TB Strategic Plan (2017-2021) - Final

NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS PREVENTION, CARE AND CONTROL (2017–2021)
REPUBLIC OF ZAMBIA
MINISTRY OF HEALTH
NATIONAL STRATEGIC PLAN

FOR TUBERCULOSIS
PREVENTION, CARE AND CONTROL
(2017 - 2021)
“Towards Elimination”
1
2
Republic of Zambia
Ministry of Health
National Strategic Plan

for Tuberculosis Prevention, Care and
Control
(2017–2021)
i
FOREWORD
One of the outstanding successes of the just-ended National Tuberculosis (TB) Strategic Plan (NSP)
was the first ever population-based National TB Prevalence Survey, conducted in 2013–2014. The
results of this survey provided clear evidence that, while there appeared to be a decline in TB notifi-
cations, the burden of TB in the country was much higher than previous World Health Organization
(WHO) estimates. With an estimated prevalence of 638/100,000 for bacteriologically confirmed TB
and a human immunodeficiency virus (HIV) prevalence of 11.6 percent (ZAMPHIA 2016), Zambia is
currently one of the 30 high TB and TB/HIV burden countries in the world. Despite the high estimated
TB incident rate of 391/100,000 population (equal to 63,000 TB cases) in 2015, only 38,326 new and
relapse TB cases were notified, meaning that over 40 percent of TB cases were not detected.
The Government of the Republic of Zambia (GRZ) through this NSP (2017–2021)—which is aligned
with the National Health Strategic Plan (2017–2021), the WHO Global End TB Strategy, and the Sus-
tainable Development Goals (SDGs)—aims to eliminate TB by 2030. The NSP sets the pace to achieve
this realistic goal. The essential approaches to attaining TB elimination are scaling up high-quality
TB prevention, treatment, and care services; expanding the TB laboratory network close to people’s
homes; and providing people-centred TB care services. The plan also prioritises early TB case detec-
tion, as well as treatment of vulnerable populations that include children and adolescents, prisoners,
miners, people living with HIV/AIDS, and women.
This NSP is a promise to increase multisectoral action as well as track progress and build accountabil-
ity towards a TB-free Zambia. The plan has outlined interventions to contribute to achieving rapid
progress towards the goal of universal health coverage through health systems strengthening, while
also ensuring universal access to quality people-centred TB prevention and care, ensuring that no
one is left behind. Additionally, the NSP has identified the primary health care (PHC) approach as a
bedrock of the TB elimination agenda. Considering that scaling up of high-impact TB interventions
requires significant human and financial investments, it is necessary to secure sufficient and sustain-
able financing from domestic and external sources.
I, therefore, welcome this comprehensive national strategic plan for the TB programme, developed
with the support and active involvement of all stakeholders including civil society organisations, as
the appropriate national response to ending the TB epidemic. I urge all public and private health
institutions, cooperating partners, and civil society organisations to plan the implementation of TB
services based on this NSP.
DR. CHITALU CHILUFYA, MP
MINISTER OF HEALTH
ii
ACKNOWLEDGEMENTS
The Ministry of Health through the National Tuberculosis and Leprosy Programme provided the
leadership and stewardship in the development of this new National Tuberculosis Strategic Plan
(2017–2021).
The development of this National Strategic Plan (2017–2021) received technical and financial sup-
port from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States Agency for
International Development (USAID) through the Challenge TB Mechanism, and the Resident TB Tech-
nical Advisor and Centers for Disease Control and Prevention (CDC). The Ministry of Health wishes
to express its profound gratitude to all international and in-country stakeholders, including civil so-
ciety organizations, for their valuable contributions towards the development and finalization of
this national strategic plan. Further, the Ministry of Health would especially like to acknowledge the
support and contributions of the organizations and individuals listed in Annex III.
DR. JABBIN MULWANDA
PERMANENT SECRETARY-TECHNICAL SERVICES
iii
TABLE OF CONTENTS
FOREWORD ii
ACKNOWLEDGEMENTS iii
Abbreviations vi
Executive Summary viii
SECTION ONE: BACKGROUND 1
1.1 Political and Administrative Structures and Economy 1
1.2 Demographic Characteristics of Zambia 1
1.3 Population Health Status in Zambia 2
1.4 Health Care System in Zambia 3
1.5 Health Sector Financing 5
1.6 Health Sector Reform and Policy Changes 5
1.7 HIV Treatment Programme 6
SECTION TWO: TUBERCULOSIS IN ZAMBIA 7
2.1 Background 7
2.2 Partner Coordination 7
2.3 The Burden of TB Disease in Zambia 8
2.4 Programme Performance 11
2.5 Drug-Resistant TB 13
2.6 Infection Control 14
2.7 Laboratory Services for TB Control 14
2.8 Management of TB Medicines 17
2.9 Involving All Care Providers (Public-Private Mix) 18
2.10 TB and the Mining Sector 18
2.11 TB in Prisons 19
2.12 TB and Cross-Border Populations 19
2.13 Partnerships 19
2.14 Routine TB Data Systems and Surveillance 20
2.15 Funding for TB Control 20
2.16 National TB Strategic Plans 24
iv
SECTION THREE: PROGRAMMATIC ANALYSIS 22
3.1 Evaluation of Surveillance and TB Epidemiological Analysis 2014 22
3.2 National TB Review 2016 22
3.3 SWOT Analysis 23
3.4 Gap Analysis 26
3.5 Rationale for National Strategic Plan 31
SECTION FOUR: VISION, MISSION, GOALS AND OBJECTIVES, AND STRATEGIC

INTERVENTIONS AND ACTIVITIES 32
4.1 Vision 32
4.2 Mission 32
4.3 Goal 32
4.4 Guiding Principles 32
4.5 Major Focus Areas 32
4.6 Strategic Interventions and Activities 33
SECTION FIVE: OPERATION PLAN 74
SECTION SIX: TECHNICAL ASSISTANCE PLAN 74
SECTION SEVEN: BUDGET PLAN 74
SECTION EIGHT: MONITORING AND EVALUATION FRAMEWORK 79
ANNEX I: TECHNICAL ASSISTANCE PLAN 80
ANNEX II: MONITORING AND EVALUATION 86
ANNEX III: ACKNOWLEDGEMENT 113
v
ABBREVIATIONS
ACSM advocacy, communication, and social mobilization
aDSM active drug safety monitoring and management
AIDS acquired immunodeficiency syndrome
ART antiretroviral therapy
BOQ Bill of Quantities
BSL3 biosafety level 3
CBO community-based organization
CBoH Central Board of Health
CDC US Centers for Disease Control and Prevention
CDL Chest Disease Laboratory
CHA community health assistant
CHAZ Churches Health Association of Zambia
CHI church health institution
CI confidence interval
CIDRZ Centre for Infectious Disease Research in Zambia
CPT cotrimoxazole preventive therapy
CSO civil society organization
CXR chest x-ray
DHIS District Health Information System
DHO District Health Office
DHS Demographic and Health Survey
DOT directly observed treatment
DOTS directly observed treatment, short course
DRS drug resistance survey
DST drug-susceptibility testing
EP TB extra-pulmonary tuberculosis
EQA external quality assurance
FBO faith-based organization
FDC fixed-dose combination
GDP gross domestic product
Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria
GRZ Government of the Republic of Zambia
HF health facility
HIV human immunodeficiency virus
HMIS health management information system
IC infection control
ICF intensified case finding
IEC information, education, and communication
IPT isoniazid preventive therapy
LED light-emitting diode
LMIS laboratory management information systems
LPA line probe assay
M&E monitoring and evaluation
MCDSW Ministry of Community Development and Social Welfare
MCH maternal and child health
MDG Millennium Development Goal
MDR/RR multidrug resistant/rifampicin resistant
MDR-TB multidrug-resistant TB
vi
MOH Ministry of Health

MoU Memorandum of Understanding
MSL Medical Stores Limited
NAC National AIDS Council
NASF National AIDS Strategic Framework
NCD noncommunicable disease
NGO nongovernmental organization
NHSP National Health Strategic Plan
NRL National Reference Laboratory
NSP National Strategic Plan
NTD neglected tropical disease
NTLP National Tuberculosis and Leprosy Programme
OHSI Occupational Health and Safety Institute
OPD outpatient department
PEPFAR US President’s Emergency Plan for AIDS Relief
PHC primary health care
PHO Provincial Health Office
PITC provider-initiated HIV testing and counselling
PLHIV people living with HIV
PMDT programmatic management of drug-resistant TB
PMTCT prevention of mother-to-child transmission of HIV
PPE personal protective equipment
PPM public-private mix
PSM procurement and supply chain management
PTB pulmonary tuberculosis
PViMS Pharmacovigilance Monitoring System
QA quality assurance
R&R recording and reporting
RMNCAH reproductive, maternal, newborn, child, and adolescent health
SADC Southern African Development Community
SNRL Supranational Reference Laboratory
SOP standard operating procedure
STI sexually transmitted infection
SWOT strengths, weaknesses, opportunities, and threats
TA technical assistance
TB tuberculosis
TB/HIV HIV coinfection with tuberculosis
TDRC Tropical Disease Research Centre
THPAZ Traditional Healers Practitioners Association of Zambia
TOT training of trainers
TWG technical working group
USAID United States Agency for International Development
UTH University Teaching Hospital
VCT voluntary counselling and testing
VRS Vital Registration System
WHO World Health Organization
ZAMBART Zambia AIDS Related TB [Project]
ZAMRA Zambia Medicines Regulatory Authority
ZATULET Zambia Tuberculosis and Leprosy Trust
ZTOC Zambia TB Organizations Coalition
vii
EXECUTIVE SUMMARY
Background
The National Tuberculosis Strategic Plan (NSP) 2017–2021, aligned to the National Health Strategic
Plan (NHSP) 2017–2021, represents a transformative approach to TB as one of the major public health
challenges in Zambia. In line with the World Health Organization (WHO) End TB Strategy, with a target
of ending the TB epidemic by 2035, this plan has been entitled Towards Elimination, as opposed to
merely controlling TB. This is the fourth National TB Strategic Plan since the reorganization of the TB
programme in 2000, and the interventions included build on the successes of the previous strategic
plans. Notable among these are the high treatment success rate, nationwide implementation of TB/
HIV collaborative activities to reduce the burden of HIV among TB patients, a reduction in mortality
rates, and expansion of the network of microscopy centres. However, whilst the National Tuberculosis
and Leprosy Programme (NTLP) has recorded an annual decline in numbers of notified cases since
2005, and based on WHO estimates, a case detection rate of over 75 percent, the 2013–2014 National
TB Prevalence Survey demonstrated that there has been a significant gap in case finding and that the
case detection rate is now less than 60 percent. To move the national programme towards elimination,
the TB programme needs to take a proactive approach to identify the missing TB cases, in contrast
to the focus on passive case finding that characterized much of the emphasis of the programme in
the last 15 years.
The NSP is based on the principles underlying the End TB Strategy—namely, government
stewardship and accountability, with monitoring and evaluation; building a strong coalition with
public and private sectors, civil society, nongovernmental organizations (NGOs), academia, research
institutions, media, faith-based organizations, and religious, traditional, civic and political leaders
and their communities; protecting and promoting human rights, ethics, and equity; adapting the
strategy and targets at country level, with global collaboration; and integrated, patient-centred TB
care and prevention. The NSP will guide the design and implementation of interventions needed to
move the country towards elimination and ensure that all efforts are in line with the Government of
Zambia’s Vision 2030 of being a middle-income country by 2030 (7th National Development Plan and
the NHSP 2017–2021).
Identify the missing TB cases

Recognizing that the undiagnosed and untreated TB patient is the main source of infection, this
NSP will focus on active screening of all clients and patients seeking health care for any reason to
find the missing TB patients, with a focus on outpatient departments, maternal and child health
settings, prisons, mines, at-risk medical patients such as diabetics, and HIV treatment centres among
others. The active screening process will use screening questions to identify presumptive TB patients
requiring further investigation. Care providers operating outside the TB networks will be included in
the recognition of presumptive TB patients, diagnosis and treatment, and active screening for TB will
be extended to community screening in TB hot spots and contact tracing.
Enhance TB diagnostic services

The plan will optimize diagnosis of TB by expanding the availability of quality assured microscopy
using LED (light-emitting diode) fluorescent microscopy and rapid diagnostic tests such as the
Xpert MTB/RIF assay (which is now an initial TB diagnostic test for all presumptive TB cases) and
other WHO-recommended rapid diagnostic tools. By 2021, the country will have more than 490
GeneXpert machines. Though the existing microscopy centres exceed the recommended number
per population, the physical location of many centres means some communities have limited access
to TB microscopy services. To address this challenge and ensure easy access to the culture facilities,
a specimen referral system will be established. Digital radiography services will be expanded to
enhance active TB screening in high-volume facilities, TB hot spot districts, and congregate settings.
viii
Expand programmatic management of multidrug-resistant TB

Implementation of the programmatic management of drug-resistant TB cases started in 2009 and
continued in the recently ended revised NSP (2014–2016). Building on this achievement, the NSP
will focus on improving the services provided in existing treatment centres through training and
mentoring of staff as well as decentralizing services to each of the ten provincial hospitals and a
number of district hospitals. Other activities will include introduction of the new shorter multidrug-
resistant TB (MDR-TB) treatment regimen and new drugs and introduction of active drug safety
monitoring and management (aDSM), as well as providing social and financial support for patients on
second-line drugs by leveraging with other sectors such as the Ministry of Community Development
and Social Welfare among others.
Enhance TB/HIV collaboration

Implementation of HIV testing for TB patients, cotrimoxazole preventive therapy, and antiretroviral
therapy for TB/HIV was successfully implemented in the previous NSP. Whilst maintaining this
success, the NSP will collaborate with the HIV programme to ensure that activities to reduce the
burden of TB among people living with HIV are implemented, including intensified case finding,
isoniazid preventive therapy, and infection control.
Strengthen multisectoral and community partnerships for TB

Recognizing the crucial role that community-based organizations and other civil society organizations
play in the provision of the full range of TB services, the NTLP will strengthen existing links with the
public and private sectors, civil society, NGOs, academia, research institutions, media, faith-based
organizations, and religious, traditional, civic and political leaders and communities, including the
traditional healers. During this NSP, a major focus will be to finalize and implement the advocacy,
communication, and social mobilization (ACSM) strategy and raise awareness of TB in communities
using print and electronic media in collaboration with the Department of Health Promotion,
Environment and Social Determinants and other stakeholders.
Improve management
The NTLP shall provide oversight of all interventions and ensure the requisite structure and human
capacity to implement, monitor, and evaluate the activities enshrined in the NSP at all levels of
the health care system. Activities will include training of staff, conducting training of trainers to
ensure a cascade system of training, strengthening the data collection system, and improving skills
in data analysis and use of data for programme monitoring and evaluation and decision-making.
Investments will be made in developing capacity for operational and implementation research in
line with the third pillar of the End TB Strategy, namely intensified research and innovation.
ix
SECTION ONE: BACKGROUND

1.1 Political and Administrative Structures and Economy
The Republic of Zambia is located in the southern part of the African continent. It covers approximately
752,612 km2 and is surrounded by eight countries, namely: Tanzania and the Democratic Republic of
Congo (DRC) in the north; Malawi and Mozambique in the east; Zimbabwe, Botswana, and Namibia
in the south; and Angola in the west. Administratively, the country is divided into 10 provinces and
104 districts. Out of the 10 provinces, Lusaka and Copperbelt provinces are predominantly urban,
while the rest are predominantly rural provinces.
With a per capita gross domestic product (GDP) of around US$1,844 in 2013, Zambia was initially
classified as a lower middle-income country; in 2014, it progressed to the Medium Human
Development category (per the United Nations Development Programme). In terms of performance,
Zambia’s annual GDP growth averaged 6.4 percent between 2005 and 2014 and inflation dropped
from 15.9 percent to 7.9 percent over the same period. Although Zambia has enjoyed economic gains
from the implementation of sound macro-economic policies and high foreign direct investment
that grew from less than US$200 million in 2000 to US$2,2 billion in 2014, large parts of population
have not shared in this overall improvement of national prosperity. Alongside great plenty for the 20
percent of Zambians who share more than half of the total national income, Zambia has pervasive
extreme poverty of around 60 percent in rural areas1. There are high income and gender inequalities,
joblessness (the unemployment rate is at 7.9 percent and underemployment at 10.2 percent),
and lack of necessities for many. In 2010, Zambia’s Gini coefficient stood at 0.65, indicating a huge
differential in wealth distribution, mainly due to variances between rural and urban areas. Poverty
levels in the rural areas are four times that in the urban areas2. Historically, the country’s economy
has been based on the copper mining industry, accounting for 95 percent of annual export earnings
and contributing 45 percent of government revenues during the decade following independence
(1965–1975). Zambia has a mixed economy consisting of a rural agricultural sector and a modern
urban sector that, geographically, follows the rail line. Currently, the construction sector contributes
14 percent of the GDP, agriculture contributes 9 percent, and the manufacturing and mining sectors
each contribute 8 percent (CSO, 2014).
In 2006, the Government of Zambia finalized the first long-term development plan that encompassed
the national vision for Zambia to become a prosperous middle-income country by 2030. Prior to
this, the development of the country was guided by successive medium-term development plans
covering 5-year periods, with the first National Development Plan covering the years 1966–1971.
Currently the country is operating under the seventh National Development Plan, covering 2017–
2021.
1.2 Demographic Characteristics of Zambia

Based on the results of the 2010 population census, the population was estimated at 16,212,000 for
the year 20153. The population of Zambia is expected to grow by an average of 2.7 percent annually
between 2011 and 2025. The population is young, with 50 percent of the total population being
children under the age of 15 years. Females comprise 51 percent of the total population. Zambia
is among the most urbanized countries in sub-Saharan Africa, with approximately 40.6 percent of
the population living in urban areas in 2011. Approximately 2.8 million people live in the capital city
of Lusaka, while Copperbelt Province has over 2.3 million people, accounting for 33 percent of the
population (see Figure 1). The life expectancy in 2016 was estimated at 52.5 years (50.8 years for men
and 54.1 for women)4.
1
Vision 2030: A Prosperous Middle-Income Nation by 2030. Republic of Zambia; 2006. Available at http://aprmzambia.org.zm/docs/2030vision.pdf.
2
United Nations Development Programme (UNDP). Millennium Development Goals Progress Report | Zambia | 2013. Lusaka: UNDP; 2013. Available at www.
zm.undp.org/content/zambia/en/home/library/mdg/zambia-mdgs-progress-report-2013/.
3
Zambia page. World Health Organization website. Available at http://who.int/countries/zmb/en/.
4
Zambia page. CIA World Factbook website. Available at https://www.cia.gov/library/publications/the-world-factbook/geos/za.html.
1
living in urban areas in 2011. Approximately 2.8 million people live in the capital city of Lusaka, while
Copperbelt Province has over 2.3 million people, accounting for 33 percent of the population (see Figure
1). The lifeNATIONAL
expectancy in 2016 was estimated at 52.5 years (50.8 years for men and 54.1 for women)4.
STRATEGIC PLAN FOR TUBERCULOSIS PREVENTION, CARE AND CONTROL (2017–2021)
Figure 1: Zambia’s population by provinces (2015 estimates)

Figure 1: Zambia’s population by provinces (2015 estimates)
According to the Demographic and Health Survey (DHS) 2013–20145, in all age groups, literacy
5
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for men were higher than for women. The total literacy level for men was 83 percent, against
68 percent for women. Literacy levels were also higher in urban areas (93 percent for men and 83 68 percent
for women.
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women) than in rural areas (73 percent for men and 54 percent for women).
1.3 Population Health Status in Zambia
The disease burden in Zambia is influenced mainly by the high prevalence of maternal, neonatal,
and child morbidity and mortality and by a high prevalence of communicable diseases. Major
communicable diseases include malaria, HIV/AIDS, TB, sexually transmitted infections (STIs), and
neglected tropical diseases (NTDs). Despite the recent improvements noted in health indicators,
maternal, neonatal, and child health problems continue to be a major cause of morbidity and
mortality.
4
The high levels of poverty in the country are reflected in the following nutritional indicators
Zambia page. CIA World Factbook website. Available at https://www.cia.gov/library/publications/the-world-
among children under five years of age: stunting 45 percent, underweight 15 percent, vitamin A
factbook/geos/za.html.
deficiency
5
54 percent,
Zambia Central Statisticaland anemia
Office 53 percent.
(CSO), Ministry of Health, University of Zambia, Tropical Diseases Research Centre,
The DHS Program/ICF International. Zambia Demographic and Health Survey 2013-14. Lusaka: CSO; 2015. Available at
https://dhsprogram.com/pubs/pdf/FR304/FR304.pdf.
Despite the predominance of communicable diseases, Zambia is facing a growing epidemic of
noncommunicable diseases (NCDs) such as mental illness, cancer, diabetes mellitus, hypertension,
and2 |oral
P a g health
e problems; for instance, the prevalence of hypertension in adults aged 25 years
and over was estimated at approximately 40 percent in 20086. Changing lifestyles, especially with
increasing affluence in the urban areas, is a likely contributor to this change. Moreover, as the
antiretroviral therapy (ART) programme matures and an increasing number of people are on long-
term treatment, it is likely that a proportion of NCDs may be because of side effects of long-term ART.
The leading causes of disease burden in terms of disability-adjusted life years are HIV, TB, and malaria,
followed by the other infectious diseases, then by maternal, neonatal, and nutritional issues and
injuries7. Zambia is a high HIV burden country; the prevalence of HIV infection in the adult population
was estimated at nearly 13.2 percent, the number of people living with HIV (PLHIV) at 1.2 million, and
the number of HIV-related deaths at 19,800 per year in 20158.
5
Zambia Central Statistical Office (CSO), Ministry of Health, University of Zambia, Tropical Diseases Research Centre, The DHS Program/ICF International.
Zambia Demographic and Health Survey 2013-14. Lusaka: CSO; 2015. Available at https://dhsprogram.com/pubs/pdf/FR304/FR304.pdf.
6
World Health Organization (WHO). Zambia: WHO Statistical Profile. Geneva: WHO; 2015. Available at http://www.who.int/gho/countries/zmb.pdf.
7
Ibid.
8
2
The death rate decreased from 27.4 per 1,000 population in 20009 to 12.4 per 1,000 population in
201610. HIV/AIDS is the leading cause of death (24.5 percent in 2012), followed by lower respiratory
infections, including TB (7.5 percent), and malaria (7.2 percent). Ischemic heart disease accounts for a
small proportion of deaths (2.4 percent in 2012)11. The under-five mortality rate per 1,000 live births
declined from 577 deaths in 1990 to 64 in 2015, and the maternal mortality rate per 100,000 live
births decreased from 580 deaths in 1990 to 224 in 2015.
1.4 Health Care System in Zambia

