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The Thrive Project AID-611-C-13-00001 Semi-Annual Report December 2013–June 2014 Submitted by: Frederick B. Henning, EdD Chief of Party The Thrive Project

July 31, 2014 MAIL ING ADDRESS PO Box 900922 Seattle, WA 98109 USA ADDRESS 2201 Westlake Avenue Suite 200 Seattle, WA, USA TEL: 206.285.3500 FAX: 206.285.6619 www.path.org

The Thrive Project Semi-Annual Report December 2013–June 2014 Page ii

Table of Contents

Acronyms .................................................................................................................................................... iv

Background ................................................................................................................................................. 1

Administration and Personnel ................................................................................................................... 1

Collaborations and Partnerships ............................................................................................................... 1

Current Status of the Thrive Project ........................................................................................................ 2

Internal Operations and Implementation ................................................................................................. 3

Module 1: NACS Package of Services Provided at health facility and Community Levels ................. 3

NACS Operational Standards ................................................................................................................. 3

NACS Materials and Job Aids ............................................................................................................... 3

Kitwe District NACS Acceleration and New Sites ................................................................................ 3

Thrive Project Provincial Stakeholder NACS Update Meetings ............................................................ 4

Engagement of Community Health Workers ......................................................................................... 4

Monitoring, Evaluation, and Reporting .................................................................................................. 4

Targets and Results to Date .................................................................................................................... 6

Challenges .............................................................................................................................................. 6

Planned Activities for Next Three Months ............................................................................................. 7

Module 2: Training, Mentorship and Supervision Provided to Health Care Workers and Community Health Care Workers ............................................................................................................ 7

Assessment of Site Readiness to Initiate NACS Package of Services ................................................... 7

Training Health Care Workers and Community Health Workers .......................................................... 7

Integrated Management of Acute Malnutrition Training ....................................................................... 8

Copperbelt and Eastern Provinces QI Training ...................................................................................... 8

QI Orientation for Wusakile and Satellite Sites ..................................................................................... 9

Facility-Based Volunteer Training ......................................................................................................... 9

Mentorship and Supervision ................................................................................................................... 9

Pre-service ............................................................................................................................................ 10

Purchase of Anthropometry Equipment ............................................................................................... 10

Printing Job Aids .................................................................................................................................. 10

Budget Realignment ............................................................................................................................. 10

The Thrive Project Semi-Annual Report December 2013–June 2014 Page iii

Challenges ............................................................................................................................................ 10

Planned Activities for July–September 2014 ....................................................................................... 10

Module 3: Local Production of Specialized Nutrient Supplement (HEPS) and Procurement of RUTF .......................................................................................................................................................... 11

Food Commodity Forecasting and Distribution ................................................................................... 11

HEPS Production and Distribution ....................................................................................................... 11

RUTF Procurement and Distribution ................................................................................................... 11

Audit of Food Commodity Supply Chain Management System .......................................................... 11

Market Survey ...................................................................................................................................... 12

Voucher Pilot ........................................................................................................................................ 12

Proposed Modification of HEPS/Yummy Soy Packaging ................................................................... 12

Retailer Assessment in Eastern Province ............................................................................................ 13

Development of National Standard for HEPS/MSB ............................................................................ 13

Environmental Compliance Issues Pertaining to the Project ................................................................ 13

Charter Development and Implementation........................................................................................... 13

Expansion Plan for Kitwe ..................................................................................................................... 14

Challenges ............................................................................................................................................ 14

Planned Activities for Next Quarter ..................................................................................................... 14

Crosscutting Activities .............................................................................................................................. 15

Gender Strategy Development ............................................................................................................. 15

CBO/FBO Identification and Selection ................................................................................................ 15

Rapid Mobile Phone Reporting System/Training ................................................................................ 15

Planned Activities for Next Quarter ..................................................................................................... 17

