Zambia

Zambia narrowly misses being one of WHO’s 22 high burden countries. HIV/AIDS has clearly fueled the TB epidemic in Zambia. The estimated incidence of all forms of TB cases is 680/100,000 (2004) and sputum smear positive (ss+) incidence is 280/100,000.  With 53,932 TB cases, 2003 data shows a case detection rate of 65%, a cure rate 67%, a treatment success rate of 75%, a default rate of 2%, and a mortality rate of 8%.  The case detection rate and treatment success rate are approaching the global targets of 70% (case detection) and 85% (treatment success) respectively.

TB CAP Highlights Zambia

Improved human and institutional capacity
The Zambia Ministry of Health vision is to provide the people of Zambia with equitable of access to cost-effective, quality healthcare as close to the family as possible. The TB CAP Zambia project contributed to this vision in human capacity development efforts in two provinces in Zambia in year three of project implementation.

In November 2006, with funding support from TB CAP, external quality assurance in TB smear microscopy was conducted by an on-site evaluation visit made to the North Western Province, and another visit made in 2007 to Luapula Province. During these visits, shortage of laboratory staff was identified as a key challenge in both provinces. In year three of project implementation TB CAP held consultations with other partners supporting supplementary laboratory staff called microscopists. TB CAP held consultations with the Ministry of Health to support this level of staff, in two of the then three target provinces. TB CAP re-programmed APA1-2 funds towards this support for the 15 microscopists’ staff salaries. Permission was obtained from the Ministry of Health to employ the microscopists under TB CAP. Advertisements were developed in consultation with the National TB Program and the Zambia national TB reference laboratory called the Chest Diseases Laboratory. Laboratory experts from the national TB reference laboratory, the provincial laboratory managers in Luapula Province and North Western Province, district level representatives and TB CAP staff carried out interviews in the respective districts were the applicants were identified. The applicants were chosen from the catchment areas where the 15 laboratory facilities that needed supplementary staff were located. Following the interview process, the 15 high school graduates were employed and trained as microscopists for five weeks with the Ministry of Health approved curriculum.

From March 2008 to date, the microscopists are successfully supporting diagnosis of TB by sputum smear microscopy in government health facilities. The Ministry of Health has provided housing and transport support for some of the microscopists, where there has been need. Some of the microscopists have participated in supplementary trainings for laboratory staff, and quarterly TB/HIV technical review meetings in their provinces. The new staff also continues to receive daily mentorship from their supervisors, and quarterly supervisory visits from the provincial laboratory staff.

Figures indicate that with TB CAP EQA support to Luapula and North Western Province, Luapula province has recorded improvement in correct reading of sputum smear microscopy in nine health facilities from an average of 81.2% in 2007, to 98% in 2008. North Western Province has recorded improvement in 10 facilities, from an average of 73.5% in 2007, to 92% in 2008. The improvement may not be solely attributed to the additional human resource provided by the microscopists. However, the presence of the microscopists will supplement the provinces’ efforts to have accurate, quality assured microscopy results.

In recognition of the efforts of microscopists in the target provinces TB CAP will support supplementary refresher training for all the microscopists in the five target provinces in year four of project implementation. TB CAP continues to support external quality assurance visits conducted by the provincial laboratory staff, and to identify and support other laboratory needs.

TB CAP Project Period (2005-2010)

Expected output(s)

• Strengthened and expanded quality DOTS in all districts of 5 provinces over 5 years.
• Improved access to TB/HIV care.
• Increased awareness of TB and TB/HIV in communities.
• Improved treatment success rate in targeted workplace settings.
• DOTS training mainstreamed into pre and in-service training.

A TB CAP mission was carried out on 7-11 November 2005 to identify the technical areas for support and develop a work plan of activities in full collaboration with the CBOH/MOH in Zambia and in line with the new Zambian TB strategic plan for 2006-2011. TB CAP has identified four areas of support to TB control in Zambia:

• DOTS strengthening,
• Collaborative TB/HIV activities,,
• Community mobilization and involvement in TB and TB/HIV care, and
• Involvement of all providers in TB control (TB/HIV in the workplace, public/private and public/public mix DOTS).

Program operations started in 2006 after the staff recruitment process was completed. TB CAP in Zambia has started improving the collaboration between TB and HIV Programs.  Routine HIV counseling and voluntary HIV testing has become an important component of care for symptomatic patients that present to health facilities. TB CAP is supporting TB staff training in HIV counseling and testing. During APA1, 26 Provincial and District TB focal point persons were trained as trainers in the newly introduced HIV counseling and testing in a clinical setting (DCT). TB CAP also printed national revised TB laboratory registers and laboratory request forms for sputum examination and also supported the revision and printing of National TB manual. A car was procured for program staff to carry out training, TA and monitoring.