Health services are provided by the following main players: the public health sector with government
owned and run facilities, faith-based not-for-profit providers, mine health facilities, private-for-profit
providers, and traditional practitioners.
1.4.1 Public health sector
The public health sector provides promotive, preventive, curative, and rehabilitative health services
to the population. Public health delivery is structured as a three-tier pyramidal referral system with
primary health care (health posts, health centres, and district hospitals), secondary health care
(provincial referral hospitals), and tertiary health care (teaching hospitals). There are approximately
2,000 health facilities in the country.
1.4.1.1 Health posts
Health posts are at the lowest level of the Zambian health care system. Each health post caters for a
catchment population of approximately 3,500 persons in rural areas and 1,000 to 7,000 people in an
urban setting. These health posts are set up within a five-km radius for sparsely populated areas. The
types of health services offered at this level are preventive, curative, promotive, and rehabilitative
care. As highlighted above, they refer patients and clients to health centres.
1.4.1.2 Health centres
There are two types of health centres in the national health care delivery system. These are urban
health centres, which serve a catchment population of between 30,000 to 50,000 people, and rural
health centres, which serve a population of approximately 10,000 people. By the end of 2010, there
were 436 urban health centres and 1,060 rural health centres throughout the country. These health
centres offer preventive, promotive, curative, and rehabilitative care services.
1.4.1.3 First-level referral hospitals
First-level hospitals, also referred to as district hospitals, are found at district level. They are the third
largest levels of care after the second- and third-level referral hospitals. These first-level referral
hospitals serve a population of 80,000 to 200,000 people and provide services such as medical,
surgical, obstetric, diagnostic, and all clinical services in support of health centre referrals. Currently,
there are 84 first-level referral hospitals in the country.
1.4.1.4 Second-level referral hospitals
Second-level hospitals, also referred to as provincial or general hospitals, are found at provincial
level. These hospitals are intended to cater for a catchment population of 200,000 to 800,000 people,
with services in internal medicine, general surgery, pediatrics, obstetrics and gynecology, dental
care, psychiatry, and intensive care. These hospitals also serve as referral hospitals for first-level
institutions, including the provision of technical back-up and training functions. Currently, there are
21 second-level hospitals in the country.
1.4.1.5 Third-level referral hospitals
Third-level hospitals, also known as specialist or tertiary hospitals, are the highest referral hospitals
in Zambia. These hospitals cater for a catchment population of approximately 800,000 and above,
and have subspecializations in internal medicine, surgery, pediatrics, obstetrics and gynecology,
9
African Health Observatory (AHO), World Health Organization (WHO) Regional Office for Africa. ZAMBIA: Factsheets of Health Statistics 2016. Brazzaville:
WHO; 2016. Available at http://www.aho.afro.who.int/profiles_information/images/7/70/Zambia-Statistical_Factsheet.pdf
10
11
World Health Organization (WHO). Zambia: WHO Statistical Profile. Geneva: WHO; 2015. Available at http://www.who.int/gho/countries/zmb.pdf.
3
intensive care, psychiatry, training, and research. All complicated cases not attended to at second-
level hospitals are referred to third-level hospitals. Currently, there are six third-level hospitals in the
country.
The Ministry of Health (MOH) regularly compiles a list of health facilities showing the number and
type of facilities in each province (see Table 1), the services offered, the sources of power and water,
the availability of the electronic health information and management systems, and the type of
communication available.
In addition to the health facilities under the MOH, the Ministry of Home Affairs, Ministry of Mines,
and Ministry of Defense have health institutions that provide health services primarily for their own
staff, but which can also be accessed by non-staff members at a minimal fee. According to recent
surveys12,13, 14 about 90 percent of patients seek care in facilities owned and run by the government.
1.4.2 Faith-based not-for-profit facilities
Catholic and Protestant Christian missionary health workers from church health institutions (CHIs)
formed the Churches Health Association of Zambia (CHAZ) in 1970. The main purpose of establishing
CHAZ was to improve the overall organizational effectiveness of the CHIs and church-based
community organizations involved in health service delivery in Zambia. CHAZ has 152 institutions:
36 hospitals (11 of which have training schools), 84 rural health centres, and 32 community-based
organizations (CBOs). Together these faith-based health institutions account for 30 percent of the
total national health care and more than 50 percent of rural health care services (percentages are
based on the population served and not on the number of health facilities and bed count). The
majority of these health institutions are located in rural and hard-to-reach areas throughout the ten
administrative provinces of Zambia and serve the poor and the underserved. Faith-based health
facilities also attend to patients from outside of their own catchment areas, districts, and provinces.
CHAZ and its member units work closely with the Government of the Republic of Zambia (GRZ)
through the Ministry of Health and within the National Health Framework. A memorandum of
understanding (MoU) guides the collaboration between government and CHAZ. Through this MoU,
the government has committed to paying salaries of health workers in church health facilities,
providing at least 75 percent of the operational costs and essential medicines for these facilities. In
this regard, the government is CHAZ’s largest partner. CHAZ has a number of cooperating partners
who support programmes that mitigate diseases of public health concern. CHAZ’s collaboration with
the government is strengthened through participation in technical working groups (TWGs), sector
advisory groups, and the Annual Cooperating Partners Consultative Meetings.
CHAZ has an unbroken track record of being a Principal Recipient of the Global Fund to Fight AIDS,
Tuberculosis and Malaria (“the Global Fund”) in Zambia since May 2003. Under this arrangement,
CHAZ is mandated to sub-grant resources to Zambian faith-based organizations (FBOs) for HIV/AIDS,
TB, and malaria. To date, CHAZ has provided funding to over 500 FBOs for these three diseases.
1.4.3 Private, for-profit facilities
The private health sector in Zambia consists of both private hospitals and private clinics. Private, for-
profit facilities are estimated to provide care to approximately 3 percent of the population.
1.4.4 Mine health facilities
Several of the mining institutions have hospitals that provide the full range of curative and preventive
care to their staff and contractors, usually situated within their place of operation. Some of these
mine-owned hospitals also serve as private hospitals with services available to the public for a fee.
Some of the mining institutions also have primary health clinics that mainly provide care to their staff
as well as site clinics that mainly cater to emergencies and basic health care.
12
Central Statistics Office (CSO). Living Conditions Monitoring Survey Report 2010. Lusaka: CSO, Zambia; 2012.
13
Central Statistics Office (CSO). Zambia Household Expenditure and Utilisation Survey 2014. Lusaka: CSO, Zambia; 2014.
14
20Masiye F, Kaonga O, Kirigia JM. Does user fee removal policy provide financial protection from catastrophic health care payments? Evidence from Zam-
bia. PLoS One. 2016;11(1):e0146508.
4
1.4.5 Traditional health care providers

The GRZ recognizes traditional and alternative medicine providers as part of the health sector in
Zambia and thus instituted various national policies governing this health sector. The Traditional
Healers Practitioners’ Association of Zambia (THPAZ), established in 1978, serves as the national body
for traditional healers and reviews and registers these practitioners for licensing. The organization has
about 40,000 members nationwide. There are still people who seek medical advice from traditional/
alternative medicine prior to seeking care in orthodox health facilities15. TPHAZ has collaborated
with the MOH in various areas, most notably in HIV, and members of this health sector have received
training in areas such as referral practices and health promotion.
1.4.6 Private pharmacies and dispensaries
Although the data show clearly that the public sector is the largest health care provider, many people
choose self-medication, most of which is bought over-the-counter from drugs stores or pharmacies.
Table 1: Number of health facilities by province and ownership in 2012
Province Number of health facilities (HF) by ownership

Government HFs Faith-based HFs Private HFs Total HFs
Central 185 9 10 204
Copperbelt 172 10 68 250
Eastern 193 13 0 206
Luapula 138 6 1 145
Lusaka 126 13 155 294
Muchinga 89 7 3 99
Northern 139 6 3 148
North-Western 143 18 2 163
Southern 227 18 8 253
Western 178 16 0 194
TOTAL 1,590 116 250 1,956
Source: Ministry of Health (2013). The 2012 list of health facilities in Zambia.
1.5 Health Sector Financing

The public health sector is funded by government resources as well as by external sources through
donor support (a combination of multilateral and bilateral funds and funds from NGOs). Government
expenditure on health in 2013 was US$54 per capita, accounting for 58 percent of the total health
expenditure; external sources provided 35 percent. In 2014, the total health expenditure per capita
accounted for 5 percent of GDP. In 2017, the health budget increased to 13 percent, which is closer to attaining the 15 percent recommended by the
Abuja Declaration 2001.
More than 75 percent of the available funds for HIV are from external resources. GRZ
funding for HIV accounts for 20 percent of the GRZ health budget. The abolition of user fees between
the years 2006 to 2012 reduced the out-of-pocket expenditure from 38 percent in prior years. In
2015, out-of-pocket expenses still amounted to 28 percent of the total health expenditure.
1.6 Health Sector Reform and Policy Changes

The health sector in Zambia has undergone a series of changes since 1993 when the GRZ implemented
policy and structural changes with the aim of increasing efficiency and quality of health services for
all Zambians. The vision underpinning the health sector reforms was to “provide the people of Zambia
with equity of access to cost-effective, quality health care as close to the family as possible”. An underlying
principle of the reforms was decentralization of health care delivery through the delegation of key
management responsibilities from provincial to district and hospital levels. National decentralization
also aimed at shifting resources from central to operational levels, where health care delivery services
are conducted.
15
World Health Organization (WHO). Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review. Geneva: WHO; 2001.
Available at http://apps.who.int/medicinedocs/en/d/Jh2943e/.
5
Over the last 23 years, various iterations of health sector reforms have been implemented that
have emphasized the importance of decentralization of services with community participation
in the management of health services and the need for a well-motivated and remunerated work
force. These included the formation of the Central Board of Health (CBoH) from 1995 to 2007,
and realignment of the health sector to include primary health care (PHC) under the Ministry of
Community Development Mother and Child Health from 2012 to 2016.
The policy direction of the current restructuring of the health system, begun in 2016, hinges on
strengthening the health systems and improving health service delivery with PHC as the vehicle
for this process and leveraging on universal health coverage. This process resulted in the creation
of a new department within the MOH, namely Health Promotion, Environmental Health, and Social
Determinants. At the heart of the new vision of the health system is health promotion, disease
prevention, investments in health and wellness, delivery of information to the community, engaging
other ministries to address water and sanitation problems, and improving the nutritional status of
the population. These overarching policies will lead to overall improvement in health with a focus on
the poor and most at-risk population, thus decongesting the hospitals and all other health facilities.
To promote health and reduce health inequalities, the following five pillars are guiding the MOH: a)
service delivery, b) human resources for health, c) health care financing, d) information management,
and e) leadership and governance.
In the last 10 years, several health-related policies and strategies have been developed to guide the
functioning of the health system, such as the Community Health Worker (CHW) Strategy (2009), the
National Health Policy (2012) (which replaced the 1992 NHSP document), the National Medicines
Policy (2012), and the Health Research Policy (2013). In tandem with the National Development
Plans, successive five-year National Health Strategic Plans (NHSP), have guided the MOH operations
while the National AIDS Strategic Framework (NASF) has guided the national response to HIV/AIDS.
The NSP (2017–2021) is aligned to the 2017–2021 NHSP.
1.7 HIV Treatment Programme

Though a decrease in HIV prevalence has been recorded in Zambia in the last 16 years, the prevalence
remains high at 13.2 percent among men and women aged 15–49 years. The highest rates of infection
were found in the Copperbelt (18.2 percent), Lusaka (16.3 percent), and Western (15.4 percent)
provinces in the 2013–2014 Zambia DHS. The prevalence is higher among women (15 percent) than
among men (11 percent) aged 15–49.
The GRZ introduced the HIV treatment programme in the public sector in 2000 and with support
from partners such as the World Bank, the Global Fund, and the US President’s Emergency Plan for
AIDS Relief (PEPFAR). The HIV treatment programme has been scaled up, and as of April 2016 over
750,000 individuals were on ART in 570 treatment sites.
6
SECTION TWO: TUBERCULOSIS IN ZAMBIA

2.1 Background
The Zambia National TB Programme was established in 1964 as a programme within the Ministry of
Health. The TB programme functioned as a stand-alone programme until 1980, when it was linked
with the Leprosy Control Programme to form the National Tuberculosis and Leprosy Programme
(NTLP). Under this structural arrangement, TB/leprosy officers were appointed in the Central Unit as
well as at the provincial and district levels, with the higher levels providing technical support and
supervision for the lower levels, and case finding, diagnosis, and treatment occurring at the health
facility and community levels. Case notification and treatment outcome data flow upwards from
the health facility through the district and provincial levels, thus allowing for aggregation of data
at all levels. Unlike most other treatment programmes, outcomes of TB treatment for the individual
patients are tracked and reported and the aggregated data at district, provincial, and national levels
are used as a measure of the quality of the programme through the quarterly cohort analysis.
Zambia adopted the directly observed treatment, short course (DOTS) strategy following the
successful pilot programme in Ndola of using community-based organizations (CBOs) to provide
supervision and support for treatment. The TB programme was combined with the AIDS (acquired
immunodeficiency syndrome) and STI programmes in 1993 to form the National HIV/AIDS/STI/TB
and Leprosy Programme as part of the health sector reform process and in order to address the
dual epidemics of HIV and TB. Full integration at the primary health care level, with abolition of the
TB/leprosy positions at district and provincial levels in 1997, resulted in a situation where the lack
of a clear system for reporting case notifications and treatment outcomes led to loss of national-
level data on TB for 1997 and 1998 (as seen in Figure 2). In 1999, a National TB Working Group was
constituted by the MOH to provide technical assistance through the Central Board of Health (CBoH)
to strengthen the decentralized TB control activities. Following strengthening of the Central TB Unit
in 2003, the TB Working Group transitioned to an advisory body to the National AIDS/STI/TB Council
(NAC) in all matters pertaining to prevention and control of TB/leprosy.
Currently, the NTLP falls under the Department of Public Health of the MOH and is responsible for
the overall coordination of TB and leprosy activities in the country. The Central Unit establishment
consists of a TB specialist with four chief TB officers (MDR-TB, public health, logistics, and TB/HIV), a
senior TB officer, and a monitoring and evaluation (M&E) officer. In 2014, a TB technical advisor was
seconded to the NTLP with support from the United States Agency for International Development
(USAID). Additional staff are allocated to the NTLP through a Cooperating Agreement between the
MOH and the US Centers for Disease Control and Prevention (CDC). At the provincial level, the TB
programme falls under the public health specialist; there is no TB-specific position, and the provincial
TB focal person is supported through the Global Fund grants. At the district level, TB is managed by
a GRZ-supported district TB/leprosy officer. At the health facility level, TB patients are seen within
the general health clinic, usually at a designated TB corner, and managed by health staff who tend
to rotate through the different departments of the clinic. Where available, community volunteers
provide links between the TB programme and the community and provide treatment support for TB
patients as well as follow-up of cases and contacts to varying extents. Support for the community
health volunteers varies across the country and is often dependent on funds from partners/donors.
2.2 Partner Coordination

To ensure coordination between the NTLP and the donors and organizations that provide TB services,
various subcommittees were formed under the TB/HIV Working Group that was established in 2005.
Quarterly working group meetings provide a forum for the NTLP to meet with all partners providing
support to TB. In addition, the NTLP holds review meetings at the provincial and district levels at
which all partners are invited to attend and make presentations. The review meetings are held
biannually at the national level and quarterly at the provincial and district levels. In 2015, the Ministry
of Health realigned the structure of the TB Working Group to cover all aspects of TB prevention,
care, and treatment and created subcommittees with membership that includes representation by
all organizations and institutions working in TB in Zambia. Membership of the TB Working Group
includes other relevant departments and programmes linked to TB within the MOH, such as the
HIV and AIDS programme and the Health Promotion Unit, the armed medical forces, CHAZ, other
partners working in TB, donors, and civil society organizations (CSOs).
7
2.3 The Burden of TB Disease in Zambia

TB continues to rank among the major causes of morbidity and is one of the top ten causes of
mortality in Zambia. From 1964, when the NTLP was established, records indicate that the notification
rate remained constant at around 100/100,000 until the mid-1980, when case notification increased
significantly; much of this increase has been attributed to HIV co-infection. Other factors such as
an increasing population, increasing urbanization with consequent overcrowding, exposure to
silica dust in mining settings, and increasing poverty have also contributed to the increase in TB
notifications in the last 25 years. The TB case notification rate peaked at 524/100,000 in 2004, after
which there was a steady decline. The TB notification rate for all forms of TB was 388/100,000 in 2013
and 237/100,000 in 2015. Figure 2 shows the trend in TB notifications between 1990 and 2015. (As
mentioned earlier, the lack of a clear system for reporting case notifications and treatment outcomes
led to loss of national-level data on TB for 1997 and 1998.)
Figure 2: Total new and relapse TB cases, 1990–2015
Source: Raguenaud, M (2016). Evaluation of TB surveillance and TB epidemiology analysis in Zambia-mission report.
2.3.1
2.3.1Age
Ageand
andgender
genderdistribution
distributionofof
notified cases
notified cases
As
As shown
shownininFigure
Figure33and
andFigure
Figure4,4,thethe
highest notification
highest ratesrates
notification are in
aretheinage
thegroup 25–5425–54
age group years. years.
There
are more
There aremales
morethan females
males in all age
than females in categories except the
all age categories 1–14the
except age1–14
group. ageThis is consistent
group. with the
This is consistent
findings of the national TB prevalence survey.
with the findings of the national TB prevalence survey.
Figure 3:
Figure 3: TB
TBnotifications
notifications disaggregated byage,
disaggregated by age,2011–2015
2011–2015
Source:
Source:Raguenaud,
Raguenaud,MM(2016).
(2016).
Figure 4: TB notifications disaggregated by gender, 2011–2015
30,000
25,000
20,000
15,000
0( 14!M
10,000
5,000 0( 14!F
8
0 15+!!M
2011 2012 2013 2014 2015
Source: Raguenaud, M (2016).
Figure 4: TB
Figure TBnotifications
notifications disaggregated
disaggregatedby by
gender, 2011–2015
gender, 2011–2015
30,000
25,000
20,000
15,000
0( 14!M
10,000
5,000 0( 14!F
0 15+!!M
2011 2012 2013 2014 2015
0( 14!M 2,131 1,847 1,726 1,590 1,354 15+!!F
0( 14!F 1,965 1,687 1,623 1,425 1,164
15+!!M 27,018 25,636 25,766 24,760 24,903
15+!!F 17,480 16,099 16,678 14,941 14,167
2.3.2 Distribution of TB cases by disease type

2.3.2 Distribution of TB cases by disease type
Pulmonary TB (PTB) cases account for the majority of the cases notified by the NTLP in 2014; 76
Pulmonary
percent TB (PTB)
of new cases PTB,
cases were account
withfor the majority of TB
extra-pulmonary the cases
cases making
notified up
by 24
the percent
NTLP in(Figure
2014; 5).
76
percent of treated
Previously new cases were
cases PTB, with
(excluding extra-pulmonary
relapses) accounted for TB11cases making
percent of allup 24 of
forms percent (Figure
TB in this 5).
period.
Previously treated cases (excluding relapses) accounted for 11 percent of all forms of TB in this period.
Zambia is one of the countries with very high rates of cases that are clinically diagnosed instead
of being isbacteriologically
Zambia confirmed.
one of the countries In 2014,
with very only 41
high rates percent
of cases thatofare
theclinically
new anddiagnosed
relapse cases were
instead of
bacteriologically confirmed, while 51 percent were clinically diagnosed. In contrast, for 2015 the
being bacteriologically confirmed. In 2014, only 41 percent of the new and relapse cases were
proportion of the new and relapse cases that were bacteriologically proven had increased to 49
bacteriologically
percent, confirmed,
most likely whileof51thepercent
a reflection were of
expansion clinically diagnosed.
Xpert MTB/RIF In contrast,
testing. Using thefor 2015 the
previous
proportionof
definition ofcases
the new
as and relapse
either smearcases that were
negative bacteriologically
or smear proven
positive, from hadtoincreased
2011 2015 the to proportion
49 percent,
most
of likely a reflection
smear-positive cases of the expansion
ranged of Xpert(2011)
from 29 percent MTB/RIF to 35testing.
percent Using the smear-negative
(2015), previous definition
casesof
ranged from 48 percent (2011) to 42 percent (2015), and extra-pulmonary (EP) TB cases
cases as either smear negative or smear positive, from 2011 to 2015 the proportion of smear-positive ranged from
24 to 22
cases percent
ranged from(see Figure 5).
29 percent (2011) to 35 percent (2015), smear-negative cases ranged from 48 percent
Figure 5: Proportion of notified new cases by type of TB disease, 2011–2015
11 | P a g e
2.3.3 Childhood TB
Between 2011 and 2015, notified TB cases in children ranged from 6 to 8 percent of all cases, which
is below the World Health Organization (WHO) recommended target of 15 percent. Figure 6 shows
the absolute number of cases of TB in children disaggregated by gender and for age groups 0–4 and
5–14 years.
9
below the World Health Organization (WHO) recommended target of 15 percent. Figure 6 shows the
absolute number of cases of TB in children disaggregated by gender and for age groups 0–4 and 5–14
years.
Figure
Figure6:
6:Childhood
ChildhoodTB
TBnotifications byby
notifications age and
age gender
and gender
1,400
1,200
Number'TB'cases
1,000
800
600
400
200
0
2011 2012 2013 2014 2015
0(4!M 998 834 743 678 485
0(4!F 814 624 616 541 424
5(14!years!M 1,133 1,013 983 912 869
5(14!years!F 1,151 1,063 1,007 884 740
2.3.4 National TB prevalence survey