The Thrive Project Semi-Annual Report December 2013–June 2014 Page iv

Acronyms

AIDS acquired immunodeficiency syndrome

ART antiretroviral therapy

BMI body mass index

CBO community-based organization

CHAI Clinton Health Access Initiative

CHAZ Churches Health Association of Zambia

CHW community health worker

DHIS2 District Health Information System 2

FANTA Food and Nutrition Technical Assistance Project

FBO faith-based organization

FDCL Food and Drugs Control Laboratory

FSMS Food Safety Management System

GMP good manufacturing practices

HCW health care worker

HEPS High-Energy Protein Supplement

HIV human immunodeficiency virus

IMAM integrated management of acute malnutrition

LOP life of project

M&E monitoring and evaluation

MACEPA Malaria Control and Evaluation Partnership in Africa

MCDMCH Ministry of Community Development, Mother and Child Health

MCH maternal and child health

MOH Ministry of Health

MSB maize soya blend

The Thrive Project Semi-Annual Report December 2013–June 2014 Page v

MUAC mid-upper arm circumference

NACS Nutrition Assessment, Counseling, and Support

NGO nongovernmental organization

NZP+ Network of Zambian People Living with HIV

OPD outpatient department

OVC orphans and vulnerable children

PCI Project Concern International

PFS Partners in Food Solutions

PLHIV people living with HIV

PMTCT prevention of mother-to-child transmission

RUTF Ready-to-Use Therapeutic Food

WFP World Food Programme

ZABS Zambia Bureau of Standards

ZISSP Zambia Integrated Systems Strengthening Program

The Thrive Project Semi-Annual Report December 2013–June 2014 Page 1

Background In the one and a half years that the Thrive Project has been implementing Nutrition Assessment, Counseling, and Support (NACS) in selected health facilities in Copperbelt and Eastern provinces, considerable progress has been made in the delivery of nutrition package of services. Efforts in making NACS a routine service for people living with HIV (PLHIV), including pregnant and lactating women and orphans and vulnerable children (OVC), are becoming more visible at health facilities and surrounding community areas. Health facilities and community structures are beginning to make efforts to streamline NACS in their daily activities in a manner that it can be better implemented in their facilities within the framework of many other challenges that they face. The facilities have also broadened their scope of client enrollments and are no longer only focusing on antiretroviral therapy (ART) clinics but becoming visibly active thorough other entry points such as services for prevention of mother-to-child transmission of HIV (PMTCT), inpatient wards, and OVC services.

Administration and Personnel The Thrive Project has engaged new staff and also experienced a number of staff resignations under the period under review. The second Community Linkages Officer for Eastern Province was engaged in quarter 1. The Copperbelt-based Provincial Training and Quality Improvement Officer departed at the end of May, and the Logistics and Supply Chain Specialist and Project Administrator left the project at the beginning of June. Meanwhile, the project has engaged two monitoring and evaluation (M&E) clerks on a temporary basis to support NACS data collection in the sites. The M&E clerks are based at the Thrive Project provincial offices in Eastern and Copperbelt provinces.

Collaborations and Partnerships The Project is cognizant of the fact that the success of NACS at the health facility level is dependent on building visible partnerships and collaborations with government entities and other stakeholders. Currently, partnerships and collaborations for integrating and implementing NACS are continuing with the government thorough the Ministry of Health (MOH), Ministry of Community Development, Mother and Child Health (MCDMCH) at the national, provincial, and district levels, as well as with the National Food and Nutrition Commission. Other partnerships are with the Food and Nutrition Technical Assistance Project (FANTA) III in Kitwe district in Copperbelt and the Zambia Integrated Systems Strengthening Program (ZISSP) and Mawa/Catholic Relief Services project in Eastern Province. Some of the collaborative activities where the government has been taking the lead in bringing together other partners and stakeholders include NACS implementation meetings, training activities, and development of information, education, and communication materials and job aids. This also instills a sense of ownership and ensures continuity of the NACS integrations and implementation after the Thrive Project ends.


The Thrive Project liaised with the Mawa Project to finalize the draft Memorandum of Understanding for the Mawa/Thrive collaboration in Eastern Province. Initial activities have been conducted to start the collaboration process, including visits to health facilities surrounding Mawa Project sites to assess the feasibility of two sites that will provide NACS (Kamulaza and Kwenje in Chipata) and similar activity in Lundazi’s Munyukwa health center.

The Thrive Project participates in the MOH Quality Improvement (QI) technical group meetings. In the reporting period, one Technical Working Group meeting was held on 5 June 2014, where all participating partners presented their activities.

In the second quarter of 2014 Thrive Project staff participated in last Child Health Week activities in Eastern Province.

Thrive Project staff also attended a Community Complementary Feeding and Learning Sessions training conducted in Eastern Province in June 2014. The training helped the Project staff understand how the two projects can collaborate at the community level.

In an effort to promote the commercialization of nutritious products, the Thrive Project is collaborating with the World Food Programme (WFP) and Clinton Health Access Initiative (CHAI). This collaboration is mainly through the establishment of the working group which focuses on affordable, accessible, and available nutritious food for lower-income households. The Thrive Project staff made a presentation of the Project’s commercialization strategy, showcasing activities that would leverage the organizations’ strengths in the working group to further promote nutritious foods.

