United Nations Public Service Awards Case Studies

Itezhi-tezhi is predominantly a rural district with Central Statistical Office population figure of about 58,000: headcount population is close to 98,000. Illiteracy and poverty levels are high. District prone to seasonal floods with poor road and communication network.

District serviced by one First Level Hospital and eleven rural health Centers. These are inaccessible for 5-6 months of the year due to seasonal flooding. Furtherest health center is 178km away from the hospital and the nearest is 25km. Most of the services offered were static at the hospital or at the rural health centers. There is only one laboratory at the hospital.

Access and utilization of health services by the community was very low with most indicators falling below the national targets. The most affected were the under-5 children and the pregnant mothers. Anti-Retroviral program started in 2005 was static and accessed only at the hospital. Patients had to walk long distances to the hospital to access the service. Transport was a big problem with no running vehicle, motorbikes or bicycles. Antenatal and under five clinics were also mostly static at the health centers. All these factors combined meant that health service delivery was a big challenge. From 2005 to 2007, a total of 1818 clients were counseled and tested. 468 commenced Anti-Retroviral Therapy. 183 were eventually lost to follow up leaving only 281 active patients. Maternal Mortality was high at 179/100,000. Supervised Deliveries was averaging 35% (National Target 80%). Antenatal Attendances were at 47% and protected Pregnancies were at 41%.

Child health Indicators were also below national Targets: Fully Immunized children under 1 were only 43% and very few children were on ART (only 27 initially but 21 lost to follow up or died leaving 6 active). Malnutrition prevalence was 1.5/1000 and Underweight Case Fatality Ratio (CFR) was 266/1000.

Majority of the population has no access to safe and clean water. Number of boreholes in the whole district is only 138 with 29 protected wells and these do not meet the needs of the communities.

What is the initiative about? (the solution)
The Project objective is to provide Integrated Mobile Community VCT and other Health services with the aim of improving the overall health of the community through improving access and utilization. There were 5 project outputs: Increase in the number of Community Health Workers and Traditional Birth Attendants. These were trained, equipped with the necessary inputs to provide mobile outreach programs in Maternal and Child health and Voluntary Counseling and Testing. TBAs also act as a link between the pregnant mothers in the community and the health center. They are able to recognize “Danger Signs” and refer pregnant mothers. This output has been achieved with First Antenatal Attendance now at 81%, Supervised Deliveries averaging 89%, and Protected Pregnancies at 87%. The number of referrals of complicated deliveries has increased from 10% to 13%. Maternal Mortality has shown some decrease from 179/100, 000 to 102/100, 000. This could be due to a number of factors. Some deaths still go unreported in remote areas. Increase in number of Mother Support Groups: Training in Growth Monitoring and Promotion and Infant feeding was aimed at reducing malnutrition and infant mortality. Most under-5 clinics were static at the hospital or at the health centers. Conducting outreach mobile immunization sessions was a strategy aimed at improving utilization of this service. Underweight Case Fatality rate has dropped from 266/1000 to 153/1000. Malnutrition prevalence has reduced by 15% from 1.5/1000 to 1.3/1000. Under-5 hospital attendances have dropped. There is increased awareness by mothers on infant feeding. Increase in the number of health services delivered: Procurement of the Ambulance, boat and Mobile Clinic has increased access and utilization. Inaccessible areas could be reached by Ambulance, boat or the Mobile laboratory unit. Mobile VCT has resulted in more people testing and starting treatment. 4788 have undergone VCT, 2830 pregnant mothers tested via PMTCT, and more than 798 patients now on Anti-Retroviral Treatment. Stigma has also reduced. 33 TB patients have been tested for HIV and now on treatment. Increase in number of water sources with wholesome water: without improving the environment of the community, it would be impossible to improve their health status. Most diseases can be prevented. Access to safe water is important. Regular water sampling is now possible with use of the motorbike. Epidemic preparedness meetings held monthly. Increased Immunization Coverage: Mobile under-5 clinics were scaled-up with use of the bicycles and motorbikes. Fully Immunized children under 1 now averaging 91%. Severe anemia cases requiring transfusion has reduced from 124 to 84 yearly. Under-5 hospital admissions for the year have dropped from 201 to 118 this year. Key beneficiaries were the mothers, under 5 children and the HIV/AIDS. The project aims to achieve a wider coverage of people in the community having access to basic health services such as safe delivery through TBAs, improved under 5 growth profile, safe drinking water, provision of mobile VCT, Anti- retro-viral therapy services and integrated TB/HIV services. All data from Health Management Information Systems (HMIS).