2.3.4
In National
order TB prevalence
to understand survey
the true burden of TB, in 2013–2014 Zambia conducted its first-
ever nationally representative TB prevalence survey. The key finding of the survey was that
In order to understand the true burden of TB, in 2013–2014 Zambia conducted its first-ever nationally
the country has a higher TB prevalence than previously estimated by WHO. The prevalence
representative
of TB prevalence
bacteriologically confirmedsurvey.
TB wasThe key
638 finding of the survey
per 100,000 was that
population the country
(95% has a 16higher
CI 502–774)
.TB
TB prevalence
prevalence than
of allpreviously estimated
forms of TB by was
in all ages WHO. 455The
perprevalence of bacteriologically
100,000 population. According confirmed
to WHO, TB
Zambia is now one of the 30 countries in the world with high TB and high TB/HIV burden. The burden
of TB and TB/HIV in Zambia are among the highest in the WHO African region.
There were wide variations in the burden of TB by location, gender, social economic status, and age
category in the national prevalence survey:
• The prevalence of TB was two to three times higher in urban than in rural areas; this was true for
12 | smear,
P a g e culture, and bacteriologically confirmed TB.
• By province, Copperbelt and Lusaka recorded higher prevalence of TB, at 1,211/100,000

population (95% CI 757–1665) and 932/100,000 population (95% CI 670–1195), respectively.
Central, North-Western, and Western provinces had a prevalence ranging from 400–600 per
100,000 population; the lowest prevalence was about 200 TB cases per 100,000 population in
Eastern and Muchinga provinces.
• The burden of TB was higher in males than in females, with a ratio of 2:1 for all forms.
• The burden of TB in urban areas was generally two times higher among the lowest wealth
quintiles compared to the higher wealth quintiles. In rural areas, however, the burden of TB was
similar across different socioeconomic groups.
• Fifty-one percent of TB cases were diagnosed between the ages 25–44 years, with the peak
being between 35–44 years (Figure 3). These individuals are in their prime working years, which
points to Zambia’s TB burden having potential economic consequences on both the micro-
and macroeconomic level. Of concern is the increased high prevalence of symptomatic non-
tuberculous mycobacteria (NTM) with wide geographical variations.
• The prevalence of TB is five times higher in HIV-positive individuals than in HIV-negative ones.
16
MOH (2014). Zambia National Tuberculosis Prevalence Survey report
10
2.3.5 TB case notification

According to WHO only approximately 60 percent of TB cases were detected and notified in 2015;
the estimated number of incident TB cases in Zambia was 63,000 but the country only notified
36,741 new and relapse TB cases, indicating that there are many undetected cases in the community.
This is clearly illustrated by a comparison of the difference between the TB cases notified from the
Copperbelt in the national prevalence survey (41 percent) compared to the cases notified to the TB
programme (20 percent) through routine notifications (Figure 7).
Figure 7: Comparison of geographical distribution of prevalent and notified TB cases, 2014
Distribution of TB prevalent cases Distribution of TB cases notified

(from prevalence survey) (new and relapse)
other
provinces
23% Lusaka other Lusaka
36% provinces 37%
43%
Copperbelt
41%
Copperbelt
20%
A possible cause for the discrepancy between the notified cases and the prevalent cases is under-
diagnosis due to inadequate diagnostic facilities in the Copperbelt compared to Lusaka. However,
the 2016 epidemiological assessment indicates that in the Copperbelt, the coverage of TB diagnostic
facilities is higher than Lusaka, with a distribution of 2.24 diagnostic centres for 100,000 population
compared to 1.44/100,000 for Lusaka. Other possible reasons for this discrepancy could include
differences in health-seeking behavior and levels of knowledge of TB, as well as higher rates of TB in
population groups that are not reached by the public health services, such as mineworkers and ex-
miners and their families. In addition, the Copperbelt has the highest HIV rates at 18.2 percent, and
this may contribute to the higher prevalence rate of TB.
Although low TB case notification is widely attributed to under-diagnosis, under-reporting cannot
completely be ruled out because there are only about 370 centres where TB patients are diagnosed
and notified whereas TB patients receive treatment in more 2,000 health facilities. Thus, some patients
may be on TB treatment but not reported to the national level.
2.4 Programme Performance

2.4.1 Treatment outcomes
In the decade of 2003–2014, the NTLP recorded an improvement in treatment outcomes for TB
patients, with the treatment success rate increasing from 81.5 percent in 2003 to 85 percent in 2014
and the death rate declining below 5 percent in 2014.
Figure 8 shows the treatment success rate for new and relapse cases for the years 2010 through
2014 by province, illustrating the fact that, for most of the provinces, treatment success is equal to
or above 85 percent.
11
Figure 8: Treatment success rate for new and relapse notified TB cases (all forms) per province,
2010–2014
Figure
Figure 8:
8: Treatment
Treatment success rate for new
new and
and relapse
relapse notified
notifiedTB
TBcases
cases(all
(allforms)
forms)per
perprovince,
province,
2010–2014
2010–2014
Source: National tuberculosis and leposy Programme routine data

Source: National
Source: National tuberculosis
tuberculosis and leposy
and leposy Programme Programme
routine data routine data
2.4.2 Unfavourabletreatment
2.4.2 Unfavourable treatment outcomes
outcomes
2.4.2 Unfavourable treatment outcomes
As
As shown
shown ininFigure
Figure 9 below,
9 below, between
between 2011
2011 and andthe
2015, 2015,
deaththe
ratedeath rateconstant
remained remained constant
around around
6 percent,
As shown
failureinrate
6thepercent, Figure
the 91 below,
failure
was rate between
was
percent, 2011
1 percent,
the loss andthe
2015,
to follow-up the
loss todeath
(LTFU) raterate
wasremained
follow-up 4(LTFU) constant
percent,rate the around
andwas 6out
percent,
4 percent,
transfer and the
rate
transfer
the
wasfailure out rate
rate
5 percent. waswas 5 percent.
1 percent, the loss to follow-up (LTFU) rate was 4 percent, and the transfer out rate
was 5 percent.
Figure
Figure 9: 9: Unfavourable treatment
Unfavourable treatment outcomes,
outcomes, 2011–2015
2011–2015
Figure 9: Unfavourable treatment outcomes, 2011–2015
TREATMENT'OUTCOME
7%
TREATMENT'OUTCOME
6%
7%
5%
6%
percent
4%
5%
3%
percent
4%
2%
3%
1%
2%
0%
1% 2011 2012 2013 2014 2015
DIED 0% 6% 6% 6% 6% 6%
2011 2012 2013 2014 2015
FAILURE 1% 0% 1% 1% 1%
DIED 6% 6% 6% 6% 6%
LTFU 4% 4% 4% 4% 4%
FAILURE 1% 0% 1% 1% 1%
TRANSFER!OUT 5% 5% 6% 5% 5%
LTFU 4% 4% 4% 4% 4%
Source:
Source: TRANSFER!OUT
National tuberculosis
National tuberculosis 5%
and leposy Programme
and routine
leposy 5%
data
Programme routine 6%
data 5% 5%
2.4.3 TB/HIV activities

Source: National tuberculosis and leposy Programme routine data
2.4.3 TB/HIV TB/HIV
Collaborative activities
activities were implemented by the NTLP from 2005 with a focus on HIV testing,
provision
Collaborativeof cotrimoxazole
TB/HIV activitiespreventive therapy (CPT)
were implemented andNTLP
by the ART for
fromTB2005
and HIV
with co-infected patients,
a focus on HIV
2.4.3
and TB/HIV activities
testing, provision of cotrimoxazole preventive therapy (CPT) and ART for TB and HIV co-infected to
formation of the National TB/HIV Coordinating Body. The WHO-recommended measures
reduce
patients,the
andburden
Collaborative formation
TB/HIV ofof
HIVtheamong
National
activities wereTB patients
TB/HIV were bysuccessfully
Coordinating
implemented theBody.
NTLPThe implemented.
2005 with In
WHO-recommended
from a 2015, 95 HIV
percent
measures
focus on
of TB patients
to reduce were
the burden tested for HIV and, of these, 61 percent were TB/HIV co-infected, percent of of
92 percent
testing, provision of of HIV among TB
cotrimoxazole patients were
preventive successfully
therapy (CPT) and implemented.
ART for TBInand 2015, 95 co-infected
HIV
the HIV-positive
TB patients were
TB patients
testedoffor
were started on CPT, and 76 percent were initiated on ART. Figure 10
patients,
illustratesand formation
the theHIV
same information
and, of
National these, 61
TB/HIV
in absolute
percent were
Coordinating
numbers.
TB/HIV
Body. co-infected, 92 percent
The WHO-recommended of the
measures
HIV-positive
to TB patients
reduce the burden of HIVwere
amongstarted on CPT,were
TB patients andsuccessfully
76 percent implemented.
were initiated In
on2015,
ART.95Figure
percent10of
illustrates the same information in absolute numbers.
TB patients were tested for HIV and, of these, 61 percent were TB/HIV co-infected, 92 percent of the
HIV-positive TB patients were started on CPT, and 76 percent were initiated on ART. Figure 10
illustrates
15 | P a g ethe same information in absolute numbers.
15 | P a g e
12
Figure 10: TB/HIV collaborative activities, 2009–2015

Figure 10: TB/HIV collaborative activities, 2009–2015
TB/HIV'COLLABORATIVE'ACTIVITIES'2009@2015
45,000
40,000
35,000
30,000
NUMBER
25,000
20,000
15,000
10,000
5,000
0
2009 2010 2011 2012 2013 2014 2015
Number!tested! 32,153 40,704 41,701 39,543 40,916 39,763 39,464
Number!HIV+ 21,442 26,571 26,737 24,330 25,305 24,198 24,116
Number!on!CPT 13,970 19,845 23,144 22,614 23,636 21,929 22,225
Number!on!ART! 9,325 12,646 14,213 14,471 16,824 17,611 18,381
Abbreviations: ART, antiretroviral therapy; CPT, cotrimoxazole preventive therapy

Abbreviations: ART, antiretroviral therapy; CPT, cotrimoxazole preventive therapy
Source: NTLP
Source: NTLPRoutine
Routine Data
Data
The
Theimplementation
implementation of of measures
measurestotoreduce
reducethetheburden
burdenofofTB
TB among
among people living with
people living with HIV/AIDS
HIV/AIDS(PLHIV)
has been has
(PLHIV) much beenslower. Intensified
much slower. TB caseTB
Intensified finding (ICF) is(ICF)
case finding included as a routine
is included procedure
as a routine for PLHIV
procedure
attending
for PLHIV attending HIV care and treatment centres, and guidelines for the use of isoniazid preventivetherapy
HIV care and treatment centres, and guidelines for the use of isoniazid preventive
(IPT) and(IPT)
therapy TB infection
and TBcontrol (IC) control
infection have been (IC)developed
have beenand produced.
developed andBarriers to implementation
produced. Barriers to of
ICF and IPT include
implementation of ICFdelays
and IPTin diagnosis and low
include delays yield ofand
in diagnosis results. To address
low yield thisTo
of results. challenge, the NTLP
address this
began the roll-out of Xpert MTB/RIF testing in 2013. Currently there are
challenge, the NTLP began the roll-out of Xpert MTB/RIF testing in 2013. Currently there are 69 69 GeneXpert machines
installed in health facilities in Zambia. Copperbelt Province has the highest number (11) of GeneXpert
GeneXpert machines installed in health facilities in Zambia. Copperbelt Province has the highest
machines. Other reasons for the slow rate of implementation of IPT noted during a recent programme
number (11) of GeneXpert machines. Other reasons for the slow rate of implementation of IPT noted
assessment include lack of single-dose isoniazid and lack of clarity on how to select patients for IPT.
during a recent programme assessment include lack of single-dose isoniazid and lack of clarity on how
Other reasons noted by health workers during this assessment were the feeling that IPT increased the
to select
pill burdenpatients for IPT.
(as many Other
PLHIV reasons
were notedon
already byART,
health workers
which during this
improved assessment
immunity) were
and, the feeling
because it was not
that IPT increased
provided by directlytheobserved
pill burdentreatment
(as many PLHIV werehad
(DOT), also already on ART, which
the potential improveddrug
to exacerbate immunity)
resistance17.
and, because it was not provided by directly observed treatment (DOT), also had the potential to
exacerbate drug resistance.17
HIV and TB in Zambia share common epidemiological patterns, which present opportunities for joint
programming. For instance,
HIV and TB in Zambia there are
share common geographicalpatterns,
epidemiological similarities.
whichThe provinces
present with the
opportunities forhighest
joint HIV
prevalence
programming. rates
Forare also the
instance, provinces
there with thesimilarities.
are geographical highest TBThe case notifications,
provinces namely
with the highestCopperbelt,
HIV
Lusaka, andrates
prevalence Southern. Additionally,
are also the provinces there arethe
with commonalities
highest TB casein the age distribution.
notifications, namelyThe age group with
Copperbelt,
the highest
Lusaka, HIV prevalence
and Southern. is adults
Additionally, aged
there 15–49 years (women
are commonalities in the age16.1 percent The
distribution. andage
men 12.3with
group percent)18
,the
and mostHIV
highest TB notifications are highest
prevalence is adults in this
aged 15–49 age
years group.16.1
(women Thepercent
peaksandfor men
TB notification
12.3 percent)correlate
18
,
with those for HIV prevalence in the 33–45 age group. Finally, TB/HIV co-infection is high
and most TB notifications are highest in this age group. The peaks for TB notification correlate with in Zambia.
In 2015, 61 percent of TB patients who were tested for HIV were found to be infected with HIV19
those for HIV prevalence in the 33–45 age group. Finally, TB/HIV co-infection is high in Zambia. In
. The TB prevalence rate in PLHIV is unknown. Though HIV testing of TB patients is 95 percent, TB
2015, 61 percent of TB patients who were tested for HIV were found to be infected with HIV19. The
treatment outcomes for the TB/HIV co-infected patients are not routinely collected and reported
TB prevalence rate in PLHIV is unknown. Though HIV testing of TB patients is 95 percent, TB
separatelyUni.
2.5 Drug-Resistant TB
17
TB Technical Work group meeting-2016
The
18 NTLP carried out a drug resistance survey (DRS) in 2008; the results indicated that the prevalence
MOH (2007). Demographic and Health Survey
of
19 any drug resistance was 9.8 percent among new TB cases with no history of prior treatment with anti-
NTLP annual data 2016
TB drugs, and that of multi-drug resistant TB (MDR-TB) was 1.2 percent. According to the WHO 201620
the estimated MDR/rifampicin-resistant (RR)-TB prevalence among new and previously treated
TB
16 |patients
P a g e was 1.1 percent and 18 percent, respectively. Following approval by the Green Light
Committee (GLC) in 2009, the NTLP began implementation of programmatic management of drug-
resistant TB (PMDT); currently there are two designated MDR/RR-TB treatment facilities in the country.
17
TB Technical Work group meeting-2016
18
MOH (2007). Demographic and Health Survey
19
NTLP annual data 2016
20
Global tuberculosis report 2016
13
The NTLP plans to establish an MDR/RR-TB treatment centre in each province in the first phase of
expansion, followed by the addition of other hospitals as treatment centres in the second phase.
Surveillance of MDR-TB cases has been initiated using separate paper registers for all patients started
on second-line drugs and data is reported as an Excel file to the NTLP; there are plans to introduce
an electronic registration system specific for MDR-TB. In 2015, 99 cases of MDR-TB were reported to
the NTLP against a target of 275 for the same year. The WHO estimated that in 2015 there were 1,500
MDR/RR-TB cases among notified pulmonary TB cases. This clearly shows that there is a wide gap
between estimated number of MDR/RR-TB patients in the country and the number detected by the
NTLP.
The country has three laboratories with robust capacity to detect TB strains resistant to first-line anti-
TB drugs through conventional culture and drug susceptibility testing (DST) and through modern
rapid molecular tests with Xpert MTB/RIF and line probe assay (LPA). The National TB Reference
Laboratory (NRL), or the Chest Diseases Laboratory as it is otherwise known, is linked with the
Johannesburg National Institute for Communicable Diseases TB Supranational Reference Laboratory
(SNRL) for second-line anti-TB drugs testing, and a treatment programme is in place partly with
support of the Global Fund. There has been an uninterrupted supply of second-line anti-TB drugs.
There are two sites where MDR/RR-TB cases can initiate second-line treatment: one at the University
Teaching Hospital (UTH) in the capital city of Lusaka and one at Ndola in Copperbelt Province. Clinical
follow-up is also provided through these two sites. The current MDR-TB guidelines advocate for
decentralization of treatment initiation and management to provincial hubs and accredited district-
level hospitals. At this time, the country is implementing only a longer MDR/RR-TB regimen that lasts
a minimum of 20 months. Shorter MDR/RR-TB regimens are expected to be introduced during the
last quarter of 2017.
Diagnosis of MDR-TB is based on laboratory-confirmed resistance to rifampicin and isoniazid through
conventional DST using either MGIT (mycobacteria growth indicator tube) or on Lowenstein-Jensen
solid media. Until the end of 2016, RR-TB cases diagnosed by Xpert TB/RIF testing were only classified
and started on MDR-TB treatment if they were category treatment regimen I or II failures; otherwise
such patients were placed on a retreatment regimen until full DST results were received. The MOH has
since issued a policy statement that all patients with confirmed rifampicin resistance following Xpert
MTB/RIF should be commenced on a full MDR/RR-TB regimen, regardless of isoniazid resistance.
Drug-resistant TB case detection is very low, as less than 10 percent of previously treated TB cases
are accessing culture and DST testing, and second-line DST is rarely done. The treatment success rate
for MDR-TB is about 30 percent. The low treatment success rate is attributed to high levels of loss to
follow-up. After patients are started on treatment at the two initiating sites, they are released back to
their home districts and provinces, where no support structure currently exists.
2.6 Infection Control

The NTLP has developed TB Infection Control Guidelines, but their implementation has been limited
and was previously mainly done through a project approach by cooperating partners such as TB
CARE I and through the 3Is project funded by CDC and USAID.
2.7 Laboratory Services for TB Control

The Zambia national TB laboratory network is well organized, with microscopy services available at
all levels of health care from the health facility through to the National Reference Laboratory. Both
fluorescent and Ziehl-Neelsen (ZN) microscopy are used, though ZN microscopy is being phased
out. Following the WHO recommendations, the country has rolled out Xpert MTB/RIF testing in 69
facilities countrywide.
The Chest Disease Laboratory (CDL), which is the country’s National TB Reference Laboratory,
oversees all TB diagnostic work and supervises the specialized Tropical Diseases Research Centre
(TDRC) and the University Teaching Hospital (UTH) and provincial laboratories (see Figure 11). The
provincial laboratories, in turn, supervise the district laboratories, which supervise the health centre
laboratories. The NRL gets feedback from the provincial and specialized laboratories, which get
feedback from the lower-level facilities.
14
Figure 11: Zambia’s microscopy network
National TB Reference Laboratory

(Chest Disease Laboratory)
Provincial and specialised laboratories

(UTH and TDRC)
District laboratories
Health centre/Peripheral laboratories
2.7.1 Microscopy services

The national TB laboratory network includes 370 microscopy laboratories across the country with
the majority of the laboratories being located in government health facilities (Table 2). Overall, the
ratio of TB microscopy laboratory to population is approximately 1: 43,000 for the whole country;
the ratio varies from 1: 30,300 population in Copperbelt Province to 1:59,100 in Lusaka Province (see
Table 3). Though this ratio is better than the 1:50,000 recommended by WHO, the distribution of
these facilities is not equitable and hence access for microscopy services is suboptimal is some areas.
Table 2: Distribution and ownership of TB laboratories in Zambia
Province GRZ Faith- based Military Mine Prison Private Total

Luapula 26 7 0 0 0 0 33
Central 26 4 3 0 1 0 34
Western 9 7 1 0 0 0 17
Lusaka 32 5 5 0 1 4 47
Copperbelt 51 9 3 4 2 8 78
Eastern 40 10 3 0 0 0 53
Southern 28 13 0 0 0 1 42
Northern 21 5 0 0 0 0 26
Muchinga 17 3 0 0 0 0 20
North-Western 10 10 0 0 0 0 20
Total 260 73 15 4 4 13 370
15
Table 3: Distribution of TB laboratories by provinces and ratio of number of laboratories per population
in 2015
Province Population Number of laboratories Ratio of TB laboratory per