Current Status of the Thrive Project The Thrive Project has made a number of notable and promising strides in the period under review in the integration and implementation of NACS activities at both the health facility and community level. These include community health worker training, QI training, and training in the integrated management of acute malnutrition (IMAM); monitoring and evaluation orientations; and selection of new sites in Copperbelt Province in partnership with FANTA III on the 100% NACS acceleration in Kitwe district, as well as transition into three new sites in Kitwe district and in two new provinces, Southern and Central. Government participated through the National Food and Nutrition Commission, MOH, and MCDMCH at national, provincial, and district levels. Government also took the lead in selecting and inviting health facility staff and other partners invited for meetings, trainings and facilitation of some sessions, and the coordination of NACS activities in general. The transition to new sites in Kitwe district and site assessments in Southern and Central provinces was done jointly with government participation at provincial and district levels.

Previously the Thrive Project focused its NACS integration and implementation activities at the ART clinic. However, lessons are being learned simultaneously as implementation takes place. The Project has embraced other client entry points such as PMTCT, inpatient wards and outpatient department (OPD).


The Project has started the process of procuring Ready-to-Use-Therapeutic Foods (RUTF) with guidance from the MOH with regard to meeting regulations and following procedures of acquiring products from within and outside the country. The Project has also been working on redesigning the current High-Energy Protein Supplement (HEPS) packaging so that it meets the Food and Drugs labeling regulations.

In addition the Project is working very closely with the government in developing and finalizing the NACS operational standards. Government has taken the lead and brought on board additional stakeholders to finalize the standards.

Internal Operations and Implementation Administratively the Thrive Project conducts its day-to-day activities under the umbrella of three modules which are operationally interlinked. Details on the work under each module are highlighted below.

Module 1: NACS Package of Services Provided at health facility and Community Levels

NACS Operational Standards

An assessment was conducted at district and health facility levels in Thrive Project operational sites to determine the practical need for the NACS standards. The assessment revealed the need for such standards. The draft NACS standards were developed in the first quarter of 2014, through a consultative process with the government.

It is envisioned that the standards will harmonize and strengthen delivery of NACS at the various service entry points such as ART, maternal and child health, inpatient care, and OPD, while promoting uniformity and standardization of how NACS issues will be dealt with. The standards are expected to be completed and disseminated by quarter 3 2014.

NACS Materials and Job Aids

A number of job aids, including food ration guidelines and reference charts, have been identified to facilitate the delivery of the NACS operational standards. In collaborations with the government through the MOH, the Thrive Project will facilitate printing and making these available in operational sites.

Kitwe District NACS Acceleration and New Sites

The partnership with FANTA III which commenced in 2013 has continued in the 100% NACS acceleration in Kitwe district. The Thrive Project is taking on three new sites in addition to the existing five health facilities.


Thrive Project Provincial Stakeholder NACS Update Meetings

The Thrive Project provincial staff have been actively involved in stakeholder meetings in their provinces convened by the government. The District Health Office coordinates and identifies the stakeholders who deal directly or indirectly with NACS to attend these meetings. The meetings provide a platform for facilities to share progress as well as challenges and mitigation in NACS implementation. The Thrive Project financially supports the quarterly NACS integration and implementation meetings.

Engagement of Community Health Workers

The Project identified that health care workers in supported sites were not undertaking all NACS activities because of their heavy work load. The Project therefore engaged 83 community health workers (CHWs) in the second quarter of 2014 - 32 volunteers and 8 data entry clerks in Eastern Province and 35 volunteers and 8 data entry clerks in Copperbelt Province.

The CHWs have been tasked with conducting nutrition assessments, classification, and counselling of clients. The overall goal of engaging the CHWs is to improve NACS service delivery in the health facilities. The data-entry clerks are responsible for entering NACS data on computers that were provided by the Thrive Project.

Monitoring, Evaluation, and Reporting

The Project has continued working with the MOH and MCDMCH structures to revise the draft Nutrition Register. Through a consultative process with the two ministries, the Project was granted permission in February 2014 to print and pilot the draft Nutrition Register in Thrive-supported sites.

Health care workers responsible for completing the Nutrition Registers at facility level have since been oriented. The register is currently being piloted in the Thrive-supported sites.

