards goals. Capacity building creates effective
community planning, organization and promotes resource mobilization and
utilization by the community (Table 13).
Show how effective
use of IRS requires national program capacity, structures and systems. Together
the public and private sector can continue to develop IRS best practices and
strengthen IRS capacity. The private sector has an important role to play in
reducing the malaria disease burden in Zambia through IRS. Companies can
protect their workers and communities by developing local IRS programs, and can
also leverage corporate strengths including logistics, distribution and
communication to maximize the effectiveness of national, provincial, district
programs and strategies (Table 14).
Explains the way
resource mobilization (RM) has been a comprehensive process involving strategic
planning, advocacy, communication and negotiation with donors’/policy makers,
communities, business community and sound management of resources. Resource
mobilization, based on these tenets, strengthens the credibility of vector
control and ensures both enhanced coordination and harmonization among malaria
elimination partners. Opportunities for resource mobilization exist everywhere
at every level. These opportunities need to be systematically explored, seized
and even created by the IRS implementation levels and its environmental health
units at provinces, districts and national levels to maximize positive health
outcomes (Table 15).
Discusses the
operational limitations and methodological gaps that have been associated with
malaria control interventions that need research. These limitations and gaps
have necessitated the need for well-tailored Malaria Operational Research (MOR)
agenda for each province especially during IRS implementation. However, there
is paucity of evidence-based information on relevant stakeholders’ experience,
awareness, perceptions and use of MOR and suggestions on setting MOR agenda. As
part of a larger study to provide data for national, provincial, district MOR
agenda setting, there is a need to assess the MOR research situation from the
perspectives of key stakeholders in Zambia and provinces and contribute to MOR
to the malaria elimination agenda for the country (Table 16).
The failure of Indoor Residual Spraying
Campaign(IRS) has been very systemic more especially the supply chain
management, leadership approaches, vision oriented by implementers and
identification of stakeholders and involvement of key stakeholders can
strengthen indoor residual spraying at all levels.
This report brings together all known records of many case studies
that aim for policies, guidelines and the program not to be optional additions,
but to be established as a new way of doing business. What is important is to
make incremental changes to the program.
Engagement of policy
actors
There must be a creation of engagement of a network of Policy Actors to
champion Indoor Residual Spraying Campaign program and strengthening intersectoral
collaboration. This could help to open up traditional organizational boundaries
and support coordination during Indoor Residual Spraying preparations,
implementation campaign, monitoring and evaluation and decision making
including policy change in some part. It is quite important to have an approach
to collaborative policy development and not merely a technocrat planning
approach. It is important to embody a whole of society and a whole of
government vision.
The policy Actors shall come from
the following cross-sectoral and multi-sectoral governance as a strong and
critical mandate:
·
Minister of Health,
·
Minister of Environment
·
Minister of Water and Sanitation
·
Minister of Defence
·
Minister of General Education
·
Minister of Tourism
·
Minister of Local Government and Housing
·
Minister of Agriculture
·
Minister of Livestock and Fisheries
·
Minister of National Parks
·
Minister of Traditional Affairs
·
Zambia Environmental Management Agency
(ZEMA)
·
Water Management Agency (WAMAR)
·
Zambia Sugar Company
·
Ministry of Transport and Communication
·
Ministry of Mines& Mines
·
Other relevant Partners &Stakeholders.
As we drive our Goal of ending malaria, putting in place a governance
structure to oversee Indoor Residual Spraying Campaign Program as a Whole-of
-Government and Whole -of –Society Approach is needed to ensure long term
benefits. Good governance drives the implementation of work across sectors,
builds ownership and increases exposure to collaborative opportunities (Table
17).
Development of
statutory instrument (SI)
There has been an urgent need for the development of a Statutory
Instrument (SI) for Indoor Residual Spraying to increase acceptance rate for
universal coverage of the intervention to the population. Vector control could
be improved by basing it on local evidence, by integrating interventions where
appropriate, and by collaborating with divisions within the health sector and
with other public and private sectors, and also actively engaging communities.
Existing policies related to malaria vector control such as the Mosquito
Extermination Act, National Health Policy, National Malaria Elimination
Strategic Plan, the Malaria Business Plan, the Public Health Act Cap 295 of the
Laws of Zambia, current guidelines for Malaria Vector Control, legislation and
regulation of pesticides and current vector control programs. These policies
might have to be amended or rephrased in order to increase support for Indoor
Spraying Campaign for Zambia (Table 18).
Strengthening or
formation of inter sectoral steering committee
An intersect oral Steering committee on Indoor Residual Spraying or
vector control in general with support of the Minister of Health is vital to
establishing intersect oral collaboration. The Steering committee will function
as an inter-ministerial governing body with responsibility to facilitate
harmonization of policies and institutional arrangements and to provide
strategic direction and coordination for implementation of Indoor Residual
Spraying activities. There is a need to develop Terms of Reference for the
Steering Committee to differentiate it from the Technical Working Group (TWG)
functions. In order to have sufficient political “clout”, the members of the
steering committee should be senior staff, such as directors or assistant
directors of departments of or institutions. They should represent several
ministries “Policy Actors” as indicated in the previous paragraph. The Steering
Committees to be at every level (Provincial Health Office, District Health
Officer & Community) as a replica of the ministries who act as “Policy
Actors” (Table 19).
Community engagement
The community has to be incorporated as primary stakeholder, the
community voices have to be incorporated to help shape action on community
participation on Indoor Residual Spraying Campaign Program [Minister of
Traditional Affairs]. They must be involved in the selection of Spray
Operators[SOP] from community based volunteers, monitoring and evaluation,
participation in indoor residual spraying, formation of community and model
implementation. Malaria elimination and sustainability of the malaria-free
areas depend on the behaviours and day -to –day activities of the affected
communities. If awareness is raised in communities and the communities are with
the necessary information, they two can exert pressure on developmental
programs under the required mitigation actions for reducing malaria risks
related to their project activities.
Raising the awareness of the communities and their leadership on the
importance of being involved in malaria elimination and prevention of
re-introduction, and their engagement and participation in these processes in
their areas are critical. The community needs to be informed when there is a
shift in the malaria strategy and should be able to contribute deliberately to
the success of malaria elimination efforts and sustenance of free malaria
states in the post elimination period. The traditional, political, religious
leaders and civil society, women groups and youths including school children
have to be seriously engaged.
Intra and intersect
oral collaboration
It has been important to share information and raising awareness among
sectors about the roles and responsibilities of the various stakeholders in
Indoor Residual Spraying Campaign. The structure at these levels (PHO, DHO AND
RHC) is just like the Steering Committee at national level. The Committee can
have different titles like PMATF, DMATF and Community Executive Committee.
Collaboration within the health sector and with other sectors- considerations
of all options for collaboration within and between public and private sectors;
strengthening channels of communication among policy makers and vector control
partners.
Integration into the
health system
Coordinating the IRS activities into the existing health system could result
in more efficient use of resources and sustained support by other stakeholders.
It is recognized that integration of IRS into the routine health services could
derive great overall impact from health resources and systems:
· We need increased implementation of Indoor Residual
Spraying-Twice per year .This has to be done in the period of October to
December and February-to April. A double impact per year will yield good
results. The selective spraying could fit well here.
· The Indoor Residual Spraying require changes
in how services were delivered by district implementation levels (MOH, NGOs,
CBOs & the private sector agencies. Existing or new health system inputs
[Such as resources, time, money or expertise] may need to be allocated
differently to support planning management, staffing, interpersonal
communication or the measurement of integrated services.