(2015) General clinical Laboratories population
laboratories with TB
diagnostic
services
Luapula 1,127,453 30 33 1:34,165
Central 1,515,086 37 34 1:44,561
Western 991,500 36 17 1:58,324
Lusaka 2,777,439 58 47 1:59,094
Copperbelt 2,362,207 79 78 1:30,285
Eastern 1,813,445 37 53 1:34,216
Southern 1,853,464 41 42 1:44,130
Northern 1,304,435 23 26 1:50,171
Muchinga 895,058 20 20 1:44,753
N o r t h - 833,818 29 20 1:41,691
Western
Total 15,473,905 390 370 1:41,821
2.7.2 TB culture facilities

TB culture facilities are available at the NRL as well as at the two specialized laboratories at UTH and
TDRC. All three culture laboratories use liquid media (MGIT), but solid media (Lowenstein-Jensen) is
available only at the NRL. The NRL also uses LPA for drug-susceptibility testing. There is suboptimal
use of culture facilities; in 2015, only 2,799 samples were processed with culture and 433 had DST. In
the same year, the number of retreatment cases was 4,847 (excluding relapses); therefore, coverage
of those TB patients that should be prioritized for DST is quite low.
2.7.3 External quality assurance and accreditation
An external quality assurance (EQA) system for TB microscopy has been implemented across the
country under the leadership of the NRL. However, because of the lack of sustained financial support,
the EQA system does not perform at satisfactory level. In 2015, of the 272 facilities enrolled in the
EQA system, only 101 participated. EQA for Xpert MTB/RIF testing has not been yet developed. In
addition, only the cultures and DSTs performed in the NRL are quality-assured by the supranational
reference laboratory (SNRL); those carried out in UTH and TDRC are not for the time being.
The NRL has not yet been accredited to ISO 15189 requirements by the relevant international
accreditation stakeholders.
2.7.4 Laboratory infrastructure issues and maintenance
The NRL has no biosafety level 3 (BSL3) facility even though it performs cultures and DSTs on a
routine basis. Many laboratories performing TB microscopy and/or Xpert MTB/RIF testing are located
in rooms that do not fit the requirement to carry out TB diagnosis activities. There is no process
and no plan to ensure the maintenance of the equipment and devices available in the national TB
laboratory network.
2.7.5 Specimen referral network
As in most low-income countries, Zambia has centralized capacity for culture in three referral
centres. This situation requires an efficient and effective specimen referral system to increase access
to culture and DST services. However, to date this service has been mainly provided under project
conditions, with the TB CARE I project providing specimen referral in five of the nine provinces from
2010 to 2015. In the remaining four provinces, CDC-funded partners provided courier services based
on programme needs. However, on completion of the TB CARE 1 project, the courier system ceased
to function. The routine transportation of specimens using a courier has not been yet implemented.
16
2.8 Management of TB Medicines

The distribution of anti-TB drugs from national to facility level flows through a number of services
and is coordinated by the NTLP (Figure 12). Case notification data from the health facility is sent to
the District Health Office (DHO), where it is validated, aggregated, and sent to the Provincial Health
Office (PHO), which then sends it to the NTLP. At the NTLP, the logistics officer in collaboration with
the M&E officer extracts logistics data and processes requisitions, which are sent to Medical Stores
Limited (MSL). MSL then assembles products accordingly and delivers them through the PHO. The
drugs are either delivered by MSL or collected by the responsible PHO, which then distributes them
to various districts.
Figure 12: Anti-TB drugs distribution flow in Zambia
Abbreviations: DHO, [District Health Office]; MOH, Ministry of Health; MSL, Medical Stores Limited; PHO, Provincial Health Office; HC, [spell out]
Source: adapted from Standard operating procedures (SOPs) for Essesntial Medicine Logistics Improvement Programme (EMLIP, Ministry of Health, 2014.
17
2.9 Involving All Care Providers (Public-Private Mix)

Zambia has a long history of engaging private health providers in TB services. The NTLP has
established partnerships with semi-governmental facilities under the umbrella of CHAZ as well as a
few private providers in Copperbelt and Lusaka provinces. Public-private mix (PPM) had previously
been supported by Global Fund Round One and by the Zambia TB CAP project (funded by USAID);
under this funding, MoUs were signed with some private practitioners and private-sector clinics,
whereby they were provided with TB recording and reporting forms, drugs, and laboratory reagents;
their personnel were supervised by the NTLP; and they were encouraged to participate in the review
meetings of the NTLP at local level and also in national training in DOTS/TB/HIV.
In the National TB Strategic Plan (NSP) 2006–2010, Zambia included the fourth component of the
WHO Stop TB Strategy—engaging all care providers—as an independent objective. However, some
PPM activities in this NSP, such as recruiting the PPM focal point; holding regular national-level
advocacy meetings with Medical Council, professional, and corporate bodies to inform and discuss
the developments in the PPM initiative; developing guidelines and the implementation plans for
DOTS/TB/HIV activities in the private sector; and negotiating contracts with private practitioners
(MoUs) to implement TB services, were not adequately implemented.
There are a number of things that still need to be done to ensure maximum inclusion of the private
sector in TB case detection. These include developing mechanisms for engaging a multitude of
diverse health providers who are currently not engaged, such as private pharmacies and chemists,
private laboratories, and traditional healers who interact with TB patients. The NTLP M&E system
also needs to be strengthened to inform the contribution of PPM in TB case detection and treatment
success.
2.10 TB and the Mining Sector
In Zambia, mineworkers have been identified as one of the key affected populations due to the
higher rates of TB that have been recorded in many mining settings. Silicosis and tuberculosis in
mineworkers are occupational lung diseases, and current legislation requires both pre-employment
and periodical or annual screening for all mine employees in scheduled areas in the mines by the
Occupational Health and Safety Institute (OHSI).
Copperbelt Province, the hub of the mining industry in Zambia, has the highest TB prevalence rates,
at 1,211/100,000 population as established by the TB prevalence survey conducted in 2013–2014.
Copperbelt Province also has the highest HIV prevalence rate (18 percent) among adults (MOH
2014)21. The high TB prevalence rate in Copperbelt Province is mainly attributed to the occupational
risk associated with the mines, but the burden of TB among mine workers and mining communities
is not entirely known. A situational analysis of TB in the mines conducted in 2016 that included a
review of TB diagnosis through the mandatory annual screening of mine employees by OHSI showed
that the prevalence of TB was not much different from that in the district where the mines were
located. An exception to this was the much higher rates observed in workers in limestone quarries
compared to the district average. The true impact of mining on the prevalence of TB in the mining
sector is not known, as routine TB data are not disaggregated by occupation and there has not
been any comprehensive study specifically to determine the burden of TB among mine workers
and mining communities. Current legislation contained in the Workmen’s Compensation Act and
the Occupational Health and Safety Act requires that any mine worker diagnosed with either TB or
silicosis should not work in a scheduled area of the mine, and this has been perceived as a barrier
to a mine worker seeking care for TB within the mine health institutions. The potential loss of
employment and income due to TB diagnosis prevents care seeking on behalf of this population,
which is at particularly high risk for TB disease.
The Heads of State in the Southern African Development Community (SADC) countries signed a
Declaration on TB in the Mines in 2012 in recognition of the burden of TB in the mines and the
specific vulnerabilities among mineworkers that increase their risk of developing TB. Following this
declaration, the World Bank and the Global Fund, through country and regional grants, have made
available funds to support the countries implementing TB services in the mining sector. Zambia is
part of the World Bank Southern Africa TB in the Mines and Health Systems Strengthening Project;
in addition, the Government of Zambia has been given a US$45 million 5-year grant from the World
Bank for combating TB in the mining sector.
21
MOH (2014). Zambia Demograpghic and Health Survey report, Ministry of Health
18
2.11 TB in Prisons
Prisons have been recognized as potential hot spots for TB for inmates, staff, and visitors alike. It has
been estimated that rates of TB are 5 to 50 times higher in prisons than in the general population22.
The Zambian prison system, with 87 correctional facilities, was developed to host about 5,500
prisoners; however, in 2016 there were reportedly more than 19,200 incarcerated individuals. In
2010, Human Rights Watch released a report that described the overcrowded conditions in Zambian
prisons, posing a risk to inmate health23. In 2010, a TB and HIV screening programme was established
in six Zambian prisons as a collaboration between the Zambia Correctional Service, the Centre for
Infectious Disease Research in Zambia (CIDRZ), and the Zambia AIDS Related TB Project (ZAMBART)
with support from TB REACH. The screening programme was continued under the 3Is project funded
by CDC and USAID from 2012 to 2015 and included three prisons. The activities carried out under
the 3Is project included routine TB and HIV screening on entry, screening for TB on all symptomatic
inmates on referral, training of prison staff on TB infection control, improvement in ventilation, and
setting up of TB IC committees and appointment of IC contact persons in the prisons. In addition,
with support from the UN Office on Drugs and Crimes (UNODC), activities such as training of staff,
peer educators, and prisoners on TB and establishment of a voluntary counselling and testing (VCT)
centre in one of the prison were carried out.
2.12 TB and Cross-Border Populations
In 2010, SADC reported that all Member States in the region were experiencing significant movement
of populations across their borders. However, very few of these countries have initiated formal linkages
with their neighbors to ensure the availability of standardized TB treatment care and prevention
services to migrant populations. The report further stated that the type of migrations commonly
seen in the SADC region include seasonal workers who return home periodically for short or long
stays; daily migrants who cross borders to work and return home after work; displaced persons who
move into a country for the long term and often are undocumented in their host countries; and long-
term migrants who seek better economic opportunities.
The lack of cross-border initiatives poses a unique challenge to providing quality TB services among
migrants because:
• Many of the migrants periodically return to their home countries, and those who are on TB
treatment stop taking the drugs during those periods. This negatively impacts treatment success
rates (as patients lost permanently).
• Neighbouring countries often use different TB treatment regimens, making it problematic to
offer a continuum of care when migrants return to their native countries.
• Language barriers pose a problem, as patients may arrive with previous medical records or
referral forms in a language different to that used in their new host country. Sometimes patients
come with no documentation or previous records of TB treatment.
2.13 Partnerships
The NTLP collaborates with several partners and stakeholders; some of them provide financial
or technical support and others are implementing partners. Table 4 lists some of the local and
international partners collaborating with the NTLP.
22
World Health Organization (WHO). Tuberculosis Control in Prisons: A Manual for Programme Managers. Geneva: WHO; 2001. Available at http://www.who.int/
tb/publications/prisons_tb_control_manual/en/.
23
Todrys KW, Human Rights Watch, AIDS & Rights Alliance for Southern Africa, Prisons Care & Counseling Association. Unjust and Unhealthy: HIV, TB, and
Abuse in Zambian Prisons. New York: Human Rights Watch; 2010.
19
Table 4: Main collaborating partners of the National Tuberculosis and Leprosy Programme
Institutions and organizations mainly providing United States Agency for International Development (USAID)
financial and technical support US Centers for Disease Control and Prevention (CDC)
Global Fund to Fight AIDS, Tuberculosis and Malaria
World Health Organization (WHO)
The World Bank
Institutions and organizations mainly implementing Joint United Nations Programme on HIV/AIDS (UNAIDS)
activities and providing technical support to some Churches Health Association of Zambia (CHAZ)
extent
United Nations Office on Drugs and /Crime (UNODC)
KNCV Tuberculosis Foundation
Zambia AIDS Related TB Project (ZAMBART)
Center for Infectious Disease Research in Zambia (CIDRZ)
Japanese Anti Tuberculosis Association (JATA)
Clinton Health Access Initiative (CHAI)
FHI360
Jhpiego
Japan International Cooperation Agency (JICA)
Copperbelt Health Education Project (CHEP)
CARE International
Community-based organizations and civil society organizations
2.13.1 Community partnerships

The NTLP has worked closely with CBOs such as Bwafano and Zambia TB and Leprosy Trust (ZATULET)
among others in the provision of supervision of treatment for TB patients. Community volunteers
working with these organizations have provided important services for TB patients at both the
clinic and the community level, supervising treatment, tracing patients that are lost to follow-up,
and assisting in the clinics. One challenge is the lack of standardization for the incentives given
to volunteers, as these are often linked to a specific project. The community is represented on the
National TB Working Group. The contributions of community organizations to TB notifications and
the TB treatment success rate are not known.
2.14 Routine TB Data Systems and Surveillance
The NTLP uses a standardized paper-based recording and reporting system that flows through
the health care system from health facilities, districts, and provinces to the national level and that
allows for cohort analysis based on individual patient-level data. Though these data were previously
reported separately from the national health management information system (HMIS), TB is now
being included in the DHIS2 system. In addition, during the life of this plan, the NTLP will establish
an electronic system for tracking TB patients.
Demographic data that are collected on individual patients include name, age, sex, and address/
contact. Data on occupation/employment are not collected by the current recording and reporting
forms.
2.15 Funding for TB Control
The NTLP is funded through different channels and at various levels of the health system. Funding
is based on plans that are developed at the lower levels through a planning process that facilitates
identification of priorities by all stakeholders, including TB patients, providers, and managers. The
NTLP is funded through the following channels:
• GRZ grants are given directly to the NTLP Central Unit, the Provincial Health Offices, and the
District Health Offices.
• Donor funds through several bilateral and multilateral organizations are given to the NTLP
through the MOH, such as funds from the Global Fund, CDC (especially for TB/HIV activities
supported by PEPFAR), and the common basket funding.
20
• The CDC also directly provide funds for some TB/HIV activities selected Provincial Medical Offices
(Eastern, Lusaka, Southern, and Western), Ministry of Home Affairs, and international NGOs
working in Zambia through cooperative agreements.
• Some funds are indirectly provided to the NTLP through bilateral agreements with the NTLP and
the MOH with organizations that facilitate implementation of TB control activities as specified
in the NSP; these organizations include the USAID-supported projects such as the Challenge
TB Project and the Zambia Prevention, Care and Treatment program (ZPCT II), whose support is
limited to six provinces (Central, Copperbelt, North-Western, Luapula, Northern, and Muchinga).
• There are also some organizations that implement TB control activities under the stewardship
of the NTLP/MOH and indirectly contribute towards achieving the NTLP goals. These include
CIDRZ, Jhpiego, CARE International, and other projects such as those implemented by JATA.
Various research organizations such as the University of Zambia-University College London
Medical School (UNZA-UCLMS), Centre for Infectious Disease Research in Zambia (CIDRZ), IMRET,
and ZAMBART are engaged in TB research that contributes to improving TB prevention, care, and
control.
In 2014, 44 percent of the TB budget was funded by domestic resources, and 56 percent came from
international resources. In 2015, the proportion of TB funding from domestic resources decreased to
29 percent, with 63 percent coming from international funders.
2.16 National TB Strategic Plans
In 2000, the MOH conducted an independent review of the programme that recommended a
reorganization of the programme and informed the development of the 2001–2005 NSP, which was
based on the WHO DOTS strategy.
In 2005, an independent review of the NTLP was conducted of the 2001–2005 NSP and made
recommendations for strategies to include in the 2006–2011 NSP. The 2006–2011 NSP was developed
in line with the national priorities included in the National Health Strategic Plan 2006–2011, in
accordance with WHO’s Stop TB Strategy 2005–2011, and towards the Millennium Development
Goals (MDGs). The overall goal of this plan was to reduce the mortality, morbidity, and socioeconomic
burden associated with TB in the Zambian population by 2011. The five objectives for this plan
included strengthening the management of TB, coordination of TB and HIV activities, health systems
strengthening for TB control (laboratory, supply chain management, infrastructure, and human
resource), health promotion strategy, and strengthened capacity for operational research.
In 2010, another independent review of the NTLP took place to assess the accomplishments of the
NSP 2006–2011, identify gaps in TB programme activities, and inform the development of the next
strategic plan for the period 2011–2015 within the context of the National Health Strategic Plan
2011–2015. The goal of this strategic plan was to reduce the burden of TB in Zambia by 2015 in line
with the MDGs and the Stop TB Partnership.
In 2014, the TB NSP was revised to align it with the revised NHSP 2011–2016. The goal of the revised
NSP was to reduce the prevalence of TB by 50 percent relative to the estimated 1990 levels by 2016
and to sustain the reduction in mortality. In line with the Stop TB Strategy and the recommendations
of the 2010 review of the TB programme, the objectives of the revised NSP were as follows:
 Increase case notification rate of all forms of tuberculosis from 321/100,000 in 2012 to 338/100,000
and screen 60 percent of previously treated TB cases for MDR by 2016.
 Increase treatment success of drug-susceptible TB from 88 percent in 2012 to 90 percent by 2016.
 Successfully treat at least 70 percent of all MDR-TB patients initiated on treatment by 2016.
 Reduce TB-related morbidity and mortality among people living with HIV through the scale-up
of TB/HIV activities to at least 80 percent of TB and HIV sites by 2016.
 Scale up TB prevention, diagnosis, and care services for vulnerable and high-risk populations by
2016.
 Enhance TB surveillance and M&E and increase capacity to conduct operational research.
 Strengthen the health system to deliver TB services through a primary health care approach and
the development of synergies.
21
SECTION THREE: PROGRAMMATIC ANALYSIS

Since 2013, there have been several activities that have contributed to a situational analysis of the
TB programme including the implementation status of the NSP, a gap analysis, and identification of
key strategic elements that need to be considered in the preparation of the NSP 2017–2021. These
include the 2013–2014 National TB Prevalence Survey, the 2016 Epidemiological Review of the TB
Programme, a TB-HIV Impact Modelling and Estimates TIME Modeling (TIME) work, and the 2016 End
Term TB Programme Review.
3.1 Evaluation of Surveillance and TB Epidemiological Analysis 2014

In 2014, an evaluation of TB seuverillance and TB epidemiology analysis was conducted to assess the
national TB surveillance system and vital registration systems, review levels and trends in TB disease
burden, and analyze their relationship to changes in TB-specific interventions.
The results of this assessment relating to TB surveillance found that the system had improved since
2014 with the use of standardized tools and quarterly reports for susceptible TB cases, inclusion of
data from the private sector, key indicators and analysis of data at provincial and national levels, and
a direct measure of HIV prevalence in TB cases. The gaps that were identified include:
 Lack of tools and systems to ensure data completeness and quality.
 Under-representation of children, especially those 0–4 years.
 Lack of information on diagnosis and treatment in high-risk groups.
 Gaps in measurement of TB deaths due to the lack of a functional Vital Registration System (VRS)
in Zambia.
The case detection rate of 59 percent, based on the higher-than-expected prevalence from the
national prevalence survey, indicates that there is under-diagnosis of TB in Zambia. Possible causes
for this include the reliance on passive case detection, poor access to health services including
diagnosis, lack of TB knowledge by health workers, and possible under-reporting.
Measurement of TB deaths would require a VRS, of which there is not a fully functional system in
Zambia. However, a Sample Vital Registration and Verbal Autopsy conducted in 2010–2012 indicated
that TB was a leading cause of death among adults 15+ and ranked as the fifth cause of death in
Zambia. In the absence of a functional VRS, TB deaths are measured indirectly using estimates of
the case fatality rate and incidence, though these estimates are accompanied by wide confidence
intervals.
To improve the surveillance system to enable the direct measurement of the level and trends of
the burden of disease from routine surveillance and measurement of TB incidence from notification
data, recommendations from the epidemiological assessment include:
 Improving gaps in data collection
 Data quality control
 Data management and analysis
The recommendations also include building capacity of the existing M&E staff in the national TB
programme at all levels in epidemiology and data analysis, as well as increasing the number of M&E
staff at the central level.
3.2 National TB Review 2016

In November 2016, an independent review of the programme was conducted with the following
objectives:
 Assess the status of the implementation and achievement of the National TB Strategic Plan
2014–2016.
22
 Identify successes and best practices that can be scaled up, opportunities to optimize, and
challenges that need to be addressed.
 Identify key strategic and programmatic elements that lag behind international standards.
The results of the review indicate that of the seven objectives in the revised NSP 2014–2016, three
were achieved, two were partially achieved, and two were not achieved as outlined in Table 5 below:
Table 5: Achievements of National TB Strategic Plan 2014–2016
Objective achieved Objective partially achieved Objective not achieved

Objective 2: Increase treatment Objective 5: Scale up TB Objective 1: Increase case notification
success rate for drug-susceptible prevention, diagnosis, and rates and the proportion of previously
TB. care services for vulnerable treated cases tested for MDRTB
and high-risk populations,
including children, by 2016.
Objective 4: Reduce TB-related Objective 7: Strengthen the Objective 3: Successfully treat at least
morbidity and mortality among health system to deliver TB 70 percent of all MDRTB patients
people living with HIV through through a primary health initiated on treatment by 2016.
the scale-up of TB/HIV activities. care approach and the
development of synergies.
Objective 6: Enhance TB
surveillance and M&E and
increase capacity to conduct
operational research.
For each objective, the successes, weaknesses, and challenges were identified, along with
recommendations to address these. The strengths and weaknesses are summarized in the strengths,
weaknesses, opportunities, and threats (SWOT) analysis included below, as well as in the gap analysis.
3.3 SWOT Analysis