To facilitate data capturing and reporting, the Project provided computers to 12 targeted health facilities in the two provinces. The computers are used for entering NACS data into the IMAM electronic database which the Project has adopted from MOH. Trained data-entry clerks have been selected and engaged at each targeted health facility. The data-entry clerks have undergone on-site orientation in NACS data management.

A data verification exercise was held in Eastern Province from 23 to 26 June 2014. One focal point person and one-data entry clerk from each of the Thrive-supported sites participated in the exercise. The exercise was aimed at ensuring that the quality of data collected in project sites is accurate, reliable, and complete. A similar exercise for all Thrive-supported sites in Copperbelt Province will take place in the third quarter of 2014. The regular on-site data verification and data audits have also continued to confirm the accuracy of the data reported.

The two M&E clerks that were recently engaged have been very instrumental in supporting the data collection efforts in the project sites. Data entry and report submission have significantly improved since


the two temporary staff were engaged. It is hoped that in the future the two temporary staff will be engaged on a permanent basis.

The development of the proof-of-concept paper has continued. The proof of concept will help to verify the viability, effectiveness, sustainability, and scalability of the Thrive Project NACS approach and interventions. The proof of concept will also provide “implementation science” feedback for the overall direction for delivering and sustaining NACS services in Zambia, including related technical issues, budgeting, and other forms of internal decision making.

During the reporting period, Thrive Project staff held meetings with clients, the government, and other partners to discuss the current version of the proof-of-concept outline in order to reach a consensus. Progress will be reported in the next quarter.


Targets and Results to Date

Table 1. Summary of Thrive Project achievements by indicator (June 2013–November 2013).

Challenges

Attrition of trained NACS staff continues to be a challenge in health facilities. Health facility staff are routinely rotated or transferred, while others leave the system. This has a negative impact on the implementation of NACS. This is a common challenge in some facilities, and one over which the Project has little control. Since Project inception, 47 health care workers have been trained in NACS in Copperbelt Province, and of those trained only 30 are actively engaged. As a mitigation measure the Project will need to orient and train new staff.

Indicator LOP target 2014

target Dec 2013 to June 2014

% reached against 2014

target Cumulative

LOP

% reached against LOP

target Number of eligible clients who received food and/or other nutrition services.

50,000 10,500 14,105 134% 17,812 35%

Number of HIV-positive, clinically malnourished clients who received therapeutic or supplementary food.

20,000 4,815 3,768 78% 4,148 21%

Number and percent of PMTCT clients (including exposed infants) who are both assessed and counseled.

1,500 350 346 99% 346 23%

Number of health care workers who successfully completed an in-service training program using the national guidelines during the LOP.

800 130 123 95% 230 29%

Number of CHWs/volunteers who successfully completed a NACS services training program using the national guidelines.

300 75 104 138% 104 37%

Number of metric tons of HEPS produced locally.

952 173 80 46% 96 10%

Number of metric tons of RUTF procured. internationally.

40 8 2.2 27% 2.2 5.5%


Planned Activities for Next Three Months

• Orientation of health staff and piloting of NACS standards.

• Finalizing and printing NACS standards.

• M&E orientation.

• Revision of pilot nutrition register.

Module 2: Training, Mentorship, and Supervision Provided to Health Care Workers and Community Health Care Workers

During the reporting period, the activities described below were undertaken.

Assessment of Site Readiness to Initiate NACS Package of Services

Site assessment of 22 potential NACS sites in eight districts in scale-up provinces (Central and Southern) to identify gaps, opportunities, and challenges began in June 2014. An additional 10 sites will be assessed in the next quarter to bring the total number of potential sites to 32. Out of the 32 potential sites, 20 sites will be selected to be part of the NACS program. Assessment findings and selected sites will be reported in the next reporting period.

Training Health Care Workers and Community Health Workers

During the period under review, the Project continued to build capacity of health care workers (HCWs) and CHWs in implementing NACS through training and mentorship, quality improvement efforts, and supervising NACS integration. The Project trained 123 HCWs in IMAM and QI. A total of 104 CHWs and volunteers have been trained to assist HCWs in Thrive-supported sites. Task shifting was inevitable because of inadequate staffing and heavy workload in the sites. Currently, trained CHWs assess, counsel, and give NACS health education and messages to clients, while clinicians and nurses mainly deal with managing complicated cases and prescribing therapeutic and supplementary foods.

During the period under review two IMAM, three QI and four CHW NACS training were held in Copperbelt and Eastern provinces. Figure 1 shows proportions of individuals trained by sex.


Figure 1. Proportion of trained health care workers and community health workers/volunteers trained by sex.

