Zambia Trachoma Elimination

Strategic Initiative

Zambia Trachoma Elimination

Changing Futures

In Strategic Initiative Fund I, the 2007-2010 Zambia Blindness Prevention Initiative successfully reached four of the seven districts in Luapula province. We equipped local medical service providers, improved sanitation, and conducted health education— positively impacting almost half a million lives. In SI Fund II, we built and expanded on SI Fund I in two ways. Firstly, we expanded the programme to include the remaining three districts, making the programme province-wide. Secondly, we identified the prevalence of trachoma and introduced a robust project to eliminate blinding trachoma as a public health problem in Nchelenge and Chienge districts. Thus an investment of $1.6 million over the four years of SI Fund II has effectively impacted the entire 1.2 million population of the Luapula province. This programme is remarkable for the integrated nature of its multiple components, including mass drug administration, water and sanitation improvements, eye health education outreach, and increased access to medical treatment. Moreover, the programme is notable for its scale, which addresses the issue of preventable blindness at a province-wide level, and aspires to enact environmental and behavioural change. And remarkably, that is what has been achieved.

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SECTOR

Health

TOTAL INVESTMENT

US$ 1,612,590

LOCATION

Zambia

LIVES CHANGED

1,506,229

SOCIAL IMPACT INDEX

70.9 (out of 100)

AVERAGE COST PER LIFE

US$ 1.07

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SI Breakdown:

Key Achievements

• 920,605 people treated with Zithromax through MDA.

• 510,250 community members sensitized to the SAFE strategy.

• 145,385 people accessed screening, diagnosis and treatment of eye infections.

• 6,163 people undergo extra-ocular surgeries.

• 54,580 community members have access to protected water sources.

• 384 new or rehabilitated clean water sources.

The Problem

The impact of blindness on people’s lives is an important health and socio-economic problem. It has severe negative consequences on individuals, families, and entire communities, especially in developing countries such as Zambia. Although 80 percent of blindness is due to either avoidable or curable causes such as cataract, glaucoma, and trachoma, its prevalence in Zambia is still significant, estimated at 1 percent of the population. Trachoma poses the most serious threat, with nearly 10 million Zambians living in trachoma-endemic areas.

Solution

The Legatum Foundation’s 2007-2010 Zambia Blindness Prevention Strategic Initiative targeted only four (Nchelenge, Chienge, Kawambwa, and Mwense) of the seven districts in the Luapula Province. In SI Fund II, the 2011-2014 Initiative extended its programme activities to the remaining 3 districts (Mansa, Samfya, and Milenge). Mansa General Hospital was brought onboard to carry out the activities in these districts. By engaging both St. Paul’s Mission Hospital and Mansa General Hospital, services have been provided across the entire province.

Critical Analysis

At the heart of an SI is the concept of synergy: that the sum benefit to a community of people in a defined geographical area associated with the SI will exceed the sum of the individual inputs, outputs, and outcomes, and will deliver a range of dividend benefits that culminate in a positive landscape change for the entire population of the area. It is necessary to rely on subjective assessment rather than the preferred evidence-based analysis. Effectively, the pool of undiagnosed and untreated eye disease has been largely eliminated. That does not mean there are no cases remaining, but case finding has been diligently undertaken, referral has been robustly performed, and treatment professionally delivered. The therapeutic coverage achieved in each of the three years of the distribution of the antibiotic azithromycin—known as brand name Zithromax by Pfizer, the donor—has been of a high level. In fact, there is sufficient scientific evidence to know that trachoma has likely been eliminated as a public health problem in the two targeted provinces, even in advance of a final impact assessment conducted by the Ministry of Health. The strong SAFE strategy systematically implemented over the course of the last three years has provided new safe water to families on a large scale. Based on the data collected, we believe that virtually the whole population has been sensitized and educated about trachoma, its causes, and prevention. This Strategic Initiative has addressed a number of basic needs at a community-wide scale. For example, healthy and health seeking communities, clean water, sanitation, domestic waste management and that blindness or refractory error do not need to be systematic disabling factors in the region any longer. The SI has raised the community’s awareness about the social contract between the population and provincial authorities as representatives of the national government. They have seen at scale examples of what can and should be available in terms of access to basic services, basic medicines, and environmental conditions. They have participated widely in the Initiative through engaging with the delivery of mass drug administration (MDA) or through the Community Led Total Sanitation (CLTS) initiative. As a result, they have examples of participation in national or central initiatives, given that MDA and CLTS are government policy. Authentic participation is a hugely important element of a democratic society. Strategic Initiative has proved a different concept: landscape-scale enhancement. We suggest that the Zambia Trachoma Elimination and Blindness Prevention Initiative proves the legitimacy of the Strategic Initiative as a developmental model. The 2008-2011 neglected tropical disease projects in Rwanda and Burundi have had impact far beyond simply deworming of a cohort of schoolchildren and their communities. This Zambia SI likewise demonstrates that a philanthropic investor, by focusing on a development issue in an affected community, can positively reshape conditions for an entire population through strategic investment.

Lessons Learned

Successes

Outstanding therapeutic coverage of MDA campaign

Mass drug administration (MDA) coverage has been outstanding in all three rounds of the Zithromax drug administration in both of the targeted districts of Nchelenge and Chienge. Over 90 percent of the population have been treated. This success is attributed to the following factors:

A well-planned and executed community mobilization programme that commenced with the involvement of all the chiefs and sub-chiefs in the two districts. Chiefs mobilized their village heads, who in turn organised their respective community heads to disseminate the MDA awareness messages in their communities.