Who proposed the solution, who implemented it and who were the stakeholders?
Itezhi-Itezhi District Health Management Team(IDHMT) is mandated to provide health services to the Itezhi-Tezhi community in line with the Ministry of Health (MOH) vision of provision of “equity of access to cost effective quality health care as close to the family as possible.” (MHSP, 2001-2005). Maternal, Child health and HIV/AIDS and TB are some of major public health priorities. These priorities are also reflected in the Fifth National Development Plan. Itezhi-tezhi DHMT is striving to realize the vision of providing quality health services to the communities, however, performance in the three priority areas is not up to the desired expectations due to amongst other things the vastness of the area, rough terrain and the long distances to nearby health facilities. Three quarters of the district is covered by the Kafue flood plains and almost half of the health facilities are out of reach for six months after the rain season. The solution was proposed by the District Health Management Team (DHMT), in consultation with the Community who had initially proposed building of more Health Centers closer to them. However, although this in government’s long term plans, it was not feasible immediately and was going to need a lot of resources. Meanwhile, the communities still needed to access the basic health services and the Integrated Community Mobile VCT and other health Services was proposed by the DHMT after consultation with the Neighborhood health Committees. A Project Proposal was written and presented to Cabinet Office Management Development Division (MDD) requesting for Service Delivery Improvement Funds. The Proposal was approved and funded by MDD. The key stakeholders are the Ministry of Health who are the key implementers and provide logistical and technical support, Management Development Division the main funders of the project, Neighborhood Health Committees whose role is to coordinate community sensitization and mobilization, the Community of Itezhi- Tezhi district who are key beneficiaries, the Ministry of Local Government under which the Council falls who have a key role in the water and sanitation, District AIDS Task Force directly involved with all HIV/AIDS activities in the district, CRAIDS have funded several community HIV/AIDS programs like construction of VCT rooms in 4 health centers, AIDS Relief under Catholic Relief Services has provided logistical and technical support, D-WASHE committee involved in water and sanitation as well as some Faith Based organizations involved mainly in Home Based care activities.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
Main strategy is the mobile unit and the boat including use of trained community health workers such as TBAs, lay counselors and Mother Support groups. The aim is to increase coverage and accessibility of basic health services. Expand by showing how this was achieved. By bringing the services as close to the families as possible, it was believed that the overall health status of the people of Itezhi-tezhi would be improved and subsequently the key health indicators would improve. To counter the human resource crisis and increase community participation and promote ownership of the project, a number of trainings were designed in a number of disciplines and activities. Lay Counselors, Community health Workers and Traditional Birth Attendants were trained. Improving the transport situation in the whole district was key by procuring an Ambulance, Mobile Laboratory unit motorbikes and a boat were key implementation strategies. Instead of just static services being provided, it was now possible to achieve wider coverage through mobile services using these project inputs. Health Education was necessary for any of the initiatives to work to try and influence the health seeking behavior of the community. Using the headmen, chiefs and other influential members of society like church leaders peer educators and advocates helped reduce stigma, myths and misconceptions on health in the community. Monitoring and Evaluation was a key implementation strategy to be able to analyze and measure the impact of the interventions. Forms were designed for Community members for data collection and reporting. The Health Centre staffs that were under the DHMT were already using the HMIS system.