Integrated Management of Acute Malnutrition Training

The Thrive Project in collaboration with the MOH conducted two 6-day IMAM trainings from 16 to 21 December 2013 in Copperbelt and Eastern provinces, training a total of 51 HCWs (14 male and 38 female).

Participants for both trainings were drawn from OPD, ART, inpatient, and MCH clinics. They included nutritionists, nurses, clinicians, and nutrition demonstrators.

Although the IMAM training is not highlighted in the Thrive project document, the MOH instructed the project to train HCWs in IMAM preceding NACS trainings because case management of acute malnutrition in inpatient and outpatient therapeutic care facilities is one of the major challenges in health care delivery in Zambia.

Copperbelt and Eastern Provinces QI Training

During the period under review, three QI trainings were held in Copperbelt and Eastern provinces: 22 to 24 January 2014, 27 to 29 January 2014, and 9 to 12 June 2014. These trainings targeted provincial and district clinical care specialists, nutritionists, M&E officers, heads of clinical care of hospitals, facility in-charges of health centers and clinics, and Thrive project staff. A total of 74 HCWs were trained. Table 2 shows QI indicators that are being monitored at facility level.

Male 31%

Female 69%

Health care workers trained in Integrated Management of Acute Malnutrition and

Quality Improvement

Male 22%

Female 78%

Community health workers trained in community NACS


Table 2. Quality improvement indicators monitored at facility level.

QI Orientation for Wusakile and Satellite Sites

An orientation was held on 27 June for 19 HCWs (6 male and 13 female) from Wusakile, Natwange, Mindolo, and Chamboli sites. These sites had not started implementing QI because they did not participate in the QI trainings that were held in Copperbelt Province in January 2014.

Facility-Based Volunteer Training

The Thrive Project identified a gap in assessment, classification, and counseling of clients in all 16 sites. To close this gap, adherence counselors and volunteers based at these sites were trained in CHW NACS. Two trainings were conducted, one in Ndola from 10 to 13 March, and another in Kitwe from 17 to 20 March. A total of 51 CHWs (7 male and 44 female) were trained.

An additional two trainings were held, 24 to 28 March and 31 March to 3 April, in Chipata for Chipata and Lundazi sites, respectively. A total of 53 CHWs (16 male and 37 female) were trained.

Mentorship and Supervision

During the reporting period, several trips were made to assist facilities integrate NACS into routine care. So far, all facilities have integrated NACS into ART, and assessment is increasingly becoming a routine service. Integration of NACS in other entry points (OPD, PMTCT, and inpatient) is still a challenge. One of the reasons is that there are not enough trained HCWs in these entry points. Assessment of all sites in Copperbelt revealed that, out of the 47 HCWs trained in NACS, only 30 are actively involved in NACS. The rest of the staff have either resigned their position, been deployed elsewhere, or are simply not interested in participating in NACS. This highlights the need to train and/or orient more HCWs in all facilities.

Indicator No.

NACS service Indicator

1 Clients are assessed nutritionally. % of PLHIV assessed for nutrition at each visit.

2 Clients are classified nutritionally. % of PLHIV correctly classified for nutrition at each visit.

3 Nutritional supplements are prescribed correctly.

% of malnourished PLHIV prescribed correctly.

4 Clients are counseled nutritionally. % of PLHIV counseled for nutrition.


Pre-service

The process to hire a consultant has begun. This assignment will seek to establish the extent to which NACS is taught in pre-service nutrition/health institutions, the flexibility of integrating NACS in the current curricula, and pre-service flexibility to adapt NACS. The recommended course of action will take into account the openness of training institutions to engage with the Thrive Project. Progress on this activity will be highlighted in the next quarter.

Purchase of Anthropometry Equipment

FHI360 completed the purchase of 75 child/mother scales, 75 height boards and 50 length boards, and 2500 child and 2500 adult MUAC (mid-upper arm circumference) tapes meant for all 50 sites to be reached by the end of the project. So far 34 scales, 36 length boards, and 38 height boards have been distributed to ART, MCH/pediatrics, OPD, and inpatient care departments in Copperbelt and Eastern province sites.

Printing Job Aids

To aid assessment and counseling, FHI360 purchased 185 counseling flip charts and 200 body mass index (BMI) charts. BMI charts have been distributed to all site entry points. Counseling flip charts will be distributed during trainings for current and scale-up sites.