· The Broader governance and capacity issues
in the health system level: There has been need for new levels of coordination
or joint planning of the policies, processes and infrastructure that make up a
health system. Integration at this level often requires significant involvement
and support from stakeholders, including donors, Ministry of Health, Policy
Actor Ministries, advocacy groups, the private sector and NGOs.
· Strengthened intersect oral coordination:
Cross-sector integration needs the health system to intersect for example with
an education system to run IRS through schools and Agriculture program to
address mosquito killing through spraying houses and controlling breeding areas
through community engagement. This integration across sector requires
engagement and commitment at multiple levels of agencies involved.
Monitoring and
evaluation
A Monitoring toolkit has been put in place to guide the field monitors
and the decision makers at every level. The tool kit or guide has to involve
both government sectors, partners and other stakeholders. Its main purpose is
to support Indoor Residual Spraying Program through systematic monitoring and
evaluation of processes and outcomes allowing timely detection of gaps and
constraints and so ensuring that adequate responses are triggered. The document
has to assist vector control managers in their daily practice but also as
background document for training and capacity building at all levels of the
vector control program.
The recent research in the three target countries has shown that, if
done correctly, IRS could be a very powerful in substantially reducing the
vector population. New ideas, policy and institutional arrangements must be
monitored and evaluated in order to ascertain the progress made and identify
areas for further attention. There has been a need for checklist at National
[pre-spray& Spray], Provincial level [Pre-spray & Spray] at district
level [checklist for district operations]. RHCS to have similar checklist for
preparations &implementation. There will be also checklist at village level
[ observation checklist: spray squads, interview acceptability of IRS, entomological
surveillance mosquito and larvae collection forms, Bioassay test on IRS
surfaces and susceptibility test on impregnated papers. The entomological
surveillance has been monitoring such aspects. There has to be also
self-evaluation form at national to look at preparation of IRS cycle at central
level and IRS activities.
Reporting on progress and performance indicators: The NMEC has to receive records of data reporting on structures and populations covered on daily basis. There should be a desk to receive reports at each of the offices [National, Provinces, District, facility and community. By close of each day (18.00hrss) coverages have to be known and by the middle of the month provinces not doing well have to be followed by the supervisory teams either by way of phone communication or visiting them. In order to facilitate effective recording and reporting of information, clear and simple data collection forms, entry forms and analysis forms have to be provided.
Table 1: Framework for success factors, lessons learned and best practices for cholera out-break in Zambia.
Table 2: From your experience, how can we improve Indoor Residual Spraying Campaign program assuming that all logistics are in place and that implementation of the program can start at the right time.
Success factors |
Lessons learned |
Best Practices |
Comment |
-Ending
cholera. A Global Road Map to 2030 -Ministry of Health [Ministerial Declaration to
Ending cholera [Vision& Mission Statement] -Aligned
MOH with cholera control structures -Development &Implementation of Statutory
Instrument [S.I 79] -Clearly defined terms, roles and purposes of
working teams starting with the Ministry of Health -Ministerial strategic focus &Operational
efficiency -Identification
of stakeholders -Community Engagement at all levels (User
Involvement) -Availability of material Logistics: Funds, Medical
Products, Transport, PPEs, Food, Human Resources [Technical &Community] -Defined the approach methodology: community
participatory approach, IEC materials, guidelines, politics, tools &Job
Aids were made available. -Management of disease surveillance
data(IDSR) -The ongoing capacity building of staff,
community(NHCs) and others relevant government sectors -Easy
access to medical products for cholera control -Support
senior leadership in the hierarchy -Commitment of resources [HR, Finance &
mobility] |
-Minister worked with people, stakeholders
&took responsibility to lead teams -Inclusion of the local government on
public health as a delegated responsibility to Local Authorities -Support Field Assessments -Strengthened monitoring & supervision of
activity implementation -Good division of roles among partners -Technical coordination of mechanisms for cholera
control of commanded Thematic Working Groups co-chair arrangements -Establishment of multi- sectoral weekly
briefing meetings at all levels -Ongoing identification of operational gaps by
selected teams |
-Minister made decisions -Team Leadership -Establishment of community-based response
mechanisms with councilors -Early identification of weak districts -Mapping hotspots -Printing of Guidelines -Transport distribution plan in place -Developing logistics management plan -Existence of communication plan with field teams -Engagement of Ministry of Education -Daily briefs from the field -Weekly monitoring of morbidity& Mortality rates -TORs given to teams for coordination mechanisms -Sharing of information on daily basis
through meetings and distribution of daily epidemiological updates -Engagement of community and government institutions
especially government line ministries -Engagement of civil society and private
sector for vehicle &other logistical support provided by private sector
companies -Partners to deploy field coordinators to
support coordination & Supervision [Malaria Commanders] for social
mobilization -Technical coordination of partners -Identification of hotspots &sharing with
partners -Province, district to national feedback mechanism |
-Feedback to communities -Use of Inter Religious leadership to sensitize own
people -Diverse utilization of communication media -Community complaints handling -Ministerial person handling of some hard issues -Partners looking for where to provide assistance -Army used where necessary -Staff reshuffles especially those not doing well -Area Councilors engagement -Different community plans developed - Effectiveness and efficiency in medical
products was noticed with excellence it deserves
|
Source: Cholera Control and management reports (2017/2018) |
Lusaka |
Western |
Central |
N-Western |
Northern |
Luapula |
Southern |
Muchinga |
-Engage community early and strengthen
community partnership through
community meetings, local media to address high refusals problem and
misconception about IRS in all the districts. -Construction of an IRS
base nearer to the district health office. -Procure and supply
adequate spray pumps and repair kits. -Adequate funds to conduct
mop up during the main spray campaign. -Adequate supply of PPE for
spray operators. -Adequate funds at PHO for IRS campaign supervision |
-The right Time is a
crucial point. Funds amongst logistics spare parts should be in place, funds
received early, all Depend on releasing funds early. Program always start rain
season. |
-Always start
the actual spraying exercise before rain
season -Empower spray
operators by slightly increasing their daily
wages -Increase the
number of supervisors and monitors |
-Intensified supervision at all levels -Intensified
community sensitization/ mobilization before, during and the campaign |
-Quality and Commitment
of IRS by spray operators: The
structures being left out as most of them do not come from the catchment
areas where IRS is being implemented. Quality of Cascade and community
mobilizers training -Weak Community
mobilization -Quality of Supervision and
monitoring |
-Involvement of
Influential leaders at planning level and a well-
coordinated community mobilization -We may also
need to conduct a Human Centered Design approach to fully understand the community’s desire with IRS. |
The program must
be Localized by ensuring that spray operators are trained in
zones in order not to miss structures as they are
familiar with the area. |
-Decentralize
IRS to be provincial specific taking into account the seasonality -Resources be
sent to Provinces for effective monitoring of its utilization by districts (accountability) |
Source: From Provincial Health & District
Offices experiences |
Table 3: Which thematic areas of Indoor Residual Spraying Campaign Program do you recommend to improve at each implementation level assuming all logistics and resources arrive at the right time and are in place in your province or districts.