Strengths Weaknesses
Established positions for TB at central (six Lack of substantive government post for TB at the
positions) and district levels. provincial level.
National TB Strategic Plan aligned with National Inadequate technical staff at central level to oversee
Health Strategic Plan. key areas of TB control; no focal person(s) in some key
technical areas such as public-private mix (PPM).
TB Working Group established with participation Suboptimal involvement and coordination of partners
of all stakeholders. for parallel planning.
Government funding available for TB Government funding inadequate based on burden of
programme; TB diagnosis and treatment free in disease and heavy reliance on donor support.
public health facilities.
Programme strategy and technical guidelines Current diagnostic policy and algorithms are not
are available. sensitive enough to identify all forms and cases of TB;
delays in finalizing key policy guidelines.
Good coverage of quality assured microscopy Distribution of microscopy centres not directly linked
services available with 1 laboratory/40,000 to disease burden; few microscopy centres relative to
population with basic (light and fluorescent) number of health facilities, (about 20 percent of health
microscopy and advanced molecular tests facilities have TB diagnostic services); continued use
(Xpert and line-probe assay [LPA]); use of of smear microscopy and underutilization of Xpert for
microscopists where there is inadequate TB diagnosis; limited use of external quality assurance
laboratory staff; electronic ordering of (EQA) for microscopy; no EQA programme for Xpert.
lab commodities through the laboratory Sputum specimen referral/transportation system not
management information system (LMIS) fully established.
23
Culture facilities with first-line phenotypic Roles of three culture labs not well defined; suboptimal
and genotypic (GeneXpert and LPA) drug- utilization of culture and DST labs; inadequate courier
susceptibility testing (DST) available in three system for transport of samples to culture facilities; long
facilities. turnaround time for culture and DST; National Reference
Laboratory not yet upgraded to biosafety level 3.
Uninterrupted supply of quality-assured WHO- TB screening in antiretroviral therapy (ART) clinics not
recommended first-line TB medicines; dedicated always linked to TB diagnostic services; inadequate
procurement and supply chain management implementation of isoniazid preventive therapy (IPT);
(PSM) officer at central level; effective national infection control not systematically implemented in
supply chain system run by Medical Stores prisons; few centres provide integrated TB/HIV services;
Limited (MSL). lack of forums for TB and HIV programme staff to interact
due to the perceived nature of fragmented HIV unit.
TB/HIV guidelines available with high coverage The true burden of DR-TB is unknown as the last drug-
of HIV testing of TB patients (95 percent), co- resistance survey was conducted in 2008; low DST
trimoxazole preventive therapy (CPT) (> 90 coverage for previously treated patients and low DR-TB
percent) and ART (75 percent); TB registers case detection; only two centres initiate patients on
capture HIV/TB activities. MDR-TB treatment.
Programmatic management of drug-resistant Low treatment success rate for MDR/RR-TB cases due
TB (PMDT) guidelines available; National and to centralized treatment model and high rates of loss
Provincial Clinical Expert Treatment Committee to follow-up with poor linkages to care; lack of contact
established; second-line drugs available; two tracing for DR-TB patient support systems; lack of tools
MDR-TB treatment sites established. for monitoring DR-TB patients.
Radiological services for diagnosis available at Limited availability of digital x-ray facilities for TB
district level. screening.
Health workers able to manage TB patients No structured tools to report contribution of civil society
available at all levels; involvement of community organizations and private clinics, including from the
members and former TB patients as treatment mining sector, to TB notification and treatment success;
supporters. no standardized system of incentives for TB treatment
supporters; no patient charter to hold staff and patients
accountable; limited engagement of the private sector
in TB control efforts.
Presumptive TB register available. Advocacy, communication, and social mobilization
(ACSM) guidelines in draft form; lack of information,
education, and communication (IEC) materials.
Evidence of positive outcomes on programme Limited use of presumptive TB register in many sites;
performance through involvement of civil limited screening for TB in antenatal/PMTCT (prevention
society, nongovernmental, and faith-based of mother-to-child transmission of HIV) sites; limited
organizations (CSOs, NGOs, and FBOs). contact tracing and TB screening of health care workers;
over-reliance on passive case finding.
Childhood TB patients recognized as a key Lack of new pediatric formulations and childhood
affected population; childhood TB working TB working group not fully functional; no structured
group established; childhood TB guidelines and system for reporting contact tracing; limited capacity to
draft training materials available; diagnostic diagnose childhood TB outside the hospital setting.
facilities available in some centres.
TB activities implemented in some prisons Entry and exit screening not available in all prisons and
including entry and exit screening and use of nutritional supplements are not available; no system for
peer counsellors. follow-up and linkage to care for discharged prisoners.
Some mine-owned health facilities report TB TB recording and reporting (R&R) forms do not capture
data to the TB programme; annual screening occupations so not possible to know burden of TB in
available for miners and ex-miners. miners; mine-owned health facilities are not included in
technical support and supervision by the NTLP.
24
A well-established, paper-based data recording Evidence of missing registers and forms in some sites;
and reporting system with clear flow of data registers and treatment cards sometime incomplete
from health facilities through districts and and not updated; lack of clear system for ensuring a
provinces to the central level; plans to migrate to complete set of data; little evidence of system for data
electronic data capture and inclusion in District quality checks; no platform to disseminate research
Health Information System 2 (DHIS2). findings.
Technical support and supervision visits from Poor documentation and follow-up of supervisory
higher to lower levels occur; data review visits; at all levels, weak capacity for data management,
meetings occur at all levels. analysis, and use; no annual reports, and no designated
vehicles to support technical support supervision visits.
Activities for TB in prisons implemented in project
mode, affecting sustainability and reach of activities.
Opportunities Threats
Government has prioritized the multisectoral High levels of out-of-pocket expenditures for health
approach to service delivery and primary health care services.
care.
Increasing government spending on health Lack of effective and progressive financial risk
and budget allocation to health in 2017 from 8 protection mechanisms such as pre-payment schemes
percent to 13 percent; government has secured for the poor and vulnerable.
a loan from the World Bank to implement
activities in the mining sectors.
Implementation of fiscal resource Realignment of the health sector to involve the Ministry
decentralization policy permits lower levels to of Community Development and Social Welfare
plan according to their priorities. (MCDSW) in 2012–2015; reversal in 2016 affected
continuity of programme activities.
Social protection schemes in MCDSW with an Fragmentation of HIV/AIDS units (ART, PMTCT,
increase in budget allocation for 2017 (to 500 childhood ART) affects the HIV programme’s ability to
million Kwacha). coordinate TB/HIV activities.
Opportunities Threats
Existence of partner funding from the United Lack of sustainability and transition plans for
States government through USAID and the CDC; community health workers when projects end.
long-term technical advisor attached to the
NTLP, supported by USAID.
Assured and predictable funding from the Underfunding of community activities and lack of
Global Fund to Fight AIDS, Tuberculosis and standardization of enablers.
Malaria.
Involvement of CSOs on TB Working Group Long government procurement processes leading to
and the Zambia GF Country Coordinating poor utilization of the Global Fund grant.
Mechanism (CCM).
The Community Health strategy provides for Only 1,369 community health assistants available.
community health assistants to be part of the
national health care establishment and to be
paid by government.
Funding available from the World Bank; Global DR-TB funding not fully under government control.
Fund supported Wits Consortium Regional
Project for TB in Mines.
Multiple funding organizations have expressed Partners prefer supporting specific provinces, leaving
interest in supporting DR-TB activities. other provinces under funded
25
3.4 Gap Analysis

3.4.1 Gap 1. Funding of TB prevention, care, and control in Zambia heavily depends on external
sources
The current funding from the government cannot ensure the full funding needed for TB prevention,
care, and control in Zambia. Many key NTLP strategic interventions and activities depend on
international financial donors, notably the Global Fund and the United States government. Most
of the time there is no funding for other critical NTLP activities, such as undertaking technical
supervision visits in districts and peripheral health facilities or training health workers at the district
and peripheral levels. In some circumstances, there are insufficient funds to print the registers and
forms required for the NTLP’s information system. Other strategic interventions have been initiated
on a small scale as projects with external financial support, but they could not be maintained or
expanded because of the absence of sustainability agreements.
Many external sources of funding focus on TB/HIV issues; others concentrate on predetermined
interventions that may not be top priorities for the NTLP.
Even though the budget allocated by the government to health has increased, the NTLP has not
seized this opportunity to advocate for additional funding from the government for TB prevention,
care, and control.
3.4.2 Gap 2. The managerial capacities of the NTLP are not optimal
The NTLP Central Unit is understaffed and thus completion of all required tasks is challenging. None
the Central Unit staff have yet received any formal training on programmatic management of TB
control. At each provincial level, a liaison officer takes care of TB and HIV activities. The provincial TB/
HIV liaison officers receive salary support through the Global Fund grants and are not government
staff; only half of these provincial officers have received training on programmatic management of
TB control (PMTC). A small percentage of TB district coordinators have been trained on PMTC. The
NTLP annual operational plan has been established but does not have a clear connection to the
annual health plan made by the Provincial Health Office and District Health Offices.
There is no staff within the NTLP Central Unit team assigned to organize and follow supervision
activities to be carried out within the NTLP network. Although there is a standardized checklist for
supervision, there are no guidelines to perform supervision visits. Many of the supervision visits are
not carried out as planned because of a lack of funding and competing activities.
No staff has been yet assigned to organize and follow training activities undertaken within the NTLP
network. In some circumstances, there is a delay in anti-TB drugs delivery from MSL to the provinces
because of recurrent logistics management issues, resulting in temporary TB drugs stockouts in
peripheral health facilities. In other circumstances, the NTLP Central Unit has no precise information
on the activities undertaken by some implementing partners in the field that could result in a
duplication of efforts and resources or overlapping of different activities.
There are still difficulties in implementing fully the DHIS2 in some districts. There is not a fully optimal
system at either the provincial or district levels to undertake an in-depth analysis of data generated
by the NTLP’s information system. The NTLP has not yet established an electronic TB case-based
system. Additionally, the existing analysis procedures do not identify or generate hypotheses for
operational research.
3.4.3 Gap 3. TB case detection is still low, and the quality of TB diagnosis may be questionable
Less than 60 percent of incident TB cases are detected and registered within the NTLP system.
PHC centres represent the first level of contact between the community and the national health
system. Field evaluations suggest that although many patients who seek health care at PHCs and
in ambulatory care settings have symptoms compatible with TB, they are not assessed for TB. In
addition, the recent programme review pointed out that health workers practicing in these settings
lack the skills and competencies necessary to identify and manage patients with presumed TB. The
NTLP has deployed presumptive TB registers in health facilities, but these registers are not fully used
in many of the health facilities where they are implemented. When these registers are utilized, the
data are neither adequately collected nor compiled and analyzed at the district, province, and Central
26
Unit levels. Therefore, the patients who are referred from PHC facilities to microscopy laboratories
cannot be traced, and their number remains unknown. No practices have been developed to link,
on a routine basis and during supervision visits, the collection of information from presumptive
TB registers with the data in the TB laboratory registers or the notification data. The existing HMIS
register does not capture information for presumptive TB patients recorded in the presumptive and
laboratory registers.
Patients with bacteriologically confirmed pulmonary TB account for less than 50 percent of all
notified TB cases annually; this was 45 percent of all TB cases in 2015. This statistic suggests that the
quality of the diagnosis of non-bacteriologically confirmed pulmonary TB might be suboptimal, and
as a result, a non-negligible number of patients are registered and treated with a false diagnosis of
non-bacteriologically confirmed pulmonary TB.
Moreover, though extra-pulmonary TB (EP TB) accounts for approximately 20 percent of all TB
cases (22 percent in 2015) there are no clear diagnostic guidelines for EP TB. The contribution of
bacteriology and histopathology in establishing the diagnosis of EP TB is unknown. The NTLP has not
yet specified appropriate clinical practices to establish such diagnosis.
The availability of digital x-ray technology is currently very limited.
3.4.4 Gap 4. The TB laboratory network is not operational to meet the NTLP needs
Even though the NTLP has developed an extended TB microscopy laboratory network, (1 laboratory
for approximately 40,000 population), there are still many communities with no access to TB
laboratory services. Most of the existing TB microscopy laboratories are still using light microscopes.
Furthermore, many of the rooms in the laboratories are in dilapidated condition or do not fit the
essential requirements to undertake TB diagnosis activities.
Given the expected increase in the coming years in the number of smear-negative pulmonary TB and
EP TB cases who need to be bacteriologically confirmed, and the number of registered PLHIV who
should be bacteriologically assessed for TB, the number of the existing Xpert machines will not be
sufficient.
Because of a recurrent funding gap, EQA ctivities have not been adequately carried out. EQA for
Xpert testing is yet to be fully established.
Although the NRL performs cultures and DSTs on a routine basis, it has not been upgraded to
biosafety level 3. There is neither a process nor plan to ensure the maintenance of the equipment
and devices available in the national TB laboratory network. There is no national sputum/specimen
referral system in the country.
3.4.5 Gap 5. Some issues in TB medicines availability and TB drug supply management
New pediatric formulations of anti-TB drugs are still not available in the NTLP network. Single anti-
TB drugs are not readily available for patients who develop adverse effects during the TB treatment,
which is a particularly difficult challenge.
In some circumstances, the delivery of anti-TB drugs by MSL to the provinces is delayed; in other
instances, the delivery from the province to the district is also delayed. This situation results in
temporary drug stockouts in health facilities where TB patients receive their treatment. The reason
for this delayed delivery of the TB medicines to the provinces and districts is primarily due to the fact
that the delivery of TB medicines is not synchronized with other general medicines.
3.4.6 Gap 6. No approach has been yet defined to tackle the issue of TB in high-burden areas
The largest number of TB cases notified in Zambia is detected in Lusaka and Copperbelt provinces;
together both provinces accounted for 57 percent of the national TB notification in 2015. Furthermore,
the last population-based TB prevalence survey carried out (in 2014) reported that 77 percent of the
TB burden is concentrated in these two provinces. Copperbelt and Lusaka also have the highest
national HIV prevalence at 18.2 percent and 16.3 percent, respectively. HIV infection is probably
fueling TB occurrence in the populations in these two provinces where the prevalence of TB is so
high: 1,211 per 100,000 population in Copperbelt and 932 per 100,000 population in Lusaka.
27
However, the NTLP has not yet developed a specific strategy to tackle the huge burden of TB in these
two provinces, such as mapping TB occurrence by identifying neighborhoods or specific groups with
high rates of disease for which systematic and active TB screening can be organized.
3.4.7 Gap 7. Implementation of collaborative TB/HIV activities is still suboptimal because of
major coordination issues
Countrywide collaborative TB/HIV activities were initiated in 2005. Significant progress has been
made in reducing the burden of HIV among TB patients; in 2015, 95 percent of TB patients were
screened for HIV, 92 percent of TB/HIV received CPT, and 76 percent were provided with ART. Slightly
more than 60 percent of all notified TB cases are HIV-positive.
During the period of the last NSP, HIV activities were not organized under a single programme
umbrella, and in fact, they were fragmented into disparate units according to their focus area, such
as HIV testing and counselling, ART, prevention of mother-to-child transmission of HIV (PMTCT),
pediatric HIV, and voluntary medical male circumcision (VMMC). Because of this fragmentation, the
coordination between the NTLP and HIV programme and partners is suboptimal. Even though there
are TB/HIV subcommittees in some provinces, many provinces do not have such subcommittees.
There are no coordination mechanisms for TB/HIV at the district and health facility levels.
There is no systematic way for collecting data on TB screening in PLHIV at HIV/ART sites. However,
field evaluation highlighted that TB screening is available on a limited basis in PMTCT sites. PLHIV
who do not have active TB based on the TB screening do not always receive IPT. TB and HIV services
are fully integrated in very few health facilities.
3.4.8 Gap 8. Poor capacities to detect and manage drug-resistant TB patients
In 2015, WHO estimated the number of MDR/RR-TB case among new and previously treated TB
patients in Zambia to be 1,500. During the same year, 196 MDR/RR-TB cases were detected and
99 received treatment with second-line anti-TB drugs; therefore, only 13 percent of the estimated
cases were detected and 6.5 percent of these cases were treated. The existing guidelines on MDR/
RR-TB case management are not quite in line with the existing WHO recommendations. There is no
clear national plan to strengthen the capacities of the NTLP to manage MDR/RR-TB patients. Not all
retreatment TB patients are assessed for drug resistance even though more than 69 Xpert machines
are currently available across the country. In fact, only 10 percent of retreatment TB cases are assessed
for TB drug resistance. In addition, the Xpert testing for retreatment TB patients is not monitored on
a routine basis. The role of the three culture laboratories is not well defined. The treatment success
rate of MDR/RR-TB patients is low because of the centralization of treatment and high rates of loss
to follow-up. The last cohort analysis (in 2013) of MDR/RR-TB cases reported a 30 percent treatment
success rate. The procedures to monitor MDR/RR-TB patients who are treated are suboptimal.
The NTLP has not developed an approach to mobilize funds from organizations which have expressed
interest in supporting drug-resistant TB activities.
3.4.9 Gap 9. Insufficient collaboration and coordination between the NTLP and care providers
practicing outside the NTLP network
The NTLP has established linkages with health facilities under the umbrella of CHAZ and a few
private providers in Copperbelt and Lusaka provinces. In many instances, the NTLP did not succeed
in establishing strong relations with the care providers practicing outside NTLP network. These
linkages have not been fully sustained because of the absence of coordination mechanisms at the
national level and in all the provinces that could help the NTLP ensure appropriate follow-up. Still, the
NTLP has not yet established a clear strategy to involve all non-NTLP care providers in TB prevention,
care, and control efforts.
There is no national task force that can help the NTLP define, develop, and implement this strategic
approach. Many private laboratories provide TB diagnosis services; however, none of them is linked
to the national TB laboratory network supervised by the NRL nor are they linked to the EQA system
established by the NRL and NTLP. The procedures used to diagnose and treat TB in non-NTLP health
settings often do not follow the national standards.
28
3.4.10 Gap 10. The network of community health workers and civil society organizations are
not yet fully involved in improving and strengthening NTLP services
Up to 50 percent of the population has limited access to health services, including TB services,
especially in high-density urban areas often characterized by a precarious social environment.
Usually, the people living in high-density urban areas are far from TB diagnosis and treatment
services. Poverty and stigma are contributing factors to the poor levels of access for TB services in
high-density urban areas.
3.4.11 Gap 11. High-risk groups (other than PLHIV) and vulnerable populations are not well
targeted by NTLP interventions
3.4.11.1 The screening and assessment of the contacts of index TB cases are poorly implemented
TB contact investigations are included in the national strategy to prevent and control TB in Zambia.
However, there are no clear national guidelines for TB contact tracing and investigation. Even
though the process of TB contact screening is partially established, there are no clear standardized
definitions of index cases and contacts. The country has no standard operating procedures (SOPs)
and no algorithms to standardize the process of systematic screening and TB assessment in contacts.
IPT is not provided to children who are contacts of index cases but have no active TB.
There is no standardized information system on TB contact tracing and investigation activities or for
IPT for children and PLHIV who have latent TB infection; therefore, there is no systematic collection
or analysis of data. The NTLP has not defined the indicators to monitor the implementation of TB
contact tracing and investigation activities in order to evaluate their outcome.
3.4.11.2 No clear approach has been yet developed to tackle the issue of the provision of TB
prevention, care, and control services within the prison system
Some TB activities have been initiated on a small scale in some prisons. No formal linkages have been
established between prison health units and the NTLP network. In fact, there is no formal coordination
mechanism at the national level between the NTLP Central Unit and the Correctional Department of
the Ministry of Justice. In addition, the NTLP has not developed a clear framework for TB prevention,
care, and control of the correctional system of Zambia. Therefore, no guidance has been issued on
when to undertake TB screening in prisons, infection control, nutritional supplements, or treatment
provision when TB patients are released from correctional services.
3.4.11.3 The health services of the mining sector have not been fully involved in TB control efforts
In Zambia, 28 mining companies employ nearly 69,300 miners, among whom 40 percent have short
renewal contracts. Miners with this type of contract have no access to medical services coverage
from their companies, and often they are not annually screened for TB. In contrast, those who have a
formal long-term contract have access to company-provided health services and are often screened
annually for TB. All the miners, irrespective of the type of contract, may be laid off from their jobs if
they are diagnosed with TB. Therefore, many miners avoid being screened for TB.
Most of the mines in Zambia are located in the Copperbelt Province. The first ever population-
based survey reported that TB prevalence was 1,211 per 100,000 population in this province. The
Copperbelt also has the highest HIV prevalence rate in Zambia (18 percent). Nevertheless, the NTLP
has not yet established a clear strategy to specifically tackle the problem of TB in the mining settings
of this province. The burden of TB associated with mining in Zambia is still unknown.
3.4.11.4 There are no well-defined practices to deal with TB in children
Childhood TB is included in the national policy to prevent, care for, and control TB in Zambia. The
working group that was specifically established to promote TB prevention, care, and control in
children is not fully functioning. There are limited capacities to diagnose TB in children in district
hospitals and peripheral health facilities. The number of children who are identified with any form
of TB is neither monitored nor analyzed on a routine basis. Data on the occurrence of TB meningitis
and TB miliary in children is not clearly monitored through the existing NTLP information system. As
highlighted above, there is a lack of the new pediatric formulations of TB drugs. In addition, IPT is
not routinely provided in children with no active TB who are exposed to index TB cases. Age is not a
variable when assessing treatment outcomes for cohorts.
29
3.4.11.5 The vulnerability of women to TB has not yet specifically received adequate attention in
the NTLP policy
There are no distinctions in providing TB services between males and females in Zambia. Women
develop TB less frequently than men do, but they tend to develop it at a younger age than men.
However, HIV prevalence is higher in women than in men (15 percent versus 11 percent, respectively).
The risk of developing TB is much greater in PLHIV than in HIV-negative people; thus, in this population
women are more vulnerable. The recent independent programme review reported that TB screening
is limited in PMTCT sites. The NTLP has not approached the Maternal and Child Health Unit, women’s
associations or NGOs dealing with women’s issues to specifically promote TB prevention, care, and
control in women.
3.4.11.6 No actions have been yet taken to consider the issue of TB in diabetes patients
It is well known that diabetic persons have a two- to three-fold higher risk of developing TB than
non-diabetic individuals. The co-morbidity of TB and diabetes has not been considered in the
national policy of the NTLP. No linkages have been established with hospitals in ensuring increased
collaboration between TB and diabetes clinics.
3.4.11.7 Trans-border populations do not have access to TB services
There is a continuous movement of people across the borders of the SADC countries. A significant
proportion of these are migrant workers, who are vulnerable and may be at higher risk of TB if they
have been working in mines. Very few TB programmes in the SADC countries have initiated formal
linkages with neighboring countries to ensure the availability of standardized TB treatment care
and prevention services to migrant populations. The lack of cross-border initiatives poses a unique
challenge to providing quality TB services among migrants because:
 Many migrants periodically return to their home countries and those who are on TB treatment
stop taking the drugs during these periods, which negatively impacts treatment success rates as
patients are permanently lost.
 Neighboring countries may use different TB treatment regimens; thus, continuum of care is a
challenge when migrants return to their native countries.
 Language barriers pose a problem as patients may arrive with previous medical records or
referral forms in a language not used in their new host country; in some circumstances, patients
arrive with no documentation or previous records of TB treatment.
3.4.12 Gap 12. Data management (including recording, reporting, and analysis) of the
information generated by the NTLP systems is still suboptimal
The NTLP adopted the 2013 information system guidance issued by WHO, which has been included
in existing training materials, yet SOPs have not yet been published. Many health workers at TB
notification sites have not yet been trained to use the new information system due to inadequate
funds. Few revised registers have been printed and made available in all health facilities. For example,
more than 50 percent of presumptive TB registers and IPT registers that were needed were not printed
because of a shortage of funding. The 2016 independent programme recent review highlighted that
in some health facilities, the registers, forms, and treatment cards were not completed. Due to weak
communication, the districts cannot collect all the quarterly reports on time. Quarterly meetings to
assess TB activities at district level are rarely held.
Data are collected at district and provincial levels and then forwarded to the NTLP Central Unit where
all the data are compiled into a singular national data set. Data analysis capacities are limited in the
districts and the provinces because of a lack of training. The capacities of the NTLP Central Unit to
undertake an in-depth analysis of the national data set are limited as well. Therefore, no hypotheses
for operational research are generated from the data analysis carried out at the central level.
The NTLP Central Unit issues an annual report on the TB situation in Zambia based on data generated
by the information system. However, this report is not widely distributed to all the districts. M&E
officers at the Central Unit have no skills in data management and/or epidemiology.
30
3.5 Rationale for National Strategic Plan