Budget Realignment

Due to limited funding and under-budgeting on some budget lines, FHI360 realigned the budget activities to attain Module 2 deliverables. The original budget underestimated the requirements, where only 50 scales, 50 height and length boards, and 50 MUAC tapes were budgeted for. The minimum requirements using NACS entry points for the 50 facilities are 105 scales, 105 height boards, and 80 length boards. The training budget line was also under-budgeted, and revision and realignment was deemed necessary so that funds are allocated where they are needed.

Challenges

The start of QI implementation after the training was delayed because facilities needed to review the charters before signing them. The QI team needed to agree on the denominator for indicator 1 because facilities capture the assessment and classification data in varied ways using different tools.

Planned Activities for Next Quarter • Commence pre-service assessment.

• Conduct IMAM and NACS trainings in Central province.

• Strengthen QI systems in Copperbelt and Eastern provinces.

• Assess scale-up sites in Southern and Central provinces.


• Conduct three CHW NACS trainings in eastern Province.

Module 3: Local Production of Specialized Nutrient Supplement (HEPS) and Procurement of RUTF

Food Commodity Forecasting and Distribution

The food commodity distribution plan that was developed in year 1 has been reviewed to include 100% NACS acceleration in Kitwe district and expansion to Southern and Central provinces under the Thrive Project. The plan has worked effectively in avoiding stock-outs in health facilities.

HEPS Production and Distribution

Under the year 1 contract of maize soya blend (MSB)/HEPS production, COMACO, a local food processor, started producing and delivering HEPS to NACS implementing sites in November/December 2013. Before production and distribution of MSB/HEPS to the 16 sites, the Thrive Project obtained an authorization from the MOH to distribute HEPS to the facilities after a certificate of analysis was obtained from a government-approved Food and Drugs Control Laboratory (FDCL). Subsequently, samples of HEPS have been drawn from every batch and submitted for analysis at the FDCL of the MOH. The laboratory results have indicated that the product meets WFP technical specifications for the manufacture of Super Cereal Corn Soya Blend with Sugar version 10.

During the period under review, COMACO produced and delivered 38.28 and 41.27 metric tons of HEPS to the 16 NACS implementing sites in Copperbelt and Eastern provinces, respectively.

The process of sourcing for HEPS for year 2 was initiated in quarter 1 and is close to completion. Based on the satisfactory performance of the supplier in year 1 and conditions of the Request for Proposal, the Thrive Project opted to renew the contract for year 2 production and supply of HEPS. The Project will procure 169.9 metric tons of HEPS for year 2 for distribution to 41 sites, including FANTA sites.

RUTF Procurement and Distribution

During the period under review, the MOH gave approval for the Thrive Project to import RUTF for distribution to selected health facilities. However, the actual importation of the product is subject to satisfying international nutritional and food safety requirements. Samples of RUTF were submitted to FDCL and the Zambia Bureau of Standards for analysis to facilitate issuance of the Health Clearance Permit. Results will be available by mid-July 2014.

Audit of Food Commodity Supply Chain Management System

During the period under review, a local consultant was engaged to undertake a desk review of the adequacy of the food commodity supply chain management system plan. The consultant made recommendations which have been implemented.


Subsequent to the desk review the Thrive Project engaged the PATH Regional Auditor to conduct an internal audit of the food commodity supply chain management system. Specifically the internal audit focused on the processes implemented for efficient and effective distribution of HEPS. The audit also focused on testing the controls implemented around distribution of HEPS for adequacy and consistency in the operations in the first and second year of life of the project. The findings of the audit will be received and reported in the third quarter of 2014.

Market Survey

After receiving approval from the MCDMCH, a market survey was designed to understand the decision-making habits and buying patterns of target clients. The survey informed the commercialization strategy on how to ensure that the MSB/HEPS products are developed and marketed in a way that ensures that clients are willing to purchase the products from retail shops.

The survey was conducted in Kitwe and Ndola districts in Copperbelt Province, and Chipata and Lundazi districts in Eastern Province. A total of 231 respondents participated by way of in-depth interviews, focus group discussions, and surveys. The target for the survey was lower-income individuals between the ages of 18 and 50 living in urban and peri-urban areas that are either affected or infected by HIV. The survey was completed in the first quarter of year 2.

Subsequent to conducting the market survey, the commercialization strategy was disseminated to the food processing companies that Thrive Project staff are working with to increase the marketability of MSB/HEPS products.

Voucher Pilot

The voucher pilot is expected to commence in the next quarter in alignment with the Thrive Project’s geographical scale-up. The strategy and budget for the voucher pilot have been developed. The Project is currently in the process of engaging a supplier for the program and is comparing three suppliers.