Lusaka |
Western |
Central |
N-Western |
Northern |
Luapula |
Southern |
Muchinga |
-
strengthened Social Mobilization activities |
-There should |
Not |
Not
answered |
-Sensitization at |
-Community Level (coordinated |
The training of |
-District |
-Regular
Review of performance |
be specific |
Answered |
all levels |
community mobilization and |
SO and |
Level |
|
meetings of IRS campaign at |
vehicle for |
|
-Occupational |
involvement of traditional leaders |
Supervision; for |
(Areas of |
|
Provincial
Level at least one (1) during |
supervision of |
|
Health and |
and other leaders in the |
the program to |
high |
|
and two (2)
after the campaign. |
spray |
|
safety- most of |
community) |
ran well the SO |
incidence |
|
-PHO
supervisors to be involved in |
operators…. |
|
the districts if |
-Facility Level (all the staff should |
by increasing the |
be mapped |
|
Training of
Trainers for IRS |
pool vehicles |
|
Not all don’t |
be involved in community |
number of days |
through |
|
-Adequate Monitoring and |
hinder |
|
have change |
mobilization) |
especially in |
HMIS and |
|
Supervision
of IRS campaigns in the |
effective |
|
rooms for spray |
-District Level (involvement of all |
application |
vigorously |
|
districts |
supervision |
|
Operator and |
the stakeholders, sensitization |
technics |
plan and |
|
-Improvement
of storage and disposal |
|
|
supervisors. |
through the media, drama in |
|
deal with |
|
of IRS
waste in all the districts. |
|
|
-Weak |
schools and market places) |
|
those areas |
|
|
|
|
Supervision and |
-Provincial Level (technical support |
|
|
|
|
|
|
Monitoring |
and involvement of stakeholders at that level). |
|
|
Table 4: How do you think we can improve supervision to IRS implementation to districts and to field activities.
Lusaka |
Western |
Central |
N-Western |
Northern |
Luapula |
Southern |
Muchinga |
-By allocating
adequate funds at provincial level to conduct support supervision |
-PHO to instruct DHDs to allocate a
four wheel drive specific vehicle to IRS program. not pool vehicle. |
By introducing team leaders and
mobilisers to ensure reaching out to all households -We can effectively
Improve supervision by assigning One supervisor to four spray operators, that
is excluding the IRS Manager. Ratio of 1 :
4. |
Supervision to be done on
daily throughout the duration
of the campaign |
-Involvement of adequate number of EHTs as focal points with district
supervisors &Community mobilisers to
bridge the gap -Orient
facility staff in IRS Campaign -Deploy motor Cycles,
bicycles, boats & oxcarts etc. -Constitute a dedicated DHO Team for M&E
duringIRScampaign -Utilized community structures (NHCs, HACs, Chiefs , Headmen,
Chas & RHC staff. -Motivation from
DSA for the IRS period [30 days] and not for k85 because of laborious work done. Chilubi
&Kasama have not been paid since 2014 |
-Supervision starts from training of
which supervisors should show
leadership and they should be given well defined and
clear supervision tools, increasing the number of supervisors can improve the effectiveness of supervising but that should also come with improved
coordination among supervisors and regular meetings for feedback. -IRS managers must be trained together with Data Clerks and M&E officer to
ensure they are at the same level. |
-Provision of motor bikes to supervisors to enable move faster and
be able to reach in hard to reach areas where vehicles can’t reach. |
-Provide adequate resources for provincial master trainers -Advocacy meetings from Provincial, district and chiefdom levels |
Source: From Provincial Health &
District Offices experiences |
Table 5: How much have we engaged the community in implementing Indoor Residual Spraying in our provinces or district.
Lusaka |
Western |
Central |
N- Western |
Northern |
Luapula |
Southern |
Muchinga |
-By
involving PHO Environmental
Health Unit in
entomological surveillance/survey. |
No response From
Western Province |
-The communities are engaged early before training commences,as well as during actual spraying. -They are the ones that mobilize and inform the community members when the spraying will be conducted. During spraying, they take the spray operators round together with the supervisors in the communities. |
All communities in all 11 districts are
involved in community sensitization, traditional leaders, civic leaders,
government departments, churches. Only of
11 districts, only 2 districts are supported by
stakeholders that is Kansanshi
mine, Kalumbila mine and Lumwana mine |
Firstly, communities are involved in mobilization and sensitization
on IRS key messages. During social and community mobilization that is
when we try to involve them Though poorly done as well and without proper supervision. However, engagement of the communities during implementation of IRS activities has been very weak and poor. |
-The
community has been engaged at
pre-planning, planning
and Implementation stages. -The general
picture at provincial
level is that few involve
communities During pre
and planning. -With few districts within the
province are able to
involve the community
at all stages. -The best
way of engaging the
community is in IRS identifying
the best working strategy
for different
community sitting. |
-Stakeholders are involved in
resource mobilization, community mobilization and program
evaluation |
-Superficially- usually they are not part of the planning and yet IRS must be community Driven. |
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Table 6: Which areas do you feel capacity has to build for effective Indoor Residual Spraying.
Lusaka |
Western |
Central |
N-Western |
Northern |
Luapula |
Southern |
Muchinga |
-Capacity
Building of EHTs in Entomological Surveillance to fully understand the vector in their respective areas not only people at the National level. |
-Supervision of
Spray operators -Selection of spray
operators we improve - Disbursement of
funds from central level and spares improve. -Strictly target hot spots centers catchment areas. |
-District Health
Directors in most districts of Central Province are new and for effective
implementation they need to be oriented in the running of the program. -Cascade
trainings should be at least minimum of 14 days for spray operators to assimilate and perfect the skills of spraying. -For TOT,
important to invite at least 3 people from the district (IRS Manager, IRS
Coordinator and one new IRS supervisor). |
-Supervision skills -Monitoring and Evaluation
skills |
-IRS management -Logistics management -Spraying techniques and insecticides formulations -Monitoring and
supervision of Spray Operators -Social community mobilization and
community engagement by DHO staff and RHC staff. -Train community volunteers
and CHAs on how to conduct door to door visitations -Local Leadership sensitization/awareness meeting during full council meetings for
councilors, chiefs and headmen on Presentations on analyzed
disease burden and the processes starting from recruitment process to evaluation. -HAC at Health Facility - Roles and Responsibilities before, during and after the campaign. How Malaria
data at facility level should be discussed zone by zone and the key high impact
interventions. -We need to train community volunteers in mobilization. |
-Effective Team leader training -Effective supervision
tools -Effective
training of all carders with the required skills -Will
coordinated community mobilization by
effectively training mobilizers? |
Monitoring and Supervision |
-District and
Health facility levels on implementation -Provincial on supervisory role |
Southern: From
Provincial Health & District Offices experiences |
Table 7: How has been the collaboration in IRS implementation within the health sector and other sectors in our provinces and districts.
Lusaka |
Western |
Central |
N-Western |
Northern |
Luapula |
Southern |
Muchinga |
-Poor collaboration between
Health Office and other stakeholders at PHO and DHO Level. |
Collaboration has been
good. We can always improve more |
-Its on the fair
side, but sectors like ZESCO so supportive in Itezhi- tezhi, ZAWA
as well , the
DC’s office and the radio White farmers in Mkushi have also
been so supportive in supporting the program by spraying in the farm block. -World
Vision in Mumbwa has also been supportive by
supplementing on the resources such as fuel and transport. |
good |
-The rest of the
sectors such as Local Authority etc. are very passive -Others mainly
think that it is the duty of the Ministry Of Health and less support from
other sectors if anything they want to be paid allowances as well. -There has been a bit of a
change with the introduction of Malaria Task Forces at least we are seeing
some collaboration through the DCs office. |
Good |
-It
has been good but we need to do more in stakeholder collaborations
at local level |
Inadequate,We
only need them at the end during implementation. We don’t engage them during planning. There is need to
use the college approach in order to increase acceptance among learned colleagues |
Source: Provincial Health & District Offices
experiences |
Table 8: How far has our advocacy on social mobilization and resource mobilization being organized with local leaders, implementers and communities and other stake holders (Business Community).