The End TB Strategy is the post-2015 strategy that was developed to replace the WHO Stop TB
Strategy, which previously served as a guide for TB control activities through various iterations
from 2001 to 2015. This new strategy has the ambitious target of ending TB by 2035, as opposed
to the previous goal of controlling or stopping the spread of TB. The strategy has an overall aim of
a world free of TB by 2035 with zero deaths, disease, and suffering due to TB. The targets of the End
TB Strategy are to reduce TB deaths by 95 percent, cut new cases by 90 percent between 2015 and
2035, and ensure that no family is burdened with catastrophic costs due to TB. The three high-level
indicators for the End TB Strategy are the TB incidence rate, the absolute number of TB deaths, and
the percentage of TB patients and their households that experience catastrophic costs as a result
of TB disease. In line with the End TB Strategy, the NSP 2017–2021 has been designed to move the
country towards elimination of TB as opposed to controlling TB. Taking the TB programme towards
elimination will require the design and implementation of ambitious interventions and activities.
Strategies are still needed to reach the thousands of missing TB cases—with the aim of reducing
transmission of infection.
Zambia is now one of the 30 high TB-burden countries in the world. According to WHO, almost 63,000
people were newly affected by TB in Zambia in 2015. The estimated number of deaths was 17,000
for the same year; 12,000 of these deaths (71 percent) occurred in persons with TB/HIV co-infection.
Even though more than 85 percent of TB patients are successfully treated through NTLP services,
only 59 percent of estimated cases are detected. This case detection rate indicates that slightly more
than 50 percent of incident TB cases are cured and, as a result, for a majority of these cases, death is
avoided.
A priority goal of Zambia’s NSP is to reduce the number of deaths associated with TB. To reach this
goal, the number of detected TB cases must significantly increase while maintaining a high treatment
success rate. For instance, if 80 percent of estimated incident TB cases are detected, and at least 90
percent of these cases are cured, 72 percent of persons who are newly affected by TB in the general
population will probably survive. Such a scenario suggests that an impact on TB mortality is possible.
Zambia is also a high HIV-burden country. Approximately 70 percent of all TB deaths occur among
HIV-positive persons. Significant efforts have been made to fight the HIV epidemic in Zambia. Great
strides have also been made in implementing collaborative TB/HIV activities. Maintaining and
reinforcing these activities is likely to contribute to reducing death from TB.
MDR-TB cases have a high case fatality rate. The number of patients with MDR-TB is estimated
to be 1,500 among new pulmonary TB and retreatment cases notified in 2015. To improve the
diagnosis of TB in PLHIV, 69 Xpert machines have been procured. The utilization of Xpert testing
will likely contribute to identifying a significant number of TB cases with rifampicin resistance and,
consequently, increase the detection of MDR-TB patients. Therefore, the NTLP should address the
issue of MDR/RR-TB in the coming years to avoid additional TB deaths.
To improve efforts to detect and treat TB patients, sustain collaborative TB/HIV activities, and tackle
MDR/RR-TB, the NTLP needs to improve its technical and managerial capacities. Without appropriate
technical and managerial practices within the NTLP network, sound prevention, care, and control
services cannot be further improved and strengthened.
This new NSP arrives at an opportune time when the Ministry of Health is making positive policy
and structural changes that favor the elimination of TB in Zambia. For the first time in many years,
the issues of health promotion, disease prevention, and identifying social determinants of health
that negatively impact TB control and elimination efforts have been prioritized. Within this current
policy change, the Ministry of Health is focusing on strengthening the overall health services. This
approach will be achieved through five pillars of health services, namely: a) service delivery, b) human
resources for health, c) health care financing, d) information management, and e) leadership and
governance. These pillars refocus the NTLP’s efforts towards improving service delivery at the lower
levels of the health service. Health service delivery at the primary health care level is the nucleus of
the national health services policy.
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SECTION FOUR: VISION, MISSION, GOAL AND OBJECTIVES,

AND STRATEGIC INTERVENTIONS AND ACTIVITIES
4.1 Vision
Contribute to Zambia’s Vision 2030 of a healthy, prosperous, middle-income country that has zero
deaths, disease, and suffering from tuberculosis.
4.2 Mission
Provide equity of access to cost-effective, quality-assured TB services as close to the family as possible.
4.3 Goal
Reduce the number of TB deaths in the population by 40 percent in 2021 compared to 2015.
4.4 Guiding Principles

The guiding principles underlying the plan implementation are:
1. Government leadership, stewardship, and accountability with monitoring and evaluation by all
partners.
2. Strong coalition with civil society organizations and communities.

3. Working in partnership with other state departments and ministries in addressing social
determinants of health that may worsen the TB problem in the country. These ministries include
Community Development and Social Welfare, Mines, Agriculture Housing and Infrastructure
Development, and Justice.
4. Align the strategy and targets with the National Health Strategic Plan, the Global End TB Strategy
and the United Nations Sustainability Development Goals (Goal 3: Good health and well-being
for people).
5. Develop the strategy, interventions activities, and targets based on the results of the population-
based TB prevalence survey.
6. Develop interventions and activities based on the principles of primary health care.
4.5 Major Focus Areas

In line with the End TB strategy and the National Health Strategic Plan 2017–2021, the NTLP will focus
on the following areas:
1. Increase TB case detection by engaging all care providers and the community, targeting the
most-at-risk groups, and using quality-assured, WHO-approved diagnostic tests.
2. Maintain the high treatment success rate through the provision of quality-assured treatment for
all cases, including drug-resistant TB, with patient support.
3. Ensure the national implementation of all TB/HIV collaborative activities, expanding the
implementation of intensified case finding, isoniazid preventive therapy, and infection control.
4. Strengthen engagement of communities through expanded collaboration with CSOs and
CBOs and ensure patient support through collaboration with other government ministries and
agencies.
5. Enhance the managerial and leadership capacity of the NTLP.
32
Objective 1: Increase:
• The number of notified cases of new TB episodes from 36,700 in 2015 to at least 59,000 in 2021.
• The treatment success rate for TB from 85 percent in 2014 to at least 90 percent from 2018
onwards.
Objective 2: Increase:
• The detection of MDR-TB patients from 196 in 2015 to 1,200 by 2021.
• The treatment success rate for MDR-TB patients from 33 percent in 2013 to 80 percent by 2021.
Objective 3: Scale up comprehensive TB/HIV collaborative activities to all facilities by 2021.
Objective 4: Strengthen management, leadership, and governance of the NTLP by 2021.
4.6 Strategic Interventions and Activities

This section provides the specific interventions and activities planned to accomplish each of the four
objectives listed above.
OBJECTIVE 1
Increase:
 The number of notified cases of new TB episodes from 36,700 in 2015 to at least 59,000 in 2021.
 The treatment success rate for TB from 85 percent in 2014 to at least 90 percent from 2018
onwards.
Strategic interventions
To meet this objective, the following strategic interventions will be implemented during the five
years of the NSP:
1.1 Improve case detection by expanding case finding to all clinical settings
1.2 Involve all care providers operating outside the NTLP network in TB case detection and manage
ment
1.3 Strengthen TB services for high-risk groups and vulnerable and key populations
1.4 Improve and reinforce TB services in high TB-burden areas
1.5 Strengthen TB diagnostic capacity through expansion and enhancement of the laboratory
network
1.6 Strengthen the technical platform to improve TB diagnostic procedures
1.7 Ensure appropriate TB treatment for all detected patients
1.8 Strengthen community systems to improve the provision of TB services
1.9 Engage other government ministries and departments in TB prevention, care, and support
Zambia has a large gap between the number of notified TB cases and the estimated number of TB
cases according to the recent TB prevalence survey24. This gap is widest in large urban settings—
namely Lusaka and Copperbelt provinces. With a TB case detection rate of only 59 percent, Zambia
is not on course to meet the End TB strategy that aims to eliminate the global TB epidemic by 203525.
The notification rates have been declining since 2004 and this trend needs to be reversed for Zambia
to meet the End TB Strategy milestones and targets and eliminate the TB epidemic in Zambia. Several
strategic interventions are required for early diagnosis and treatment of all people with any form of
TB, including early recognition of presumptive TB patients through the introduction of TB screening
in all clinical settings. This will include improved TB screening practices, optimization of existing
24
Zambia National Tuberculosis Prevalence Survey 2013-2014
25
Global Tuberculosis Report 2016
33
and new tools and technologies, expansion of equitable cost-effective services close to the patient,
and tackling of TB in high-risk and vulnerable groups and high-risk provinces of Zambia. Activities
will aim to increase the number of presumed TB patients being identified and screened for TB and
to standardize these activities and the diagnostic process. The NTLP diagnostic guidelines will be
revised in line with the latest WHO guidelines, and algorithms and SOPs will be developed as a basis
for standardized identification, screening, and diagnosis of presumed TB patients.
Activities
1.1 Improve case detection by expanding case finding to all clinical settings
The National TB Manual, which is the main guidance document for the TB programme, was last
reviewed in 2011, when the emphasis of the programme was activities aimed at reaching the Stop
TB Strategy and the MDGs. As there have been several advances in the approach to TB diagnosis,
including expanded use of the WHO-recommended rapid diagnostics and the need to be proactive
in finding presumptive TB cases, an important first step is the revision of the TB manual. As one of
the objectives of the NSP will be to engage all care providers, including those operating outside
the NTLP network, which includes the private sector, the NSP will develop a set of SOPs, wall charts,
and other job aids that will be circulated to all health care delivery settings to guide clinicians in the
diagnosis, treatment, and referral of presumptive TB patients.
1.1.1 Update the TB manual in line with the latest WHO recommendations
To ensure uniformity in the diagnosis and management of TB, existing guidance documents
will be revised and updated in line with WHO recommendations and disseminated to all health
institutions. The TB manual will describe all the components of the NTLP strategy policy, including
its organizational and managerial aspects; the document will provide comprehensive details on
the identification and management of patients with presumptive TB in all health care settings, TB
diagnosis methods and referral practices for presumptive TB cases, the prescription and follow-up of
TB treatment, the monitoring and evaluation procedures that need to be used, the indications to use
WHO-recommended rapid diagnostics (e.g. Xpert testing), and other issues.
Sub-activities
1.1.1.1 Procure technical assistance (TA) (one international) for two weeks to revise the TB manual
and develop SOPs, algorithms, and other job aids.
1.1.1.2 Hold 2 five-day workshops of 30 participants each to update and finalize the TB manual,
SOPs, algorithms, and job aids.
1.1.1.3 Print 20,000 copies of the TB manual.
1.1.1.4 Distribute the TB manual to all health facilities.
1.1.1.5 Conduct a five-day workshop of 15 participants to develop and finalize the job aids.
1.1.1.6 Print job aids and distribute to all health facilities (40,000 pocket guides, 3,500 flipcharts,
3,500 desk guides, 3,500 wall charts, 10,000 SOPs and 4,000 algorithms for systematic
screening in clinical settings, and 3,500 SOPs and 3,500 algorithms for screening high-risk
groups).
1.1.1.7 Hold a two-day orientation meeting for 25 participants at national level on the new
manual, SOPs, and algorithms (two participants/province).
1.1.1.8 Hold 10 two-day meetings for 250 district staff (four participants per district) at provincial
level to orient them on the revised manual and SOPs.
1.1.1.9 Hold 104 two-day meetings to orient 2,000 district staff (at least one from each facility) for
two days on the revised manual, SOPs, and algorithms.
34
1.1.2 Increase the capacity for identification of presumptive TB patients in ambulatory and
outpatient settings
To identify the missed TB cases, the focus of the NTLP will move from a reliance on mainly passive
case finding for diagnosis of TB to include active identification of presumptive TB cases in all clinical
settings such as outpatient departments (OPDs) using the screening questions found in the TB
manual. Algorithms and SOPS on systematic and active TB screening for all patients and clients
accessing health care services will be developed and distributed to all primary health care providers
in all clinical settings. Community volunteers will be assigned to OPDs and HIV treatment sites
to triage all coughing patients. District TB and clinical care officers will orient all staff in the new
approach to improving case detection. Presumptive TB registers will be placed in OPDs to capture
the referrals for TB investigations. District TB officers will include hospitals and clinic OPDs in their
technical support and supervisory visits to monitor the implementation of the strategy.
Sub-activities
1.1.2.1 Hold a one-day meeting for 25 people to orient provincial TB and clinical care specialists
on the new screening strategy, SOPs, algorithms, and reporting formats (developed in
Sub-activity 1.1.1.5, refer to 1.1.1.7).
1.1.2.2 Hold 10 one-day orientation for 208 district TB and clinical care officers on the new
screening strategy, SOPs, and algorithms (see Sub-activity 1.1.1.8).
1.1.2.3 Hold 150 one-day sensitization workshops for 2,500 (two/facility for primary health
care staff, two/department for hospitals) in all the health facilities on the use of SOPs,
algorithms, and presumptive TB registers (to take place as an extra day during orientation
on revised TB manual, SOPs, and algorithms in Sub-activity 1.1.1.9).
1.1.2.4 Print and distribute presumptive TB registers to the PHOs (20,000 per year).
1.1.2.5 Distribute information, education, and communication (IEC) materials aimed at raising
awareness of TB among clinicians (see Sub-activity 1.9.6.2).
1.1.3 Implement systematic contact investigations
Contact investigation has previously not been conducted in a systematic fashion by the NTLP; where
this has taken place, it has primarily focused on contact investigation for children of smear-positive
individuals. Lessons learned from the structured and systematic methods that were pilot tested in
project conditions (3Is and TB REACH projects) will be used to develop a programme for routine
contact investigations.
SOPs, recording and reporting forms (enumeration forms), and contact tracing registers will be
developed, printed, distributed, and disseminated. These activities will be integrated into the
implementation plan for health facility–based case detection and for household and community
outreach. CSOs and CBOs will be important partners during implementation and will be provided with
enablers to support their activities. The screening will primarily be conducted using questionnaires
and complimented with chest x-ray (CXR) screening where CXR is available.
Data generated will be collected, compiled, and analyzed on a routine basis at facility level, district
level, provincial level, and NTLP Central Unit level.
Sub-activities
1.1.3.1 Procure one local TA consultant for one week to develop guidelines for contact tracing
and investigation.
1.1.3.2 Hold a five-day workshop for 20 people to develop national guidelines, SOPs, and
recording and reporting forms for household contact investigation in line with WHO
guidelines.
1.1.3.3 Print 3,500 copies of the guidelines and SOPs and 10,000 recording and reporting forms.
35
1.1.3.4 Conduct a one-day orientation of 35 provincial TB officers, information officers, and CSO
representatives on the household contact investigation SOPs and guidelines.
1.1.3.5 Conduct 10 one-day orientations of 312 participants (district TB officers, information
officers, and CSO representatives) on the household contact investigation SOPs and
guidelines.
1.1.3.6 Conduct 208 one-day trainings of 30 health care providers in each district on contact
investigations (clinic staff and community health assistants).
1.1.3.7 Identify and train 10,000 community health workers in contact investigations (see Sub-
activity 1.8.2.3).
1.2 Involve all care providers operating outside the NTLP network in TB case detection and
management
Increasing TB case detection and minimizing the number of missed TB cases requires the full
involvement of all care providers practicing outside the NTLP network through PPM approaches.
Involvement of all care providers in the public and private sector will help ensure that all TB cases
are reached, diagnosed, and notified to the NTLP and that all TB patients receive treatment with
quality-assured standardized TB treatment regimens. The NTLP, under the direction of the MOH, will
establish MoUs with non-MOH partners who should participate in TB detection and management.
Organizations that collaborate with the MOH though this MoU will be provided with registers, referral
slips, drugs, and other logistics support based on the scope of work included in the agreement.
1.2.1 Strengthen leadership and coordination mechanism for PPM at national and provincial
level by 2018
To improve coordination and implementation of PPM, the existing national TB TWG terms of reference
will be revised to include coordination of other providers in TB care through a PPM subcommittee
that will steward the PPM agenda. NTLP will ensure the presence of a PPM focal person at the central
level. Furthermore, the NTLP recording and recording forms will be revised to record the source of a
patient’s referral and type of service provider to monitor the contribution of the private sector to TB
case detection and treatment success.
A PPM handbook will be developed to provide guidance on the roles and responsibilities that
each organization will play, and training manuals based on this handbook (including SOPs) will be
developed for each type of organization. During the five years of this strategic plan, the NTLP will
conduct PPM activities in the four provinces along the line of rail, namely Copperbelt, Central, Lusaka,
and Southern provinces, as they have the largest number of private providers. The activities will be
primarily conducted in 30 districts in these provinces.
Sub-activities
1.2.1.1 Procure TA (one international, one local) for 14 days to develop the PPM handbook that
includes the expected functions of the private-sector care providers, develop the PPM
training package, and participate in the national-level training of trainers (TOT).
1.2.1.2 Hold a five-day workshop for 20 people to develop the PPM handbook with the roles and
responsibilities expected for various kinds of private providers, criteria for establishing
an MOU between the MOH and the various types of private providers, a template for an
MOU, SOPs, and a training package for different private providers.
1.2.1.3 Print 2,000 copies of the PPM handbook.
1.2.1.4 Conduct a one-day orientation for 20 provincial staff in PPM-based TB activities in the four
highly urbanized provinces.
1.2.1.5 Conduct four half-day orientations for 90 district staff (four/district) on PPM-based TB
activities.
1.2.1.6 Conduct quarterly one-day PPM sub-group meetings for 25 people each year.
1.2.1.7 Conduct semi-annual one-day PPM meetings with 50 people, including professional
associations and bodies, to strengthen oversight of TB services each year.
36
1.2.2 Strengthen the linkages with faith-based health institutions

CHAZ has 152 CHIs including 36 hospitals, 84 rural health centres, and 32 CBOs. The hospitals and
health centres offer a full range of health care and provide more than 50 percent of health care in
the rural areas. Under the conditions of the MOU signed between the MOH and CHAZ, government
provides for the operating expenses of the institution as well as salaries for staff. The support provided
includes TB drugs, laboratory reagents, and reporting and recording forms and registers and, in turn,
the CHI is obliged to report data to the MOH.
Sub-activities
1.2.2.1 Hold a one-day meeting for 20 people including representatives of the CHIs to develop a
mechanism to strengthen the collaboration between the NTLP and the CHIs.
1.2.2.2 Conduct joint supervisory visits with CHAZ to the CHIs during the routine technical
support and supervisory visits (see Activity 4.4.1).
1.2.2.3 Include CHIs in the review meetings conducted at district, provincial, and national level
(see Activity 4.4.4).
1.2.3 Enhance the role of CBOs, CSOs, and NGOs in TB diagnosis, care, and treatment
The community, through the contribution of volunteers and TB treatment supporters, is a strategic
partner for the TB programme. In addition to playing a vital role in supporting patients throughout
treatment, they also have a role in tracing patients who are lost to follow-up. With the NTLP’s new
active case finding approach, the role of the community will need to expand to include other activities
such as contact tracing and community-level TB screening activities and awareness creation, among
others. To streamline the MOH support to the CBOs, CSOs, and NGOs involved in TB activities, the
NTLP will sign an MOU with the Zambia TB Organizations Coalition, an umbrella body for community-
based organizations working in TB, through which this support will be provided. Although central-
level support to these organizations will be channeled through the umbrella body, at district level
organizations can establish relationships with the district directly without going through the umbrella
body. Working with the organizations, the NTLP will develop a template for an MOU that can be used
at provincial and district levels. This activity is in line with one of the foundational principles of the
End TB Strategy, which is to build strong coalitions with civil society and communities.
Sub-activities
1.2.3.1 Hold a one-day consultative meeting for 50 people with CBOs, CSOs, and NGOs to finalize
the MOU.
1.2.3.2 Print 500 copies of the MOU by NTLP.
1.2.3.3 Disseminate and distribute the MOU through the district and provincial health offices.
1.2.4 Engage private hospitals and clinics in TB care and treatment
The NTLP has developed MoUs with some private hospitals and clinics under previous NSPs. This
sub-intervention therefore aims to improve, strengthen, and expand the involvement of private
hospitals and clinics in TB prevention, care, and control. As not all private facilities will have the
capacity to be diagnostic and treatment centres, use of private facility diagnostic and treatment
hubs will considered. This will minimize the number of facilities to supervise and will assure quality of
services. This strategy will allow patients who are averse to accessing care in public facilities to access
treatment within the private sector that is supervised by the NTLP.
Sub-activities
1.2.4.1 Conduct a one-day meeting for 20 people, including representatives of the Private
Practitioners Association, to review and update the existing MOU that establishes linkages
between private hospitals and clinics and the NTLP.
37
1.2.4.2 Print 100 copies of MOU (in-house).