It is proposed that either Southern or Central province take part in the pilot. Selection of the retail stores will be conducted at the time of the scale-up site assessment in July 2014.

Proposed Modification of HEPS/Yummy Soy Packaging

The Thrive Project is working with COMACO to develop new packaging for their MSB/HEPS product. The Project decided to use the existing packaging which is available in retail stores in order to link with the commercialization component and because it was determined that the information provided on the packaging in terms of instructions and ingredients was sufficient for the clients. In consultation with the MOH, the Project has revised the MSB/HEPS packaging by changing from 500-g to 100-g sachets to assist clients to better meet the daily recommended ration of 400 g, to mitigate food safety hazards, and to improve the preparation instructions. While the project proposed to use similarly branded packaging at the health facility and retailer level, the MOH advised the use of non-branded packaging to avoid giving


an advantage to any one company producing similar products on the market. Thrive Project staff took this opportunity to work with COMACO to redesign the packaging, and COMACO was more than willing to comply. The new packaging has been redesigned and is waiting for approval from the MOH.

Retailer Assessment in Eastern Province

During the period under review, an assessment of retail stores was conducted in Eastern Province in collaboration with COMACO. The purpose of the assessment was to determine which retailers would be suitable to partner with to commence the distribution of MSB/HEPS at the retail level. It was also intended to understand COMACO’s current distribution network in Eastern Province to identify any gaps and determine ways to increase their market share for highly nutritious foods.

A total of 54 retailers were visited in Lundazi, Chipata, and Katete, as well as Sinda districts. The Thrive Project decided to assess retailers in Sinda district because of its proximity to Katete and access to services at St. Francis Mission Hospital. These retailers included those linked to one of the community- based organizations that the Thrive Project is currently working with, as well as many of COMACO’s key clients. Seven retailers were selected in the Katete/Sinda areas, six in Lundazi, and 12 in the Chipata area. MSB/HEPS will be introduced to the market through a series of market days which will be conducted in July 2014, after which the products will be made available in the selected retail stores.

Development of National Standard for HEPS/MSB

During the period under review, the Technical Committee, which included Thrive Project staff, constituted by the Zambia Bureau of Standards (ZABS) in October 2013 to develop the National Standard for MSB/HEPS, produced a draft document. The standard will harmonize production of HEPS/MSB in Zambia. The draft National Standard was distributed for public comment in quarter 2 and is expected to be approved by the ZABS Council by the end of August 2014.

Environmental Compliance Issues Pertaining to the Project

The Thrive Project has continued working with the Zambian government toward properly sourcing raw materials and assisting to process, package, and store HEPS at health facilities and processor sites to avoid environmental issues. The Project has also continued to work with COMACO in pretreating and cleaning of maize and soybeans, as well as ensuring proper storage and distribution of HEPS. At the health facilities, the Thrive Project staff have been fully engaged with environmental health technologists to ensure compliance with environmental health regulations based on the approved Environmental Mitigation and Monitoring Plan.

Charter Development and Implementation

The Thrive Project has chosen to work with the food processors COMACO and High Protein Foods to build their capabilities in the manufacture, marketing, and distribution of MSB/HEPS products. The technical assistance provided to food processors is being executed through four project charters: Food


Safety Management System (FSMS); Optimization of Production Processes and Formulation; Marketing Strategy Development; and Supply and Distribution Management System Implementation. The overall objective of the charters is to grow the food processing companies’ position in the MSB/HEPS value chain as a whole while increasing their production volume to allow for reduced cost and improved product quality and safety.

During the period under review, Thrive Project staff have been working through virtual media with volunteer experts from Partners in Food Solutions (PFS) translating critical knowledge and expertise to the food processors with respect to the four charters mentioned above.

While this has been in progress, the quality of HEPS purchased for the project is monitored and ensured by examining production log sheets for every batch and submitting samples of the finished product to the FDCL of MOH and the ZABS for testing, where the results are compared with Codex and WFP standards. The results of the analyses so far have consistently met the Codex and WFP standards.

Although engagement with High Protein Foods was initially delayed, volunteer experts have been identified and program implementation activities are getting back on course.

Expansion Plan for Kitwe

As mentioned previously, the Thrive Project will be working with FANTA III in the NACS acceleration in Kitwe district. Activities that the Thrive Project will implement include the identification of the mini-hub, orientation of health personnel handling project food commodities, and monitoring of safety and integrity of food commodities.