Lusaka |
Western |
Central |
N-Western |
Northern |
Luapula |
Southern |
Muchinga |
-Social and
resource mobilization adequately done only during IRS implementat ion not
afterwards.
Inadequate National Malaria
Week activities in the Province. |
Fairly good on going.
|
-In Itezhi-tezhi
Social mobilization is
always done through the
radio and visiting our chiefdoms to sensitize them
on the exercise but fan enough for resource mobilization its just ZESCO that
are helping us with the storage and ZAWA transport, tractor especially during
rainy season. -The local authorities have provided storage facilities in most districts and
other partners have
offered transport especially through the District Administration. |
-Its limited only to the
period during IRS implement ation |
-Advocacy is
more with human resource only and not financial resource and this hampers
effective mobilization owing to long distances mobilizers have to cover due
to inadequate resources to recruit and train more community mobilizers. Advocacy with stake holders
still is a challenge, officers think of monetary
gain when called for meetings and
or monitoring. MOE is one ministry that needs to be on board.The area of advocacy with the business community is one
area not fully explored and need attention. Strategies on how to bring them on board e.g. meetings should be utilized. -Local leaders
are not fully utilized in the implementation
process more when it comes
to refusals. The teams rarely visit the headmen during implementation
and after the day’s work. The community on the other hand has been involved
in mobilization and implementation but contribution to allow for community
ownership and sustainable development. This has been a poorly done the office
of the health promotion officers has not been actively involved in IRS
community mobilization as well as .-At
times districts have been using already existing structures at health
facilities such malaria task forces, NHCs and other community structures. |
-Not very impressive (more energy and time should be invested in this area) |
-We have not exploited much however the
process is still on going. |
-Very low, the
issue is never brought to round table for discussion so that planning can be
done together. |
Source: Provincial Health & District Offices
experiences |
Table 9: Have we ever conducted an operational research/assessment/survey for IRS Campaign in our province/districts? If any what were our findings and recommendations to that effect.
Lusaka |
Western |
Central |
N-Western |
Northern |
Cupula |
Southern |
Mooching |
-No operational
research/ assessment/ or
survey for IRS has ever been done in Lusaka Province to the best knowledge of PHO. |
-Yes as an
academic paper. Findings revealed: -Many
houses were missed not sprayed
likely some spray operators not
doing job well. -Supervision was
not very good. -Rains affected
spraying on certain days prolonging spraying days -IRS was
effective in malaria control -People welcomed
the program. |
-In Itezhi-tezhi Social
mobilization is always done through the radio and
visiting our chiefdoms to
sensitize them on the exercise but fan enough for resource mobilization its
just ZESCO that are helping us with the storage and ZAWA transport, tractor
especially during rain season. -Thelocalauthorities
have provided storage facilities in most districts and other partnershave
offered transport especially through theDistrict Administration. |
No |
Not yet however, some districts such as Chilubi conducted one this
year on acceptability of IRS in urban community. It revealed that urban
community recorded low acceptability of IRS and difference reasons were
explained. Mporokoso also did structure verification and assessment and
findings were that there more
structures left unsprayed due to long distances and most of these structures
are scattered. Many of these structures were not even mobilized.
Recommendations to this effect were to increase community mobilizers, increase spray
operators and increase spray period to ensure all areas are sprayed
effectively. Also making sure that if all villages were to be sprayed, all
headmen should be involved for ownership. |
-No (most of the time plastic
surveys are done and not well defined ones) |
-Yes; we did an
operational entomological survey on the effectiveness of IRS where a mosquito
catch was done before and after IRS to measure the density of the
mosquitoes. The results were not
even; in some houses there were great change while in others there
was no change. This therefore meant that some SO
applied the chemicals well
while others did not do a good job |
-Low IRS acceptance in
urban parts of the districts -Centralized
operational management increases the
cost of doing the Program |
Table 10: What can make us fail in Indoor Residual Spraying campaign as a Province or District.
Lusaka |
Western |
Central |
N-Western |
Northern |
Luapula |
Southern |
Muchinga |
-Late IRS implementation on -Non engagement of key stakeholders in IRS implementation -Late delivery of IRS logistics -Poor social
mobilization |
The
following may make us fail -Starting program when rains have started
in the middle of rain season -Late
receiving of implementation funds -Poor selection of spray operators if we
do not do on merit houses will be missed and if supervision is poorly coordinated. |
-In Itezhi-tezhi Social
mobilization is always done through the radio and visiting our
chiefdoms to sensitize them on the exercise but fan enough for resource
mobilization its just ZESCO that are helping us with the storage and ZAWA
transport, tractor especially during rainy
season. -The
local authorities have provided storage facilities in most districts
and other partners have offered transport especially throu District Administration. |
-Lack of logistics -Inadequate or lack of supervision at all levels -Lack of
community involvement |
-Poor
transport system & Failure by IRS managers to analyze and evaluate the
program -Lack of commitment and dedication in short
ownership of the program -None engagement of the community and traditional
leadership -Inadequate monitoring and supervision of SOPs. -Inadequate social and community mobilization -Absence of publicity and sensitization on IRS.
Implementation of IRS activity during intensive phase of rain season -Inadequate coordination of the program by
responsible officers. -Late delivery or at times insufficient logistical
and supplies due to the CSO population data used for planning purposes. -None involvement of stake holders -Inadequate
planning |
-If, we don’t involve influential leaders
from the beginning and the issue is that as we involve these leaders we should move with an open- minded
approach. |
-The quality of SO training, equipment (sprayers) and quality
of supervision |
-If program is centrally managed instead
of allowing districts to plan for its implementation -If program has no connotation of
responsibility to EH staff |
Source: Provincial Health & District Offices
experiences |
Table 11: From your experience colleagues how can we improve Indoor Residual Spraying Campaign program assuming that all logistics are in place and that implementation of the program can start at the right time.
Partners-1 |
Partner-2 |
Partner-3 |
-Commitment from every stakeholder involved. The biggest issue
in IRS apart
from resources is commitment by supervisors. They need to have passion
for the program |
-Engage community leaders and their subordinates. -Advocate for more cascade training days. -Entomological survey
results to guide the type of spraying to be done in a particular area i.e.
IRS or Overhead. -Construct standard IRS centres in all districts with proper change
and store rooms. -Capacity build all supervisors -Conducting operational
research studies would be of help in the program analysis. |
-Adequate political
commitment and social acceptance of IRS; Adequate information on local
vectors, especially insecticide susceptibility status and indoor versus
outdoor feeding and resting behaviors; |
Source: Partner consultation |
Table 12: Which thematic areas of Indoor Residual Spraying Campaign Program do you recommend to improve at each implementation level assuming all logistics and resources arrive at the right time and are in place in your province or districts.