1.2.4.3 Conduct a five-day assessment by a team of three of the private hospitals and clinics in
each province to determine eligibility to enter into a MOU using the guidance in the PPM
handbook in the four provinces.
1.2.4.4 Conduct four (one in each province) two-day training sessions on TB for 25 health workers
in each session from the private hospitals and clinics identified by the provincial teams as
eligible to participate in the MOU.
1.2.4.5 Conduct supportive supervision quarterly to all private hospitals and clinics during the
quarterly supervisory visits (Activity 4.4.1) by the province.
1.2.4.6 Include private hospitals and clinic in the review meetings at provincial and district level
(Activity 4.4.4).
1.2.5 Engage private laboratories in TB diagnosis
There has been an increase in the number of private hospitals and laboratories that operate outside
the NTLP network. At the time this plan was developed, there were 370 laboratories offering TB
diagnosis (see Table 2); of these, 109 were non-MOH labs (faith-based, military, mines, correctional
facilities, or other private organization). These private laboratories will be engaged by the NTLP
for the provision of appropriate bacteriological TB diagnosis services and to serve as TB diagnostic
laboratories. This will enable the NTLP to include these laboratories in quality assurance (QA) and
supervision.
Sub-activities
1.2.5.1 Hold a one-day consultative meeting for 20 people to finalize the MOU that establishes
linkages between private laboratories and the NTLP.
1.2.5.2 Print 50 copies of the MOU.
1.2.5.3 Conduct a five-day assessment by a team of three of the private laboratories in each of
the four provinces to determine eligibility to enter into an MOU using the guidance in the
PPM handbook (see Sub-activity 1.2.4.3).
1.2.5.4 Conduct 4 one-day training sessions for 15 staff in the private laboratories by the provincial
laboratory staff.
1.2.5.5 Provide private laboratories with relevant consumables for TB diagnosis and treatment
services, along with stationery for the information system used in the NTLP.
1.2.5.6 Conduct supportive supervision quarterly to all private laboratories involved in TB
diagnosis during the regular laboratory supervision (see Sub-activity 1.5.6.2).
1.2.6 Engage private pharmacies and chemists in TB case identification
There are 165 private pharmacies and chemists in Zambia at present. With an estimated 30 percent
of the population engaged in self-medication and these facilities providing much of the over-the-
counter medication, private pharmacies and chemists are a valuable source for the identification of
presumptive TB patients.
Sub-activities
1.2.6.1 Hold a one-day consultative meeting for 20 people to finalize the MOU that establishes
linkages between private pharmacies and chemists and the NTLP.
1.2.6.2 Conduct a five-day assessment by a team of three of the private pharmacies and chemists
in the four provinces to determine eligibility to enter into an MOU using the guidance in
the PPM handbook.
1.2.6.3 Conduct 20 one-day training sessions at district level for 500 staff in the private pharmacies
and chemists.
38
1.2.6.4 Provide private pharmacies and chemists with presumptive TB registers, referral slips, and
sputum containers for presumptive TB patients.
1.2.6.5 Conduct supportive supervision quarterly to all private pharmacies and chemists (Activity
4.4.1).
1.2.7 Enhance the linkage with health services provided by the Ministry of Defense and Ministry
of Home Affairs
Other than the MOH, other government departments and ministries such as Defense and Home
Affairs provide TB services. The Ministry of Defense provides a full range of medical services through
hospitals and clinics that are targeted primarily to their staff but that serve the general population
where the facilities are not within their camps. The Ministry of Home Affairs primarily provides health
care through prison-associated clinics that target inmates and the staff of the correctional facilities
as well as camp clinics within the police residential areas. The NTLP will implement measures to
strengthen the collaboration with these institutions and ministries to improve and strengthen TB
case finding and management through the following actions.
Sub-activities
1.2.7.1 Map the Ministry of Defense and Ministry of Home Affairs TB service areas/clinics and
laboratories.
1.2.7.2 Hold a one-day meeting for 20 people to draft an MOU that establishes linkages between
Ministry of Defense and Ministry of Home Affairs and the NTLP.
1.2.7.3 Hold a one-day consultative meeting for 15 participants with Ministry of Defense and
Ministry of Home Affairs to finalize the MOU and agree on start and end dates.
1.2.7.4 Print 20 copies of the MOU.
1.2.7.5 Hold a national TOT workshop for five days for 20 people in TB care and prevention .
1.2.7.6 Hold 10 provincial trainings every other year for five days for 30 participants each using
NTLP training materials.
1.2.7.7 Conduct supportive supervision quarterly to Ministry of Defense and Ministry of Home
Affairs (see Activity 4.4.1).
1.2.8 Involve traditional healers and practitioners in identification of presumptive TB cases
This activity seeks to improve and strengthen the involvement of the traditional healers in TB
prevention, care, and control. The role of traditional healers will be to identify and refer presumptive TB
patients. Traditional healers will be provided with training that aims to improve their understanding
of the TB burden in Zambia, including morbidity and mortality associated with TB; create awareness
about the role they can plan in minimizing TB burden; and train them on how to identify presumptive
TB patients and refer them to a health facility.
Sub-activities
1.2.8.1 Conduct a desk review to map traditional healers and practitioners through the traditional
healer association.
1.2.8.2 Organize a one-day consultative meeting with 30 traditional healers and practitioners to
finalize the MOU that establishes linkages between traditional healers and practitioners
and the NTLP.
1.2.8.3 Print 1,000 copies of the MOU (in-house printing).
1.2.8.4 Conduct 2 five-day workshops with 10 people to develop and finalize the training manual
for traditional healers (see Community).
1.2.8.5 Print 300 copies of the training manual (see section on Community TB care).
39
1.2.8.6 Conduct 2 five-day national TOT sessions for 20 people at provincial level.
1.2.8.7 Conduct three-day training sessions in 104 districts for 15 people per district.
1.2.8.8 Conduct supportive supervision quarterly to traditional healers and practitioners (see
Activity 4.4.1).
1.3 Strengthen TB services for high-risk groups and vulnerable and key populations
Providing integrated patient-centered care and prevention, as described in the first pillar of the End
TB Strategy, requires that the programme focuses on early diagnosis and treatment of all TB cases as
well as systematic screening of contacts and high-risk groups. The NTLP has identified the following
high-risk groups as the focus in this NSP: PLHIV, contacts of TB patients, individuals with diabetes,
incarcerated individuals, miners and mining communities, children, and women of childbearing age.
These vulnerable groups have previously been included in TB activities, but, as this is the first post-
2015 TB strategy and as the programme seeks to move towards elimination, a concerted effort will
be made to implement specific activities to diagnose and treat TB for these groups.
1.3.1 Improve and strengthen collaborative TB/HIV activities (objective 3)
The NTLP has been implementing TB/HIV collaborative activities since 2005 and, as fully outlined in
Section 3, the NSP will endeavor to maintain the success achieved in reducing the impact of HIV on
the co-infected TB/HIV patient. Working closely with the HIV programme, the NTLP will strengthen
the activities to reduce the impact of TB on HIV-infected individuals such as intensified case finding,
TB infection control, and isoniazid preventive therapy.
1.3.2 Promote TB services for patients with diabetes
The NTLP will collaborate with the Non-Communicable Disease (NCD) Unit within the MOH to detect
TB among high-risk medical groups. In this plan, screening for TB among this high-risk medical group
will be part of the integrated package of hospital-based TB case detection, and all newly registered
diabetic patients will be eligible for routine TB screening as part of their ongoing care. The capacity
of all diabetes clinics in third and second level hospitals will be improved to systematically screen
diabetic patients for TB at least once in a year. Capacity for surveillance of diabetes among TB patients
will be built in TB clinics. Guidance on systematic screening for TB in diabetes clinics and for diabetes
in TB patients will be included in the updated National TB Manual and SOPs.
Anticipated staff constraints for TB screening in designated diabetes clinics would be addressed with
the deployment of community volunteers. Joint coordination between the TB programme and the
NCD Unit will be established and strengthened.
In addition, training on diabetes in TB patients will be incorporated in the initial training of health
workers in health facilities. Supervision of these activities will be carried out by NTLP at all levels as
part of the supervisory visits.
The TB review meetings organized on quarterly basis at national, provincial, district, and health
facility levels will include a review of these activities.
Sub-activities
1.3.2.1 Conduct a three-day workshop for ten participants (NTLP and NCD units) to adapt the
WHO framework to the national framework for TB and diabetes and SOPs for active
screening of TB in diabetes patients.
1.3.2.2 Print 5,000 copies of the national framework on TB and diabetes.
1.3.2.3 Print 5,000 copies of SOPs (symptom screening tools) for active screening of TB in diabetes
patients.
1.3.2.4 Hold a two-day orientation for 20 health care workers at the province level.
1.3.2.5 Hold 4 two-day orientation meetings for 20 TB and clinical care staff at the district levels
on the national framework of TB and diabetes.
40
1.3.2.6 Hold 8 three-day trainings of 200 health care providers working in diabetes clinics, OPD
staff, and community health workers, with a focus on active screening for TB in diabetes
patients.
1.3.2.7 Hold 40 one-day trainings of TB clinic staff on TB and diabetes for 20 people per district.
1.3.3 Improve and reinforce TB services in correctional settings
TB services have been initiated in almost all correctional facilities in Zambia but have not been closely
monitored. Activities will be conducted that will enhance TB screening, diagnosis, and management
of prisoners with TB and minimize transmission within the correctional facilities. To prevent spread of
TB from outside the prison, entry screening will be scaled up to all correctional facilities. To enhance
diagnosis, TB diagnostic services will be established at correctional facilities that have existing health
facilities and that have high numbers of incarcerated populations (> 800). Provincial correctional
facilities will be targeted. Highly sensitive diagnostic tools will be deployed (namely, Xpert). Access to
digital x-ray technology will be enhanced through procurement and placement of units in selected
prison facilities. On discharge from the correctional facility, all individuals with TB and HIV will be
referred to the public health service.
Sub-activities
1.3.3.1 Hold a five-day workshop for 20 people to develop TB in Prisons Guidelines, including all
partners involved in TB in correctional facilities.
1.3.3.2 Hold an annual one-day meeting with 20 participants between the NTLP and the Head of
Health services in correctional settings to discuss and plan the TB activities in the prison
system in line with the established MOU.
1.3.3.3 Hold a five-day training session for 35 health workers practicing in the correctional facility
system and who have not been yet trained on TB prevention, diagnosis, and treatment
(using NTLP guidelines, SOPs, and training materials).
1.3.3.4 Conduct a three-day refresher course for 35 correctional facility health workers who have
been already trained on TB prevention, diagnosis, and treatment (using NTLP guidelines,
SOPs, and training materials).
1.3.3.5 Equip the health unit of eight correctional facilities with Xpert platforms in addition to the
three correctional facilities which are already equipped.
1.3.3.6 Conduct a three-day training for eight health workers of eight correctional facilities newly
equipped with Xpert machines on Xpert testing.
1.3.3.7 Provide LED microscopes to the health units of 16 correctional facilities in addition to the
four correctional facilities that are already equipped.
1.3.3.8 Link the health units equipped with TB laboratories to the existing EQA system (see
Activity 1.5.4).
1.3.3.9 Conduct a five-day training for the 16 health workers from 16 correctional facilities newly
equipped with fluorescent microscopes on sputum smear examination in line with
national guidelines on TB microscopy.
1.3.3.10 Conduct a three-day refresher course for the eight microscopists of the four correctional
facilities already equipped with a microscopy laboratory on sputum smear examination.
1.3.3.11 Supply the correctional facilities health units with Xpert cartridges, microscopy slides,
and other consumables.
1.3.3.12 Conduct universal entry screening for all correctional facility occupants.
1.3.3.13 Implement periodic active case finding for incarcerated prisoners using Xpert testing.
1.3.3.14 Conduct systematic contact screening for all cell inmates of the prisoners diagnosed with
TB using Xpert testing.
41
1.3.3.15 Establish correctional facility health committees with specific TB/HIV training (with
focus on screening, prevention, and control). Correctional facility health committees will
comprise peers and correctional facility staff.
1.3.3.16 Conduct systematic HIV screening for all inmates diagnosed with TB.
1.3.3.17 Conduct systematic TB screening for all HIV-positive inmates.
1.3.3.18 Conduct 65 two-day trainings of correctional facility staff in infection control.
1.3.3.19 Conduct 65 two-day refresher trainings of correctional facility staff in infection control
each year.
1.3.3.20 Conduct 65 two-day trainings of 30 peers in infection control.
1.3.3.21 Conduct 65 two-day refresher trainings of 30 peers in infection control every other year.
1.3.3.22 Establish isolation rooms with adequate ventilation.
1.3.3.23 Ensure discharged prisoners who are on TB and HIV treatment are coordinated between
the correctional facilities health units and NGOs operating in the correctional facility
system.
1.3.3.24 Transport sputum samples collected from correctional facilities with no diagnostic
centres to the nearest TB diagnostic centres.
1.3.4 Strengthen TB control within the mining sector
Mineworkers in Zambia are exposed to substantial environmental and occupational risk factors such
as exposure to silica. The primary drivers of TB in the mines are thought to include HIV infection,
silicosis, poor access to routine health services, accommodation in overcrowded hostels, and circular
migration. There is also poor access to appropriate TB screening and diagnosis services, particularly
among contract workers. The risk of TB in the mines also affects the surrounding communities,
since mineworkers with TB risk transmitting the disease to those living nearby. Further, migration of
mineworkers across provinces makes the TB in the mining sector a complex problem.
In 2012, the Heads of State in the SADC countries signed a Declaration on TB in the Mines in recognition
of the burden of TB in the mining sector and the specific vulnerabilities among mineworkers that
increase their risk of developing TB. Following this declaration, the World Bank and the Global Fund,
through country and regional grants, have made available funds to support regional projects on
improving TB services in the mining sector. These projects will implement a range of activities at
both regional and country level that span the whole spectrum of TB prevention, care and treatment,
policy and legislation, improving health and safety in the mines, and cross-border coordination and
tracking of TB patients, as well as community systems strengthening.
In Zambia, legislation that governs safety and health in the mining industry as well as compensation
and compulsory screening for TB and silicosis in the mineworkers falls under the Ministry of Mines,
the Ministry of Labour, and the Ministry of Health. The MOH will play a catalytic role in convening a
consultation of all stakeholders in the area of health and safety in the mines to develop a coordinating
committee for TB and silicosis in the mines. This committee will develop an action plan to address
TB in the mines that will include a review of the existing legislation in line with international best
practices.
Sub-activities
1.3.4.1 Map all the stakeholders (regulatory authorities, donors, implementing partners, mining
unions, community) involved in TB activities in the mines (desk review).
1.3.4.2 Hold a three-day consensus meeting for 100 participants to discuss the coordination
mechanism, roles of each stakeholder, and mapping findings and develop an action plan
to address TB in the mines.
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1.3.4.3 Hold an annual one-day consultative meeting for 30 participants with Ministry of Mines,
the Ministry of Labour, and the Ministry of Justice to advocate for a review of the legislation
regarding mine worker safety and health and updating of health inspection guidelines
and protocols.
1.3.4.4 Hold quarterly one-day meetings for 20 members of the National Technical Committee
on TB in Mines.
1.3.4.5 Procure 25 four-module and two 16-module GeneXpert machines for the mining towns.
1.3.4.6 Establish systems for transportation of sputum samples and other commodities (Activity
1.5).
1.3.4.7 Build 25 prefabricated buildings for smear microscopy in mining communities.
1.3.4.8 Hold monthly one-day community meetings for 25 participants for planning and
reporting purposes (Activity 1.8.3).
1.3.4.9 Hold quarterly one-day community meetings for 50 participants to provide feedback to
the community.
1.3.4.10 Hold a four-day meeting for 30 participants to develop IEC materials targeted for mining
communities, including pre-testing the IEC.
1.3.4.11 Print 10,000 copies of the IEC materials.
1.3.4.12 Distribute the IEC materials through the sputum collection points.
1.3.5 Improve and strengthen TB services for children and adolescents
Childhood TB has not received the attention it needs, and capacity to detect and treat TB among
children is not yet fully developed at the periphery level. The proportion of children notified is low at
6 percent and declining compared to the global target of at least 10 percent. The capacity to diagnose
TB in children is limited to referral centres and facilities with pediatric expertise. There are missed
opportunities in finding childhood TB and for preventing TB through systematic contact investigation
and provision of IPT for child contacts of bacteriologically confirmed TB cases. An opportunity exists
to conduct outreach activities and community engagement for improved case detection among
children in household contacts. The programme does not routinely report the treatment success rate
among children on TB treatment. There is, however, a functional childhood TB working group that has
developed guidelines and training manual, which must be implemented within the programmatic
context. Health facilities will be supported with diagnostic algorithms, x-ray films/equipment, and
GeneXpert testing to support TB diagnosis in children. Alongside the provision of diagnostic tools,
clinical skills in the management of childhood TB will be improved through a system of mentorship
provided by experienced pediatricians and medical officers to provincial and district-level facilities.
A focal point person for childhood TB activities will be appointed to work with the NTLP Central Unit.
Sub-activities
1.3.5.1 Conduct quarterly (one-day) childhood TB subcommittee meetings of the National TB
subgroup for 10 persons (Sub-activity 4.2.1.2).
1.3.5.2 Conduct a baseline assessment of childhood TB services for 10 days by three teams of
three people each.
1.3.5.3 Hold a one-day meeting for 30 people to disseminate findings of baseline assessment.
1.3.5.4 Conduct 2 five-day workshops for 15 people to develop a childhood TB pocket guide,
SOPs to implement the guidelines, job aids for sputum induction, dosing charts for new
fixed-dose combinations (FDCs), IPT registers and patient cards for child contacts, and IEC
materials for childhood TB, including the new FDCs.
1.3.5.5 Print 40,000 copies of the childhood TB pocket guide, 3,500 SOPs, 6,000 IPT registers, and
3,500 FDC dosing charts.
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1.3.5.6 Conduct an initial five-day TOT session for 30 health care workers on childhood TB,
including mentorship in 10 provinces (three from each province).
1.3.5.7 Conduct 10 three-day for 350 staff (three staff per district).
1.3.5.8 Conduct 5 three-day trainings on childhood TB in each of the 104 districts (150 participants
per district) for private facilities, mines, and CSOs, including training on sputum induction
and specimen collection.
1.3.5.9 Conduct quarterly two-day on-site post-training clinical mentorship visits by a team of
two (a pediatrician/medical officer and a provincial/district TB officer) to 150 hospitals at
provincial and district levels (to general and district hospital).
1.3.5.10 Hold a one-day consultative meeting for 15 participants between NTLP, Reproductive
Maternal, Newborn, Child, and Adolescent Health (RMNCAH), and Nutrition units on
provision of childhood TB services to discuss the best approach to use to integrate
childhood TB activities in other relevant public health programmes.
1.3.5.11 Hold a five-day meeting for 20 participants between NTLP, RMNCAH, and Nutrition units
to develop job aids and revise the integrated management of childhood illnesses (IMCI)
and growth monitoring tools.
1.3.5.12 Procure 300 nebulisers (2 for each of 150 facilities targeted).
1.3.5.13 Procure 250 suction foot pumps.
1.3.5.14 Procure 25,000 specimen traps (same quantities specimen—quantities require an
estimate of number of pediatric presumptive cases under the age of 12 years per district
or facilities targeted).
1.3.5.15 Procure consumables for sputum induction for 150 facilities (FG Nasal Gastric tubes in
size 6/8/10, specimen containers).
1.3.5.16 Equip sputum induction units with required consumables for practical demonstrations at
all provincial and tertiary hospitals.
1.3.5.17 Procure 25,000 Mantoux tests for 150 facilities (all district, provincial, tertiary, and third,
second, and first level hospitals).
1.3.5.18 Procure 1,000 vials of PPD (purified protein derivative for Mantoux test, 1 vial can be used
for 10 tests) for selected large-volume district hospitals, provincial hospitals, and tertiary
hospitals.
1.3.5.19 Conduct a two-day national dissemination meeting for revised treatment and dosing
guidelines for TB in children for 40 participants (4 participants per province).
1.3.5.20 Procure new pediatric FDCs (rifampicin/isoniazid/pyrazinamide [RHZ] 75/50/150 mg and
rifampicin/isoniazid [RH] 75/50 mg).
1.3.6 Promote TB services for women
Pregnant women are at a particular high risk for TB. This risk is even higher where HIV infection
is also present. To improve TB services and reduce deaths from TB in this population, systematic
screening for TB will be introduced in antenatal/PMTCT clinics so that every woman is screened at
each antenatal visit. Women who do not have TB but who have HIV infection will be provided with
IPT. TB/HIV sensitization will be conducted in maternal and child health (MCH) clinics (under-five)
and growth monitoring points to raise awareness of TB and create demand.
Sub-activities
1.3.6.1 Hold a one-day consultative meeting for 20 participants between NTLP and RMNCAH
unit, on provision of TB services (see Sub-activity 1.3.6.10).
1.3.6.2 Hold a two-day meeting for 10 participants to incorporate TB in the RMNCAH job aids and
RMNCAH antenatal booklet.
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1.3.6.3 Print 40,000 copies of the revised antenatal booklets.