b. What were the key development and implementation steps and the chronology? No more than 500 words
The key development and implementation steps of the project were as follows: Signing of The Memorandum of understanding between Ministry of Health who are key implementers and Cabinet Offices’ Management Development Division. Formation of Project Implementation Committee was done in September 2007 with induction/orientation of the PIC members and implementing institutions in Project Management and other issues and guidelines. Orientation of DHMT staff and other relevant key stakeholders was done in October 2007. Mobilization and sensitization of the communities was also done in October 2007. In November, a Baseline Survey was conducted in order to gather baseline information to assess the extent of the problem in the different localities. Collection of quotations, tendering and procurement of some project inputs was done. Selection and training of Community Health Workers and Lay Counselors was done in December. They were equipped with bicycles and other project inputs and started Mobile Maternal and Child Health activities with wider coverage of the vast areas. Identification, selection and training of Traditional Birth Attendants were done in March 2008. . Their main role was to act as a link between the community and the health centers. By recognizing “Danger Signs” in pregnant mothers, they are able to refer these mothers to health centers where they can get professional help. They also do health education and help with mobile outreach Antenatal clinics. The trained TBAs are able to conduct clean and safe deliveries for some mothers and refer them later to the health center. Training of Adherence Counselors was conducted in May 2008 to act as a link, recognize side effects and adverse drug reactions of the drugs and refer patients to the health centers. Mother Support Groups were formed and trained in Growth Monitoring and Promotion cooking demonstrations. Static and some limited Mobile integrated health services were conducted with the bicycles and motorbikes that were procured by Cabinet Office for the project. The ambulance, boat and the utility vehicle had not yet been procured. The activities focused mostly on Maternal and Child health activities and Anti-Retro Viral services. Technical Support Supervision and Performance Monitoring was done on a monthly basis with reports being forwarded to Cabinet Office MDD and to the Provincial Health Office and to PIC members. Procurement of the Boat and Ambulance was done and delivered to the district around July. This greatly improved the delivery of services to the community and the Integrated Mobile VCT took off on a larger scale. The utility vehicle was delivered in September. A review meeting was held in September to assess how the projects were doing with regard to the impact of the interventions and to address some of the challenges the different projects were still facing. Ongoing Mobile VCT and other integrated services are done with weekly visits to different catchement areas.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
Delay in procurements due to the complicated tendering process and the late delivery of inputs by suppliers like Toyota Zambia for the vehicle, ambulance and mobile laboratory unit. Human Resource is another major constraint with only one Medical Doctor, 3 Clinical Officers and 36 nurses in the whole district at the start of the project. 6 of the Health Centers are run by untrained staff. The training of the CHWs, Lay Counselors, TBAs and MSGs was aimed at trying to mitigate this. Ideally, all patients are supposed to be attended to by trained & skilled personal. This crisis is not about to be resolved in the near future. These trained Community act as a link between the health center staff and the community and are able to refer patients from the community to the centers. They also help out in outreach programs like Antenatal clinics, Child health Growth Monitoring and Promotion activities. With the motorbikes and bicycles, the trained Lay Counselors and TBAs were able to use these inputs to reach wider coverage in providing mobile services. Traditional and cultural beliefs: Getting the community to change their perceptions and beliefs on health matters was one of our biggest challenges. The project would only be successful if we had clients to not only access the services but also utilize them. There are a lot of myths and misconceptions in the community. Most people are unable to make informed choices on matters relating to their health. To mitigate this, community sensitization was done using the Chiefs and Headmen, Councilors, Church Leaders and other respected members of the community. Local drama groups were used and held Focus Group Discussions with the community. Health Education was key with emphasis on the benefits of any particular health action with the knowledge that people will only effect behavior change if they perceive a benefit. Seasonal floods compounded by the poor road network are ongoing challenges. The initiative was to procure a boat that could be used when most of the roads were impassible. We also developed a network where the centers that could not be reached could refer their patients to the nearest accessible center close to them with the view that the next health center could sometimes be reached by boat or by a motorbike.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The bulk of the financial resources came from Cabinet Office Management Development Division is the main funder of the project with final approved amount of K1, 784, 034, 071. This was used for procurement of project inputs, all the trainings and other logistical requirements. The human resource and operating costs has been mainly from the Ministry of Health through the District Health Management Team. All the Community members work as volunteers with no remuneration. As for the DHMT staff, most of the work for the project is part of their normal duties but performed on a new level (scaling up) to meet the targets and sometimes they have to work out of their normal working hours but with no extra pay for overtime. There are issues of opportunity costs for both the community volunteers and the DHMT staff. Technical assistance was from the Ministry of Health especially on Policy issues and guidelines for the different trainings. This was also sought from the various stakeholders like the District AIDS Task Force, AIDS Relief and Ministry of Local Government and Council on Environmental issues, D-WASHE on the water and sanitation. The chiefs and traditional leaders were consulted on cultural beliefs. The Ministry of Health is also providing free Anti-Retroviral drugs, laboratory reagents and other logistics like HIV test kits for the program. AIDS Relief has provided assistance through support of our data management with procurement of computers and other furniture, a motorbike for the adherence program and a motor vehicle for the mobile VCT. Center for Diseases Control (CDC) has also helped to support our Prevention of Mother to Child Transmission (PMTCT) program and Pediatric ART with trainings and other logistical support.