Partner-1 |
Partner-2 |
Partner-3 -Adequate and sustainable financial, logistical and human
resources; and an IVM
platform, which is also relevant for insecticide-resistance
management where insecticides with different modes of action can be rotated
to reduce selection for resistance |
|
Community Level -Quality of spray by SOPs. -Understanding
by the community that this intervention requires both individual and
community effort. The community need to know that for IRS to be effective and
for them as individual households to be protected, they need to know that
their neighbor too need to open up their houses. -Quality of supervision by district staff. -Effective engagement of the community by community mobilizers. |
-Social and resource mobilization
|
|
|
-Quality of supervision by district staff. -Effective engagement of the community by community mobilizers. Facility Level -Accurate quantification of the number of structures
and their distribution. -Leading examples to communities by ensuring that their own houses are
sprayed. -Incorporating the importance of IRS and
the need for the community to accept the intervention during public
sessions at facilities e.g. during child health week and pre/ante natal visits. District Level -Monitoring of
the program to ensure that the right things are being done. The DHDs must
carry the vision and own the program. -Bring the
district stakeholders on board through MATFs. In other words, it is not just
meetings and it ends there, but it should involve actual contributions in
kind and monetary if that is possible. Provincial Level -Monitoring of
the districts through weekly reporting by the districts. -Frequent field
visits to the districts. National Level -Monitoring of
the districts through weekly reporting by the districts. -Occasional
field visits to ascertain happens on the ground. |
-Community engagement -Advocacy meetings (stake holders meetings)
-Storage facilities -Evaporation tanks/ soak pits -Construction of standard IRS Centers at district level.
|
Availability of
all the necessary resources at the right time and place
|
|
Source: Partners for malaria elimination
consultation |
Table 13: How do you think we can improve supervision to IRS implementation to districts and to field activities.
Partner-1 |
Partner-1 |
Partner-3 |
-Enhance by the
districts. The intervention should not be seen as donor driven. -Supervision
should not be remote/under autopilot. Instead supervisors must be with the
field teams. -Engage
dedicated staff who have passion. Under performers should be beckoned |
-Enumerate
supervisors according to stipulated government conditions i.e. ---Give a subsistence/lunch allowance where it is due and not bow down to partners’
conditions which are not favorable at times. (compare the K100 camping
allowance given to the supervisors to a K700 night allowance) -Provide adequate transport
for supervisors in the field. Capacity build supervisors Emphasize on comprehensive
local monitoring. |
-Reassessment of existing
supervisors, their knowledge and suitability for the program. -Timeous, appropriate and
adequate retraining and training of supervisors and spray operators. -Stringent and monitoring
and supervision to include: *Use and accountability of
insecticide * Evaluation of coverage * evaluation of
client satisfaction * Follow up
entomological activity (bioassay evaluations)-re monitor quality of spray operations. |
Source: Partners for
malaria elimination consultation |
Table 14: How much have we engaged the community in implementing Indoor Residual Spraying in our provinces or districts.
Partner-1 |
Partner-2 |
Partner-3 |
-Mobilizers have been trained and engaged in door to
door mobilization of the communities. -SOPs have been drawn from the community. |
-50% logistics
were not disbursed in time due to inadequate community engagement |
Not Applicable |
Source: Partners for
malaria elimination consultation |
Table 15: Which areas do you feel capacity has to be built for effective Indoor Residual Spraying.
Partner-1 |
Partner-2 |
Partner-3 |
- Supervision -Data interpretation |
-I feel capacity should be
built to CHWs/MCA unlike the temporal ones engaged on contract basis who are
just interested in money and not to fulfill the program objective. -Community members
involvement -Through
effective community engagement strategies. |
Adequate program and health
system capacity to deliver good- quality, well-timed and high coverage IRS; |
Source: Partners for
malaria elimination consultation |
Table 16: How has been the collaboration in IRS implementation within the health sector and other sectors in our provinces and districts.
Partner-1 |
Parner-2 |
Partner-3 |
-It has not been
effective looking at the fact that other
sectors do not actively get involved in IRS implementation. |
Business community in Gwembe in southern province is small (only small
fishing camps exist) |
Not sure |
Source: Partners for malaria elimination consultation |
Table 17: How far has our advocacy on social
mobilization and resource mobilization being organized with local leaders,
implementers and communities and other stake holders (Business Community)?
Partner-1 |
Partner-2 |
Partner-3 |
-A lot has been done to engage the following and
talking points have been developed: . Traditional leaders . Religious leaders . Not much has been done to engage other stakeholders. . No much
success so far on resource mobilization outside the usual GRZ and partner
resources. |
Business
community in Gwembe is small (only small fishing camps exist) |
There
was no response from HEDC on this part as the organization is from outside
Zambia though operation in Zambia under social marketing |
Source: Partners for
malaria elimination consultation |
Table 18: Have we ever conducted an operational research/assessment/survey for IRS Campaign in our province/districts? If any what were our findings and recommendations to that effect.
Partner-1 |
Partner-2 |
Partner-3 |
No response given |
-Not really a research but
a comparison done on the traditional IRS that we have been doing over time to
the facility based. (tried in Sinafala) -Traditional IRS : the one where
all sprayer operators start at the same time and moving
from one catchment to the other
as a group is to involving and
does not yield
a desirable coverage. - Facility based: this is a
strategy where a group of sprayer operators is used to spray the whole
catchment of a particular facility for a specific number of days. Recommendations -Consider decentralization
of spray teams ie from one district team to various facility teams of 5
sprayer operators per team. -Increase the number of
sprayer operators -Increase the number of
sprayers per district -We need to add value to
the program by improving amenities attached to it. -Engage CBVs (CHWs/ MCA) as
sprayer operators for the sake of objectivity and sustainability of the
program. (in defense not all CBVs are above the recommended age limit for
participation in spraying |
No response given |
Source: Partners for
malaria elimination consultation |
Table 19: What can make us fail in Indoor Residual Spraying campaign as a Province or District.
Partner-1 |
Partner-2 |
Partner-3 |
-Inadequate supervision, inadequate leadership, lack of vision |
-If the component of
supervisor enumeration is not attended to. -If logistics keep coming
in bits and not in the required amounts. -If we continue
implementing it in the same traditional way. -If we continue spraying
during the rain season |
- Identify relevant
stakeholders and involve them from the onset -Coordinated program
implementation with all stakeholders (I.e. PMI(ABT/Vector link), MACEPA,
NMEC, and Private Sector etc.) |
Source: Partners for
malaria elimination consultation |
Table 20: Indicators of process and outcome for monitoring and evaluating progress in each component of integrated malaria vector control [21].
Capacity |
Process Indicator |
Type of data |
Outcome |
Type of data |
Policy |
-Focal point person for malaria vector control -Identified situational analysis completed -Economic impact for malaria vector borne disease
assessed |
L L L |
-National malaria vector control policy in place -National policy on pesticide policy in place |
L L |
Institutional Framework |
-Mandate &composition of national steering
committee on malaria vector(IRS) developed -Terms of Reference for national coordinating
Unit on vector control developed |
L
L |
-National Steering Committee on malaria vector
control IRS in place -National Coordinating Unit on vector control in
place |
L
L |
Organization& Management |
-Task Force constituted to revise job
descriptions & operating procedures -Task Force Constituted to develop professional
standards on vector control and public health entomology |
L
L |
-Number& percentage targeted staff with job
descriptions that make reference to vector control and public health
entomology in place |
L |
Planning &Implementation |
-Required resources for implementation of malaria
vector control IRS costed and mobilized -Required staffing level &competences for
malaria vector control IRS identified -Epidemiological data disseminated &utilized
by program for decision making &impact evaluation -Institutions to carry out operational research
identified -Technical Assistance provided to programs to
utilize results of operational research |
D
D
D
D
D |
-National strategic and implementation plan on
malaria vector control IRS in place -Number and percentage of targeted staff trained
on malaria vector control-IRS -Epidemiological surveillance system on
vector-borne diseases in place
-Number of targeted sentinel sites with
functional vector surveillance and insecticide resistance monitoring -Number of operational research priorities on
vector control the have been addressed -Number of operational research outcomes on
vector control that have been utilized by implementation program |
L
L
L
L
N |
Advocacy &Communication |
-Advocacy materials prepared; case studies
conducted &documented -Major stakeholders have identified the
requirements for vector control -Targets set for number of villages to receive
campaigns on behavioral change on vector control; resources allocated and
persons trained -Guidance given to villages on organizing and
planning of vector activity |
L
L
L
D
|
-Advocacy meetings on malaria vector control IRS
in place -Number of targeted villages received campaigns
on behavioral change on vector control
-Number of targeted villages where communities
have mobilized on vector control |
N N
N |
Capacity Building |
Curricula developed for each required competence;
Institutions for training and certification identified |
D |
Certified training courses on malaria vector control(IRS)&Judicious
use of pesticides in place at national and regional level |
L |
Key:
L, Logical data (Yes/No); D, Descriptive data; N, Numerical data |
Table 21: Module of the structure for training on IRS by weight given to each module by target group and Period [22].