Employing the Luapula community radio to carry out messages of MDA on a daily basis for close to one month prior to and during the MDA. The messaging encouraged people to take the drug, as well as informed them what and what not to do before taking the drug.

Increasing the number of MDA days from five (Monday to Friday) to seven (Monday to Sunday) allowed the MDA to reach family members who are normally away from home on farmsteads during the weekdays. This extended timeline was coupled with a door-to-door distribution method in which community-based distributors go from house to house to administer the drug.

Open Defecation Free communities

The Community Led Total Sanitation (CLTS) is the process of ‘triggering’ community members’ awareness through a series of steps. The steps are designed to provoke a sense of shame, disgust, and irresponsibility if open defecation is practiced by a community. Through this process,

community members appreciate the fact that open defecation is unpleasant, unhygienic, and unnecessary. As a result, individuals become motivated to stop open defecation and to build their own toilets.

One of the successes of this programme was achieved through the efforts of Every Home for Christ Zambia’s 102 water and sanitation volunteers. Volunteers were placed in teams of three who, in collaboration with existing village WASHE (water and sanitation health educators) conducted week-long CLTS sessions in 196 villages. Of these, 101 villages have been able to be declared Open Defecation Free. We will not claim attribution, but it is important to note there has not been a single case of cholera contracted in Luapula Province in 2014.

Private ownership of water sources

Every Home for Christ Zambia (EHCZ) implemented a self supply model of community water provision. Under this model, EHCZ did not use the conventional provision of boreholes for collective community ownership of 200-500 households which we have used in the past. EHCZ instead rehabilitated existing functional shallow wells privately owned by individual community members and protected them by installing simple hand pumps. In some communities, they facilitated the digging of new shallow wells. In both scenarios, a beneficiary family signed a covenant to share with their nearest neighbors. With this approach, the improved wells continue to be a property of an individual who takes personal responsibility for ensuring its maintenance and proper use. Nearly 300 shallow wells serving a total of 54,580 family members have been provided through this system.

A self-sustaining, revolving drug system

The creation of a sustainable supply of essential second-level medicines that was introduced in 2011 is now in full operation. The clinic, which has a full-time pharmacy assistant, now dispenses all second-level drugs to eye patients at a fee. At the end of December 2013, St. Paul’s drug revolving fund had close to $8,000 in its bank account and drugs stocks for another one and a half years.

Quality implementing partners

This programme has highlighted the central role of quality implementing partners. This programme has been successful across almost seven years because of the professionalism of partners, notwithstanding the actual failure of two partners at critical times.

Challenges

Misuse of project funds by Jesus Cares Ministries

It was a great disappointment when it emerged that Jesus Cares Ministries (JCM), a highly respected implementing partner, was detected to have misdirected project funds. The initial explanation was that the misdirected funds had been used to offset late-arriving funds from other donors’ programmes. However, the audit commissioned by Geneva Global revealed that the funds had largely been used to fund other miscellaneous activities that are still not clear to us. The funds were returned, but the delay in repayment resulted in a serious delay in all aspects of the JCM project which was responsible for delivering the hygiene-related components of the SAFE strategy of trachoma control.

Supply chain inadequacy

The International Trachoma Initiative (ITI) will only donate Zithromax, used to treat trachoma, to a Ministry of Health (MOH). We were very pleased when Zambia qualified to receive a donation, due in part to the strength of our partnership. However, ITI subsequently commissioned a supply chain audit of the government system before releasing the drug donation. Unfortunately, Zambia initially failed the audit. This led to the delayed delivery of the Zithromax to Zambia and, consequently, to the rescheduling of the three rounds of the MDA programme from the initial period of 2011 to 2013 to 2012 to 2014.

Insufficient Stock of Tetracycline Eye Ointment

In the trachoma MDA, pregnant women in the first trimester and children below six months of age are not permitted to take Zithromax. Instead they are given Tetracycline Eye Ointment (TEO) which, according to ITI requirement should be provided by the implementing national government. It was therefore disappointing to learn just a week before the MDA that the Zambian government was unable to supply the estimated 15,000 tubes of TEO required for Nchelenge and Chienge. Fortunately St. Paul’s Mission Hospital had 5,000 tubes of TEO available in their drug store for their routine dispensary, but many women and children were still unable to receive the expected treatment. This situation also created a TEO drug shortage for St. Paul’s Eye Clinic.

Zithromax transport from the Government Central Store to the respective districts

The Zambian government as the principal stakeholder, is responsible for specific activities in the implementation of the MDA, including the transportation of the drug to the respective district centers. However, the Zambian government abdicated that responsibility in all three years by asking implementing partners such as St. Paul’s to transport the drug from Lusaka to Nchelenge, which is very expensive.

Transfer of the only ophthalmologist from Luapula

Dr. Consity Mwale was the only ophthalmologist for the entire Luapula Province, responsible for the entire region with a population of 1.2 million people. Dr. Mwale was transferred out of Mansa General Hospital in October 2013 and no replacement has since been provided. This transfer has affected surgeries for both Mansa General Hospital and St. Paul’s Mission Hospital. During the subsequent monthly eye camps, both hospitals had to seek the services of doctors from outside the province, which turned out to be quite costly.

Increased MDA cost due to government-imposed per diems

During the second year of MDA implementation (2013), the government increased staff field allowances by 120 percent. These allowances are paid to the Ministry of Health personnel who ‘leave their desk’ to support work in the field. The effect was that the cost of the MDA doubled for 2013 and 2014. The Legatum Foundation provided additional funds to cover this shortfall of nearly $50,000. This was unfortunate as the elimination of blinding trachoma is a very serious national health programme, whereas the increase in the allowances was a mere fulfillment of election campaign programme by the newly-elected government.