Is the initiative sustainable and transferable?
Sustainability all the Project Outputs are in line with mandate of the Ministry of Health to provide health services to the community. We receive a monthly grant from MOH for service provision and the running of the Hospital and Health Centers. They also provide all the free drugs and other logistics like test kits and laboratory reagents, Human Resource and Policy direction and guidelines. All the project activities are being mainstreamed into the activities of the DHMT. and will be planned and budgeted for in the District Annual Action Plan., Continued community participation - Ongoing Health Education and community sensitization will help strengthen and sustain community participation. The community has actually taken up ownership of the program and is now beginning to understand that matters relating to their health are best handled with their full participation and cooperation. To overcome the cultural and gender barriers, we have done trainings in Male Involvement in PMTCT, formed Male Action Groups (MAGs) who are peer educators to their male counterparts in matters of health as well as encouraging them to help women make informed choices. Culturally, most women fail to make decisions without consent from their husbands for fear of divorce or other repercussions.. The project has been disseminated at national level with different organizations and ministries present. Replication-The initiative and has been disseminated at various fora and can be replicated to other districts and provinces and regionally.. The problems of inadequate trained staff, remote and inaccessible areas, long distances to health facilitates and other barriers to access and utilization of health services are common to most developing countries. Project activities can be mainstreamed in to the normal duties of the ministry of health. This is a necessary solution to ensure a continuation of quality health service provision while governments are trying to improve conditions and equity of access. It is cost effective and produces similar results.

What are the impact of your initiative and the lessons learned?
The key impact of our initiative was improvement of the overall health status of the people of Itezhi-tezhi as evidenced by the improvement in most of the Health Indicators. More people are coming forward to test for HIV and more people have been started on Anti-Retroviral Therapy. At project start, only 1818 clients underwent VCT from 2005 t0 2007. There were 468 clients started on Anti-Retroviral Treatment with 187 subsequently lost to follow up. Now more than 6406 clients have undergone VCT with 798 patients started on ART. This translates into less patients suffering from Opportunistic Infections as their immunity is improved by the ARVs. There a fewer hospital admissions and Out-Patient Attendances (OPD) and the average length of stay in hospital for patients who are admitted has also reduced. In the area of Maternal Health, most women were not attending Antenatal clinics with indicators like First Antenatal attendance and Protected Pregnancies well below the National targets. Supervised deliveries were low at 35% and Maternal Mortality was high at 179/100, 000. Child health indicators like Underweight Case fatality Ratio which was 266/1000 Malnutrition prevalence was 1.5/1000 has dropped to 1.3/1000. Fully Immunized children under 1 was 43% and is now averaging 92% The project has helped to overcome some of the barriers to utilization of health services, improve community participation and improve the moral of the communities and reduce stigma especially in matters of HIV/AIDS. It has also improved moral among health workers because despite the long working hours and burnout, they are able to see some results of their hard work. This has made them more determined to continue proving quality health services to the community. Communities have ownership of the project and they were part of the solutions and not just being told what to do by the health workers. If people perceive that they came up with the ideas and initiatives for the problems they are facing, they are more likely to sustain their actions and effect behavioral change. Ongoing support from all the key stakeholders was also instrumental in making this initiative a success


Institution Name:		Itezhi Tezhi District health Office
Institution Type:		Government Agency
Contact Person:		Mulenga Rosemary Kasoma
Title:		District Director of Health
Telephone/ Fax:		+260 3 263057/71
Institution's / Project's Website:		+260 3 263071
E-mail:		chilubi.mafwenko@cabinet.gov.zm
Address:		Itezhi Tezhi District Health Office
Postal Code:		P.O Boz 34
City:		Itezhi Tezhi
State/Province:		Southern
Country:		Zambia

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information