Module |
Weight (%) |
Target Group |
|||
Group |
|
Community non Specialist |
Village or district non Specialist |
Public Health Professionals |
Academic Students |
Introduction to vectors of human disease0 |
15 |
+ |
+ |
+ |
+ |
Planning& organization |
30 |
+ _ |
+ - |
+ - |
+ - |
Organization& Management |
20 |
- |
+ |
+ |
+ |
Policy& Institutional Framework |
10 |
- |
- |
+ |
+ |
Advocacy &Communication |
10 |
|
+ |
+ |
+ |
Monitoring Evaluation |
15 |
+ |
+ |
+ |
+ |
Estimated duration(days) |
|
+ 4-8 |
+ 6-8 |
+ 8-10 |
+ Above 15 |
Not
required; plus, minus partly required; +required 0 not in the handbook |
Table 22: Functions and Competencies Expected of Partners Indoor Residual Spraying.
Level |
Function |
Type of Competence |
National, subnational |
-Advocacy |
-Access and communication |
|
-Set strategic direction and conduct overall
evaluation -Advise on policy and institutional arrangements -Conduct epidemiological &vector assessment,
stratifying -Supervise decentralized organization and
management -Prepare curriculum and Train Trainers -Coordination of Emergency Response -Advise on research problems |
-Planning and evaluation -Policy analysis -Technical knowledge -Facilitation, Technical knowledge -Training -Management, Technical Knowledge -Technical Knowledge |
District, Village |
-Advocacy |
-Access &communication |
|
-Establish Inter sectoral partnerships and net
working -Plan &implement local IVM strategy -Monitor &evaluate -Organize & Manage -Conduct local vector surveillance -Train, educate and raise awareness |
-Access and communication -Analysis & decision making -Operational -Management -Training &communication |
The attitude of the
community towards IRS can be assessed through community knowledge, attitude,
behaviour and practice surveys: The surveys have to be conducted and
information has to be collected during spraying campaign include community
acceptance, or reasons for not accepting the spraying, locking rooms or
plastering of walls or sprayed rooms. The information could guide the
development of educational messages to improve IRS Program performance.
Indoor Residual
Spraying operational reviews to be undertaken at end of each spray campaign
season to determine whether all aspects of the operation have been carried out
as planned: Hold comprehensive annual review meetings 1-2
months after spray round has been completed to review the overall Indoor
Residual Spraying Operation to ensure program target and objectives have been
achieved and to outline adjustments and improvements for the next year`s
operation. Reports have to be prepared by District and Provincial IRS Coordinators.
The Technical Working Group (TWG) for vector control to meet to review the
performance of provinces and districts and provide a feedback to partners
meeting for Vector control. This will help to identify trends and strengths and
weaknesses that could be instrumental in making decisions about future
expansion of interventions or reduction of target areas and objectives.
Operational research: At this point
there has been a need to identify operational research areas. Indoor Residual
Spraying must be guided by research in order to strengthen the evidence base
for decision making. Opportunities should be taken to build capacity for
operational research within Indoor Residual Spraying. Strong desire for
research help target key problems in the field, thus increasing applicability
and use of research findings. Operational research conducted within the program
will helps ensure shared use of human and logistic resources. The link with
research institutions is very important at all costs.
International cooperation: Cross Border
Malaria Initiative (CBMI) - International or regional cooperation has been
found to be useful for sharing expertise and accessing research findings. For
example, through the African Net Work on Vector Control resistance to insecticides,
capacity for resistance monitoring has been strengthened and results shared.
Existing networks could be expanded to share the local evidence base for
decision making, for example for vector identification, ecology and behaviour.
Cooperation and networking can be done through existing regional networks
through new international networks. It is important to synchronize Vector
control programs through harmonized policies of each country.
Cross-Border collaboration between countries in the elimination phase
and those in the control phase is more challenging than between countries in
the same phase. This because the strategies and priorities of the two phases of
the programs differ. Monitoring must be supported by a formal system with the
capacity and mechanism to foster collaboration in cross-border vector control.
This will be in addition to strict passive and active case detection and
radical treatment of all imported cases in border areas to mitigate the malaria
transmission. It is unlikely that countries in the malaria elimination more can
achieve or sustain zero levels of local transmission unless they ensure a
significant and sustained reduction in malaria transmission in the border areas
neighbouring countries in the control phase. There should be a full coordinated
and strong CBMI and a need to share information and harmonization of vector
control strategies including synchronization of interventions.
Vector surveillance: During and after
IRS to determine target interventions of malaria elimination and monitor the
impact of interventions. Implementation of interventions of malaria elimination
needs more precision than the control phase because the aim has been to
completely eliminate existing pockets of transmission risk. Vector surveillance
has been found to guide the target interventions in specific foci. Monitoring
of vector bionomics including abundance, feeding and resisting behaviours and
insecticide resistance is pertinent.
Strengthening the system, capacity and establishing functional vector surveillance
systems are critical, when IRS is implemented for malaria elimination. The
challenge has been vector abundance declines enormously as malaria elimination
program progresses to the elimination phase. This makes the measurement more
important entomological identification extremely difficult owing to the low
levels of vector mosquitoes to be found in the environment. This direct
assessment of the quality to interventions through bioassay tests and measuring
of larval and adult tests and measuring of larval and adult vector densities is
very essential.
Monitoring
implementation of vector control measures
It has been highly
desirable to routinely assess through sustained vector surveillance the impact
of IRS campaign in achieving objectives of eliminating local disease
transmission and reducing the risk of its re-introduction. After an IRS
Campaign, bioassays must be conducted monthly during the expected effective
residual life of the insecticide applied (Table 20).
Cross-border malaria
initiative: Zambia and bordering countries in the control phase
need to collaborate in the elimination phase and prioritize areas bordering
those countries in vector control measures. In situation where such areas are
not the priority for the country in the control phase, the country in the
elimination could support implementation of vector control interventions a
cross - border (SADC Guidelines, ECOWAS &IGADI). Evolving from malaria
control to elimination does not entail changing the entire vector control
strategy and interventions but just the focus and intensity of malaria control
strategies already in place.
Stratification of
malaria epidemiology in elimination: Stratification
refer to the classification of disease endemic areas by their epidemiological
and ecological characteristics. It has been the dynamic process of identifying
the areas to which interventions must be targeted to tackle residual and new
focus transmission. A foci in malaria elimination phase could be classified
into six types: endemic, new potential, new active. Residual active, residual
non-active and cleared up [10]. It has been found that as malaria transmission
is interrupted in various localities in the process towards its elimination
nationally, the type and distribution of foci well can change continuously.
There is need to continuously stratify and micro stratifying malaria
epidemiology. Stratifying has been found critical in targeting vector control
interventions. Stratification can range from basic to very complex. In its form
stratification has been conducted to differentiate between areas with different
incidence rates of a disease within the country, in relation to population
census data. WHO Global malaria program uses stratification to differentiate
provinces or districts according to four levels of malaria endemicity: with
100, 1-100, less 1 and 0 cases per 1000 population per year. Overlay maps of
individual malaria vector disease assist in identifying areas in which more
than one disease occurs.