Challenges

The sustainability plan for the Project through the commercialization process is currently facing a set- back, as the proposed use of the same packaging for the food commodity MSB/HEPS in health facilities and retailers was rejected by the MOH. Therefore, the Project will face a challenge in linking clients who are receiving MSB/HEPS in the facilities with retailers who will be selling the product because of legislation restrictions. In addition, clients will not know that the product they are receiving in the health facility is the same product available in retail stores.

The protracted process of the MOH approving the new packaging for food commodities is affecting the supply of HEPS/MSB in the health facilities. This delay may lead to stock-outs in health facilities. The Thrive Project will be requesting a waiver from the MOH to continue supplying the health facilities using the old packaging until the new packaging is launched.

Planned Activities for Next Quarter • Procurement of 10 metric tons of RUTF.

• Conducting marketing exercises to promote COMACO’s MSB/HEPS product in the retail market in Eastern and Copperbelt provinces.


• Completion of the supply and distribution management system charter with COMACO.

• Facilitating GMP compliance inspection by ZABS at COMACO, leading to GMP certification (i.e., recognition that the manufacturer has gained knowledge, skills, and competence in implementing GMP at their manufacturing facility).

• Continuation of work on the three remaining charters with COMACO, as well as commencement of work on charters with High Protein Foods.

• Commencement of delivery of MSB/HEPS to the additional sites.

Crosscutting Activities

Gender Strategy Development

During the period under review, the Thrive Project worked closely with a local gender specialist and PATH researcher in gender and gender-based violence to finalize the gender strategy. The strategy was finalized in May 2014. The purpose of the strategy is to address gender imbalances within the project parameters.

CBO/FBO Identification and Selection

Identification of community-based organizations (CBOs) and faith-based organizations (FBOs) was conducted through district-level planning meetings. The meetings were coordinated by the District AIDS Task Force to help the Thrive Project identify organizations to work with. The Project is working with nine CBO/FBOs in five districts to conduct demand-creation activities. Both Copperbelt and Eastern have identified seven CBO/FBOs for each province. The CBO/FBO volunteers identified in Copperbelt and Chipata and Katete districts of Eastern Province received basic NACS orientation and began making referrals, follow-up, and infection prevention and control sessions on hygiene during the first and second quarters. The Project is planning to provide training in NACS to volunteers in Eastern and Copperbelt provinces during the third quarter to further enhance the performance of the CHWs/volunteers in strengthening NACS at the community level.

Rapid Mobile Phone Reporting System/Training

A community database was developed during the first quarter. The Thrive Project continued working on the mobile phone-based reporting tool in coordination with the MACEPA M&E specialist. Additionally, the District Health Information System 2 (DHIS2) database was successfully tested in quarter 2 in Ndola district. Test results indicated that use of this tool will facilitate the management of aggregate data, as well as data presentation (using data visualization features such as geographic information system [GIS], charts, pivot tables, and dashboards). The data from the community database will form the basis of decision-making with regard to community activities.


Following the successful testing of the DHIS2, the Thrive Project trained CBO/FBOs on the use of mobile phones for reporting. The training in Copperbelt was targeting seven CBO/FBOs, including Mufulira NZP+ (Network of Zambian People Living with HIV), Kitwe NZP+, Hosanna Mapalo, Kitwe Nutrition Group, AROS, Bwafwano Care Group, and the Judith Chikondi Foundation.

The training was replicated in Chipata district, with a total of three participants from each organization, including Kachere Development Program, Katete NZP+, and Churches Health Association of Zambia (CHAZ). The remaining organizations, Lundazi NZP+, Lumezi Catholic Diocese, and Kayanga Catholic Diocese, will participate in trainings in the next quarter.

Participants in the training were provided with internet-enabled phones for reporting purposes. They were also given tools (source documents) for generating data at the community level prior to uploading into the DHIS2 database. Figure 2 shows data entered for Copperbelt Province.

Figure 2. Data from mobile phone training–Copperbelt Province.


Planned Activities for Next Quarter

• Identify CBO/FBOs to work with in Southern and Central provinces.

• Link newly identified CBOs, PLHIV support groups, and other community structures to Thrive NACS provision facilities and other local NGOs.

• Orient CBOs, PLHIV support groups, and other community structures to identify nutritionally vulnerable households and individuals.

• Collaborate with Project Concern International (PCI), Lift, Assist, and FANTA in Kitwe to conduct community mapping and mobilization for behavior change communications and NACS training.

• Identify gender messages to be incorporated in the CBO, CHW, and health care worker trainings.

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