Mobilization of
resources [Health sector, public sector& private sector]
Financial Resources
from the health sector: The available resources must be used to
transform a conventional system of malaria vector control. The new capacities,
structures and activities of IRS require start-funds for their establishment
and recurrent funds for maintenance. Some funds can be available from the
monthly grant and further fund could be provided by the other public sectors
and the private sector or by external donors. The Zambia government must
contribute tremendously to IRS rather than relying on donor money assistance to
ensure national stewardship and the sustainability approach. Indoor Residual
Spraying must be seen as one of the strategies for strengthening health
systems, not as a separate program with a separate budget line. Let funds
earmarked to support local health systems become available for IRS as part of a
strategy to increase efficiency of overall disease control. Indoor Residual
Spraying must benefit the health system, government and society in several
ways. Integrating the resources into one strategy can result in cost saving
measures, for example by combined interventions and joint monitoring and
evaluation. The reach of other health services might be extended by combining
them with IRS activities at community level, also contributing to more
efficient use of resources. IRS could also benefit the health system by
increasing the status and motivation of health staff, improving their
analytical and decision making abilities and partnerships with other sectors
[11-15].
Financial resources
from the public Sector: What has been found to stimulate other
funders from the public sector is the vector control policy framework
availability at national level and evidence of the importance of vector control
or preventive measures to each sector through health impact assessments. The
ministries that might be involved in generating funds for IRS in their own
sectors are those of finance, agriculture, environment, local government,
commerce, Road Development Agency and tourism. Civil society organizations,
including international and non- government organizations could also
collaborate in generating funds for Indoor Residual Spraying [16].
Financial resources
from the private sector: The business zones, tourist areas, mining
industries, Zambia Sugar, civil society, faith based.
Planning and the
implementation of indoor residual spraying: The epidemiological
and vector control situation of the country, province and district including
communities, assessment of requirement pre-spray, during spray and post spray
have to be known. Assessment of requirements and resources and preparation of
locally appropriate implementation strategies have to be discussed prior to
start of Indoor Residual spraying. The steering committee has to sit and share
the type of resource needs. Various constructive decisions must be made in
planning for IRS such timing, targets, mapping, methods, funding for especially
supervision, management of resources and stakeholder participation at all levels.
Planning involves continuous adaptation of management choices to a
heterogeneous and ever-changing environment. Making decisions on any of these
issues requires valid, accurate, locally specific information that is
accessible to all parties involved. There is a need to involve all partners at
every level in analysing the local situation, selecting options and assessing
requirements [17-20].
Entities involved in
implementation: Partners to play a big role in implementing IRS
have to be known by the steering committee. The activities could involve
promotion messages, awareness-raising, social marketing, distribution of spray
teams. Nonetheless, other partners, such as communities, schools, the private
sector and public sectors have important roles in planning and implementing
IRS.
Entities responsible
for implementation: Partners have to be fully involved and
allocated areas that they are to be responsible. Government offices other than
health can and should however share responsibility for some activities. The
involvement of multiple stakeholders in IRS require a functional organizational
structure for effective coordination of activities, to ensure that the joint
efforts are consistent and have common goals. The local organizational
structure at district and rural health centre should have broad participation
of stakeholders including community members.
Entities responsible
for monitoring and evaluation: Local partners should monitor and evaluate
the implementation and maintenance of their activities to identify shortcomings
and suggest remedial action. Monitoring and evaluation conducted by an external
agency (government and nongovernmental is likely to increase accountability for
IRS and help to ensure unbiased results [21,22].
Advocacy and
communication: Indoor Residual Spraying must be communicated
effectively at all levels to ensure its adoption, to foster collaboration and
networking among partners and to empower communities. The targets of advocacy
are policy-makers (Minister of Health & Other Policy Actors, Ministry of
Traditional Affairs including Members of Parliament) with key messages. During
transition and consolidation of IRS strategy, continued advocacy and feedback
on the performance and impact of IRS will be required to ensure sustained allocation
of resources and to expand the strategy to new areas. Staff in the public and
private sectors and in civil society organizations will be expected to
implement and sustain Indoor Residual Spraying campaign. A school debate motion
for Indoor Residual Spraying has to be suggested for campaign season.
Communication with the general public creates awareness, drives behavioural
change and empowers people to become involved in analysis and decision-making
and adopt practices for indoor residual spraying. Tools for reaching the
general public for IRS should be village meetings, debates in schools include
the media and educational interventions to increase knowledge and skills. To
put IRS on the national agenda, advocacy is needed to present it as a cost-saving
and more effective system of vector control. Associating the benefits of IRS
with broader developmental issues, such as strengthening health systems and
empowering communities, could increase support. The anticipated result is that
political leaders raise malaria vector control on the national agenda, shape
policy agendas to promote IRS and communicate the policy change direction to
public sectors, health professionals, researchers, civil society organizations
and communities. Each year message development will be tailor made to gaps
identified after each spray campaign. Continued advocacy for IRS is
particularly critical at this time, in order to avoid “fatigue” among the
players. In these situations, malaria may no longer be a public health concern
but the management of vector populations must be sustained, because low vector
populations will reduce the risks for resurgence or reintroduction of disease.
Continued investment in IRS is justified, even after elimination, by the very
real risks for disease resurgence when prevention efforts are relaxed. One way
to ensure continued support is to measure the cost effectiveness of an
investment in terms of the disease burden that is prevented after successful
elimination. To make the case for IRS, advocacy must be based on strong
evidence, as policy- and decision-makers must be convinced of the benefits of
IRS before giving it their full support and high priority in allocation of
resources. They will ask:
Why should I support
IRS
Politicians are bound to have reservations about changing the existing
malaria vector control system, and they have to know how investment in malaria
vector control will pay off in terms of health, social and economic benefits
and whether IRS can be sustained financially. Purposeful analysis of the
available evidence and effective use of advocacy are essential. Advocacy could
be through person-to-person communications and forum meetings with visual
presentations to the public at grass root levels [23-27].
Preparing an
advocacy strategy
To persuade government policy- and decision-makers to endorse malaria
vector control, a strategy for advocacy is needed, with a clear vision and a
feasible plan. The following steps are suggested for Indoor Residual Spraying
Campaign:
Communication and
empowerment
To create an enabling environment for IRS at community level, people
implementing malaria vector control strategy should be aware of any
sociocultural barriers, so that all opportunities can be best used. The
challenges are: changing human behaviour to reduce vector biting and disease
transmission, increasing compliance with interventions and motivation for
vector control activities and removing misperceptions and misguided methods of
vector control. It is important to provide access to information and services
on malaria and ensure mutual interaction and communication. The main challenges
are to improve access to information and services and to change behaviour.
Interventions designed to remove sociocultural barriers generally focus on
increasing the knowledge and skills of the general public by giving them better
access to information and services. This should lead to a change in behaviour
and in activities that will reduce vector-borne diseases. Information and
awareness campaigns do not, however, always result in new or modified
behaviour. Many risk factors for malaria are within people’s sphere of
influence, which is the peri-domestic environment. Public services cannot
easily reach this environment, and communities must take control and assume
responsibility. Clearing roof gutters in order to control dengue vectors, for
example, should be the responsibility of household members rather than of
health teams [28].
People must therefore be “empowered”, not just to be aware of the risks
but to take appropriate action of self-protection and vector control when and
where needed. Empowerment means that people take more control over their lives.
People need empowerment in areas in which they themselves can contribute to
improving their situation, with less reliance on scarce external services such
as the health sector. Empowerment occurs only when two basic conditions are
met. First, the necessary means or enabling factors must be in place:
challenges, responsibilities, opportunities, resources and capabilities must be
used to achieve empowerment. Secondly, a process of analysis and
decision-making for subsequent action must be accepted and followed. While the
“means” refers to capacity- building and a group approach, the “process” refers
to active involvement in the planning and implementation of IRS at local level.
Numerous tools have to be used: the media; information, education and
communication; communication for behavioural impact. The approach begins with
an analysis of the situation to determine behavioural barriers [Low acceptance
rate, absenteeism] and constraints in a certain group. A significant purpose of
communication for behavioural impact is to ensure that effective methods are
effectively used at community level. Integrated malaria vector management strategies
could benefit from the rich experience in school debates integrated field-based
education during weekly school meetings and special meetings. Information,
education and communication programs have had positive effects on knowledge and
attitudes, but concern has been expressed about the slow pace of achievements
and the lack of documented behavioural impact of this approach. People might
understand the behaviour needed to reduce a health risk but fail to act
accordingly. Communication for behavioural impact requires considerable effort
for specific outputs, but the results suggest that it affects people’s
behaviour. Both, information, education and communication and communication for
behavioural impact are designed for situations in which the messages are
general applicable in targeted areas. Farmer field schools are designed to help
people design locally appropriate methods or solutions and are applicable in
complex, changing settings [29].
Monitoring and
evaluation
Progress in advocacy and communication must be monitored and evaluated
to identify areas for further attention. Process indicators such as: Advocacy
materials prepared; case studies , Advocacy meetings on IRS in place conducted
and documented , Major stakeholders have identified the requirements, Number
(and percentage) of targeted stakeholders that for IRS have allocated resources
for vector control, Targets set for the number of villages to receive IRS,
Number (and percentage) of targeted villages that campaigns on behavioural
change on IRS acceptance and availability; Received campaigns on behavioural
change on IRS resources allocated and persons trained, control Guidance given
to villages on organizing and Number (and percentage) of targeted villages
where planning of IRS activities, communities have been mobilized on IRS
activities.
Capacity-building: Capacity-building
has been a significant challenge in implementing an IRS strategy. The strategy
depends heavily on the knowledge and skills of people in functions at national,
subnational, district and village level/community level. In this section, ways
of developing the appropriate knowledge, skills and infrastructure are
discussed.
Learning
environment: The development of human resources requires a
supportive environment, with political and financial commitment for training,
recruitment and career paths. Substantial investment in training courses will
be required to upgrade and maintain the knowledge and skills of people involved
in an IRS strategy. The IRS approach itself provides a supportive environment
for learning, as it is a problem-solving approach to mosquito population, in
which analysis and decision-making are central and participation is vital.
Observation, analysis and decision-making are the ingredients of a learning
cycle, which stimulates continued learning by interacting participants. This
results in an environment that is conducive to learning and development. Hence,
once an IRS strategy is operational, it could serve as a self- enforcing
mechanism of generating knowledge and skills.
Core functions and
required competence
The planning and implementation of IRS require appropriate knowledge and
skills for management, analysis, problem-solving, communication and
facilitation. Human resource development begins with an assessment of the
current competence of all relevant personnel in order to identify the
requirements for others.
National and
subnational level
At national level, an IRS strategy requires a high-level Inter sectoral
Steering Committee, as mentioned previously. Specialized partners and technical
working groups could work under the guidance of the steering committee, for
example on the components of evidence-based decision-making, capacity-building
and monitoring and evaluation. The teams and working groups should include
people with competence in epidemiology, entomology, malaria disease control and
elimination and program management. This competence is often available in
existing systems but might require reorientation or strengthening to address
Indoor Residual Spraying. The functions and essential competence of malaria
vector control partners at national and subnational level are listed in Table
below an important function at national level, apart from providing direction
and advice, is facilitating activities at lower levels of administration and
implementation, requiring facilitation skills. Advocacy is a growing
responsibility of health professionals and program managers, and the skills and
experience for such active communication strategies should be strengthened in
most countries (Table 21).
District and village
level
Reorientation of IRS activities has often
required training or retraining of public health staff involved in the program
to increase their knowledge and give them the required skills for their roles
in malaria vector control partnerships. Staff in other sectors and
representatives of civil society organizations may also need additional
training. In districts or villages, inter sectoral partnerships should be
established; consequently, the health sector should have working relations with
other public sectors. In particular, analysis and decision making skills should
be developed and maintained in community leaders and local malaria vector
partners to ensure appropriate planning and implementation of local strategies
(Table 22).
Indoor Residual Spraying needs rational decision-making process to
optimize the use of resources for malaria vector control. The implementation of
Indoor Residual Spraying (IRS) helps to find and use more local evidence, to
integrate the intervention where appropriate and to collaborate within the
health sector and with other sectors, as well as with households and
communities. By reorientation to IRS, malaria vector control program will be
better able to meet the growing challenges in the control of malaria in the
face of dwindling public sector human and financial resources. There is need to
have an operational framework for monitoring and evaluation to guide managers,
supervisors, partners and those implementing IRS in designing more efficient,
cost-effective approach and implementation systems. As a nation, Zambia needs a
Malaria Vector Control Policy and an intersect oral steering committee that
will be able to establish IRS national strategy. IRS has to transform the
conventional system of malaria vector control by making it more evidence based,
integrated and participative. This may require changes in roles,
responsibilities and organizational links. The transition to new IRS paradigm
involves both reorientation of malaria vector control programs and embedding
IRS within local primary health systems. Intersect oral partnerships and
collaboration at both national and local levels will result in cost savings and
benefits to other health services. Other relevant sectors, such as agriculture,
environment, mining, industry, public works, local government and housing,
should incorporate IRS into their own activities to prevent malaria vector
proliferation and disease transmission. Capacity-building, in particular human
resource development has been the major challenge, because the IRS strategy
requires skilled staff and adequate infrastructure at central, provincial,
district and local levels. Like any new approach, IRS must be actively
advocated and communicated in order to become established. The general public
must also be made aware of the strategy and participate in its implementation.
There has been a need to strengthen the capacity at all levels in order to
timely implement and strengthen quality performance for Indoor Residual
Spraying Campaign Program for malaria elimination in Zambia.
I would like to thank my colleagues from the provinces who opened doors
for consultation whenever I was into a terrible spot or had a question about my
research or writing. They consistently allowed this paper to be my own work and
steered me in the right direction whenever I needed their thoughts. I would
like to further thank experts who were involved in the validation of the
assessment for this research paper. Without their passionate participation and
input the assessment could not have been successfully conducted.
CHAs: Community Health Assistants; CMTAF: Community Malaria Task Force;
CSO: Central Statistics Office; DHO: District Health Office; DMATF: District
Malaria Task Force; DSA: Daily Substance Allowance; ECOWAS: Economic Community
of Western African states; EHT: Environmental Health Technologist; HACs: Health
Advisory Committee; HR: Human resource; IDSR: Integrated Disease Surveillance
and Response; IGADI: Intergovernmental Authority Development international;
LLINs: Long Lasting Insecticide Nets; NHCs: Neighbourhood Health Committees;
PHO: Provincial Health Office; PMTAF: Provincial Malaria Task Force; SADC:
Southern African Development Cooperation; TOR: Terms of Reference; ZAWA: Zambia
Wild Life Agency; ZESCO: Zambia Electricity Supply