1.3.6.4 Print 20,000 copies of the revised job aids.
1.3.6.5 Procure 500 GeneXpert Omni devices for antenatal clinics.
1.3.6.6 Conduct on-site one-day training in GeneXpert Omni device for 1,000 nurses.
1.3.6.7 Distribute TB screening job cards and screening tools to antenatal clinics.
1.3.6.8 Ensure referral forms are available in all antenatal clinics.
1.3.6.9 Carry out TB screening for all pregnant women during every antenatal/postnatal visit.
1.3.6.10 Ensure monitoring and evaluation on screening activities in women using the existing
registration system of RMNCAH.
1.3.7 Implement annual screening of health workers for TB
Health care workers have been classified as one of the high-risk groups for tuberculosis and are
therefore eligible for systematic screening for TB in the workplace by the WHO. Providing TB screening
as part of occupational health and safety measures can contribute to earlier diagnosis of TB in health
care workers, resulting in early treatment with better outcomes of treatment for the health workers
as well as reducing the probability of transmission of infection to co-workers or patients.
Sub-activities
1.3.7.1 Engage policy makers, hospital heads on implementation of the policy on health worker
screening for TB.
1.3.7.2 Conduct 2 five-day workshops for 15 partcipants to develop the guidelines, SOPs, and
reporting forms and modalities for screening of health workers for TB.
1.3.7.3 Print 3,000 copies of the guidelines, the SOPs, and the forms.
1.3.7.4 Hold a one-day dissemination meeting for 100 participants on the guidelines and SOPs to
representatives of professional bodies, such as the Health Professions Council of Zambia,
Zambia Nursing Council, Zambia Medical Association, clinical care specialists, and health
workers union.
1.3.7.5 Distribute the guidelines, SOPs and forms.to provinces, district and health facilities
1.4 Improve and reinforce TB services in high TB-burden areas
The WHO recommends systematic TB screening in populations with TB prevalence of 1 percent or
more. Highly urbanized, densely populated settings with crowded poor housing have been identified
as TB hot spots. Copperbelt and Lusaka provinces were identified to have the highest prevalence
of TB. In Lusaka, notification of TB is highest in peri-urban, over-crowded settlements that have TB
notification rates above the provincial average and above the country average. During this strategic
plan, the NTLP will focus on 60 high-burden districts from all 10 provinces, to be determined through
an analysis of the 2016 TB notifications. These TB hot spots will be targeted with systematic TB
screening activities including symptom screening, sputum collection, sputum testing by GeneXpert,
screening by digital x-ray, and HIV testing.
1.4.1 Conduct mapping of high-risk populations in high desnity areas of Lusaka and Copperbelt
province using facility-level notification data and GIS (geographic information system).
1.4.2 Hold a two-day meeting for 20 people to develop tools for community TB screening
campaigns.
1.4.3 Conduct 60 two-day meetings to review the TB hot spots and develop an action plan to
address these hot spots for 10 participants per district (district TB coordinator, district
health information officer [DHIO], district environmental officer, community health
assistants, and TB CSO representatives).
1.4.4 Conduct annual TB/HIV community sensitization meetings for 3 months in 60 districts (in
schools, in churches, and at traditional ceremonies and other public gatherings) using
45
public address systems, community drama groups, and local radio stations
1.4.5 Conduct 10 bi-annual mass screening campaigns in selected hot spot districts by a team
of 10 staff for 2 weeks with door-to-door active case finding by community volunteers,
static sputum collection points, and use of mobile digital x-ray technology.
1.5 Strengthen TB diagnostic capacity through expansion and enhancement of the laboratory
network
Laboratory services are the cornerstone of TB diagnostics in Zambia. This strategic intervention
will ensure the provision of quality-assured laboratory services. Laboratory capacity will be
strengthened through the revision of diagnostic guidelines algorithms and SOPs, introduction of
WHO-recommended rapid diagnostic tools such as LPA and Xpert MTB RIF, laboratory infrastructure
renovation, equipment procurement and maintenance, specimen transportation, use of laboratory
management information system (LMIS), and quality assurance services (QA).
1.5.1 Strengthen the TB microscopy network
The NTLP will strengthen the TB microscopy network by scaling up the use of LED fluorescent
microscopy for monitoring treatment of drug-susceptible TB. The light microscopy (Ziehl-Neelsen,
or ZN) method for TB diagnosis will be phased out by the end of 2018. The programme will use
Xpert MTB/RIF testing as a first diagnostic tool. A consultative process between public health and
Clinical care and diagnosictics departmets will ensure that there is harmonization of staff and lab
infrastructure.
Sub-activities
1.5.1.1 Conduct a desk review to map the location and functional status of the existing TB
laboratories in the country.
1.5.1.2 Hold 2 one-day meetings for 25 people (from the technical working group) on the
findings of the desk review, identify facilities in which to open new diagnostic centres,
make recommendations for strengthening the existing laboratories and expanding the
network, and develop a road map for development of new facilities.
1.5.1.3 Procure 170 fluorescent microscopes to replace the light microscopes in all the remaining
laboratories that need them by early 2018 (of the existing 370 TB microscopy laboratories,
200 are already equipped with fluorescent microscopes).
1.5.2 Revise microscopy and Xpert guidelines and SOPs
Sub-activities
1.5.2.1 Hold 2 five-day workshops for the revision of the microscopy and Xpert guidelines and
SOPs for 20 participants, including recording and reporting forms (linked to Sub-activity
1.1.1.2).
1.5.2.2 Print 1,000 copies each of the revised guidelines and SOPs.
1.5.2.3 Print 100,000 copies of the recording and reporting tools (break down by recording tools
and reporting tools).
1.5.2.4 Distribute the recording and reporting tools to all relevant facilities (budget for
transportation).
1.5.2.5 Train laboratory staff on the revised recording and reporting forms (integrate it in the
training of health workers on smear microscopy and Xpert testing).
1.5.2.6 Disseminate SOPs to all facilities.
1.5.2.7 Conduct 15 five-day workshops to train 350 technologists in the 170 labs newly equipped
with fluorescent microscopes (training will include EQA and LMIS/recording and reporting.
46
1.5.2.8 Conduct 10 annual three-day refresher training courses for 200 technologists in labs
already equipped with fluorescent microscopes. In each training, a session will be devoted
to EQA (and another session to the new laboratory recording and reporting forms).
1.5.3 Expand the provision of Xpert tests to make it the first-line diagnostic test starting with all
sites that have an Xpert machine
In line with the End TB Strategy, the Ministry of Health through NTLP will revise the diagnostic
algorithm to ensure that all presumed TB patients have universal access to WHO-recommended rapid
diagnostic tools. This will be done by making the Xpert assay a first-line diagnostic test in all facilities
that have access to a GeneXpert machine. Smear microscopy will be used for monitoring treatment.
There are currently 69 GeneXpert machines in the country with an additional 31 on order. NTLP will
procure 390 GeneXpert machines to bring the total in the country to 490. An initial procurement
of 200 GeneXpert machines will be done in the first two years and further requirements assessed
during the mid-term review.
Sub-activities
1.5.3.1 Procure and install 15 GeneXpert XVI machines.
1.5.3.2 Procure and install 385 GeneXpert IV machines.
1.5.3.3 Hold 2 one-day meetings per year of the laboratory subcommittee of the National TB TWG
which will allocate new GeneXpert machines to facilities, including correctional facilities
and other congregate settings.
1.5.3.4 Hold 10 three-day trainings for 300 staff in the new sites for Xpert testing.
1.5.3.5 Hold 4 one-day refresher trainings for 100 laboratory staff who are dealing with Xpert
testing; this training will include a session on the use of the new laboratory recording and
reporting forms.
1.5.4 Strengthen external quality assurance (EQA) system
Sub-activities
1.5.4.1 Hold a five-day workshop with 20 participants (Laboratory subcommittee of the TWG and
NRL staff ) to revise the national EQA guidelines.
1.5.4.2 Print 1,000 copies of the revised national EQA guidelines.
1.5.4.3 Disseminate and distribute the national EQA guidelines to all facilities.
1.5.4.4 Hold 10 three-day EQA trainings for 20 laboratory supervisors and EQA implementers.
1.5.4.5 Enroll all LED microscopy sites in the EQA programme.
1.5.4.6 Enroll all the existing GeneXpert sites in the EQA scheme.
1.5.4.7 Pay for transportation for proficiency testing samples for the three TB culture and DST
laboratories from the SNRL.
1.5.4.8 Conduct EQA activities for smear microscopy in 450 microscopy centres for 10 days per
quarter per year by two staff.
1.5.5 Improve laboratory coordination and supervision
Sub-activities
1.5.5.1 Hold an annual one-day review meeting on TB laboratory activities, including a review of
EQA results for the TB laboratory network of Zambia for 30 participants, and develop an
action plan to address identified deficiencies.
47
1.5.5.2 Conduct 5 three-day mentorship visits by two (national/provincial/lab subcommittee)

staff to selected facilities in each province per year to be selected based on outcomes of
the annual review meeting.
1.5.6 Improve laboratory infrastructure
To offer quality TB laboratory services, the infrastructure must be of acceptable standard and
environmental infection control measures must be included in the construction and renovation of
laboratories that process TB specimens. The NTLP will ensure that new laboratories have infrastructure
that supports the diagnostic services that are being offered. Furthermore, existing TB laboratories
that have infrastructural limitations will also be renovated to make them fit for use.
Sub-activities
1.5.6.1 Conduct a needs assessment for existing laboratories during EQA visits and develop a
priority list for upgrading, renovations, and construction of new facilities
1.5.6.2 Develop a Bill of Quantities (BOQ) based on needs of the laboratory.
1.5.6.3 Renovate 10 existing laboratories.
1.5.7 Procure laboratory equipment
To ensure optimal operation of the laboratory, equipment will be procured for the TB laboratory
network. This equipment will be distributed to the TB laboratory network and culture laboratories
according to needs that will be identified from the laboratory assessments and visits.
Sub-activities
1.5.7.1 Procure three (24-bucket) centrifuges—one for each of the three culture laboratories.
1.5.7.2 Procure three autoclaves.
1.5.7.3 Procure 400 printers for GeneXpert machines and uninterrupted power supply units.
1.5.8 Ensure equipment maintenance
Maintenance of laboratory equipment is a requirement if optimal and uninterrupted service is
to be provided. The NTLP will ensure laboratory equipment is maintained by the procurement of
the services and supplies needed (for example, calibrators and modules will be procured for the
GeneXpert machines). For the culture facilities, safety will be enhanced by ensuring that biosafety
cabinets are serviced. A service contract for two years will be provided as part of the purchase price
and an extension warranty will be procured for an additional three years. The extension warranty will
include calibrator kits and replacement modules and therefore these will not be procured separately.
Each machine should be calibrated at the end of the first 12 months in order for the initial warranty
to be valid.
Sub-activities
1.5.8.1 Ensure maintenance contracts for 69 existing GeneXpert machines.
1.5.8.2 Ensure service contracts for 490 GeneXpert machines.
1.5.8.3 Hold 10 four-day GeneXpert maintenance trainings for 10 laboratory personnel in 10
provinces.
1.5.8.4 Procure three service contracts for biosafety cabinets.
1.5.8.5 Procure GeneXpert replacement modules (under warranty).
1.5.9 Strengthen existing culture and drug-susceptibility testing facilities
Zambia has three culture facilities; two are located in Lusaka and one in Ndola. The three culture
laboratories will continue to offer culture services and DST services by liquid and solid media
48
methods. For DST services, first- and second-line drug-susceptibility testing will be offered using LPA.
The Chest Disease Laboratory (CDL) and Tropical Disease Research Centre (TDRC) TB laboratories
have molecular equipment in place except for the University Teaching Hospital (UTH) TB laboratory.
The NTLP will procure the LPA equipment for UTH to enhance service provision.
The UTH laboratory has a BSL3 facility. However, the National TB Reference Laboratory has
infrastructural challenges and needs to be upgraded to BSL3. Other issues to be considered for
culture and DST are equipment maintenance, availability of supplies, and trainings.
Sub-activities
1.5.9.1 Build a laboratory to accommodate BSL3 for the NRL facility by 2018.
1.5.9.2 Secure maintenance contracts for all three culture laboratories.
1.5.9.3 Purchase one GT Blot 48 LPA system for the UTH laboratory.
1.5.10 Enhance skills of laboratory staff
Sub-activities
1.5.10.1 Conduct a five-day refresher training for 15 staff from culture facilities (5 from each lab) in
culture, DST, and molecular techniques at SNRL in Uganda.
1.5.10.2 Hold 15 three-day training meetings for 225 staff in laboratory techniques, including
biosafety and biosecurity.
1.5.10.3 Train six staff from the culture facilities as auditors for five days at the SNRL in Uganda.
1.5.10.4 Train four staff from the culture facilities as quality officers for four days at the SNRL in
Uganda.
1.5.10.5 Train 20 staff for five days on packaging and transportation of infectious material
(according to International Air Transport Association [IATA] regulations) in South Africa.
1.5.10.6 Conduct on-site half-day training for 900 lab staff in packaging and transportation of
infectious materials.
1.5.11 Procure laboratory logistics and supplies
The NTLP will support the microscopy and culture laboratories by procuring the reagents that are
needed to provide quality and timely services. The support will include reagents for the provision
of culture and DST services for first- and second-line anti-TB drugs. Other supplies to be procured
include personal protective equipment (PPE) for the laboratory staff.
Sub-activities
1.5.11.1 Procure two million sputum containers to cover the needs for the five years covered by
the NSP.
1.5.11.2 Procure two million Xpert cartridges to cover the needs for the five years covered by the
NSP.
1.5.11.3 Procure 20,000 OMNIgene SPUTUM reagent for culture.
1.5.11.4 Procure 500 GenoType MTBDRplus kits for first-line LPA.
1.5.11.5 Procure 50 GenoType MTBDRsl kits for second-line LPA.
1.5.11.6 Procure 20 CM boxes for LPA.
1.5.11.7 Procure 900 boxes of BD BACTEC Mycobacteria Growth Indicator Tubes (MGITs).
1.5.11.8 Procure 700 MGIT supplement boxes.
49
1.5.11.9 Procure 1,100 streptomycin isoniazid rifampicin ethambutol boxes.

1.5.11.10 Procure six million orange sticks.
1.5.11.11 Procure 1,000 50-g bottles of auramine O.
1.5.11.12 Procure 2,000 2-L bottles of hydrochloric acid.
1.5.11.13 Procure 10,000 2-L bottles of 99.9% ethanol.
1.5.11.14 Procure 5,000, 2-L bottles of phenol.
1.5.11.15 Procure 600 TB identification boxes (Capilia TB-Neo assay for detection of MPT 64 antigen).
1.5.11.16 Procure 90,000 boxes of slides to cover the needs for the five years covered by the NSP.
1.5.11.17 Procure one million N95 masks to cover the needs for the five years covered by the NSP.
1.5.11.18 Procure PPE for laboratory staff (100 gowns, 3,000 lab coats, 500 head cover, 100 laboratory
shoes, and 500 safety shoe covers) to cover the needs for the five years covers by the NSP.
1.5.11.19 Procure 600 TB identification kits.
1.5.11.20 Procure 500,000 surgical masks.
1.5.11.21 Procure 50 N95 fit testing kits.
1.5.12 Provide a courier system for specimen transportation
A specimen transportation system will be established under this strategic plan. The system will be
at two levels. Firstly, courier services will be sourced for the transportation of specimens to the three
culture facilities. Secondly, specimen transportation will be established, linking the Xpert testing
hubs to other facilities that do not have Xpert. This will enhance accessibility for all the sites that
need the Xpert testing services.
Packaging supplies will be procured to ensure that samples are transported in a safe way whilst
preserving the integrity of the sample.
Sub-activities
1.5.12.1 Procure courier services for the 104 districts to three culture laboratories.
1.5.12.2 Procure courier services for inter-district sample transportation system from the 1,500
health facilities to 490 Xpert testing sites within the provinces.
1.5.12.3 Procure two million specimen biohazard bags.
1.5.12.4 Procure 500 electric cooler boxes.
1.5.12.5 Procure 500 (1-kg units) absorbent material.
1.5.12.6 Print three million copies of dispatch and transportation forms.
1.5.12.7 Procure 2,000 biohazard signs for cooler boxes.
1.5.13 Enhance laboratory management information system
GXAlert connectivity software will be installed to link the planned 490 GeneXpert machines in order
to facilitate monitoring of their performance and utilization. To do that, internet connectivity will
need to be ensured for all 490 GeneXpert machines. This will be done by procuring modems and
servers and paying for internet connectivity.
An LMIS will also be established that will link the three culture facilities to the 450 microscopy centres
and 490 GeneXpert facilities.
Sub-activities
1.5.13.1 Install GXAlert system to link 490 GeneXpert machines to main system at central level.
50
1.5.13.2 Procure 490 modems for internet connectivity.

1.5.13.3 Procure internet connectivity for 490 GeneXpert machines.
1.5.13.4 Conduct 20 two-day trainings for 300 laboratory staff in GXAlert system in the districts.
1.5.13.5 Establish LMIS linking culture facilities to 490 laboratories and DR-TB management
facilities using DHIS2 and the SmartCare electronic medical records system.
1.5.14 Ensure laboratory accreditation
As part of strengthening the delivery of quality health services, the NTLP will support the three culture
laboratories in accreditation to ISO 15189 standard. This will include on-site mentorship support by
an international mentor and visits to accredited labs.
Sub-activities
1.5.14.1 Conduct nine mentorship and supportive visits to each of the three culture laboratories
for two weeks at each laboratory.
1.5.14.2 Conduct five mentorship visits to SNRL in Uganda for 15 staff from the culture facilities.
1.5.14.3 Conduct three external audits by an accrediting organization (one each for CDL, UTH, and
TDRC culture labs).
1.6 Strenthen the technical platform to improve TB diagnostic procedures
1.6.1 Expand the use of chest x-ray as a TB screening tool
The role of x-ray technology in screening for TB is increasingly being recognized. Emerging evidence
suggests x-rays can help identify presumptive TB patients who can be missed by symptom screening
due to atypical presentation of TB, especially in the face of HIV. Digital x-ray machines will be
procured to support the TB diagnostic process and to increase the number of patients identified
as presumptive TB patients. The MOH has embarked on a programme to expand the availability of
digital x-rays as part of radiological services, with a central server at the University Teaching Hospital.
The NTLP will liaise with the radiological service to utilize the proposed central server and database.
Sub-activities
1.6.1.1 Purchase four mobile digital x-ray machines for TB hot spot districts.
1.6.1.2 Purchase one million CDs for saving CXR images (procure servers, ensure internet
connectivity).
1.6.1.3 Deploy four technicians to operate the mobile digital x-ray machines.
1.6.1.4 Ensure the maintenance of the digital x-ray equipment by having service agreements
with the suppliers of the equipment or approved in-country dealer.
1.6.2 Enhance the diagnosis of extra-pulmonary TB
EP TB comprises about 24 percent of the annual TB notifications. Most diagnoses are made based
on clinician impressions and not on microbiological diagnosis. This intervention will include
development of guidelines for the diagnosis of EP TB and enhancing the capacity for specific
microbiological diagnosis of TB.
Sub-activities
1.6.2.1 Hold 2 five-day meetings for 20 people to develop and finalize guidelines and algorithms
for EP TB (combined with Sub-activity 1.1.1.2).
1.6.2.2 Print and distribute 10,000 copies of EP TB diagnostic algorithms.
1.6.2.3 Train 20 provincial TOT (two from each province) in EP TB diagnostics including procedures
51
(pleural biopsy, lymph node biopsy, and lumbar punctures).

1.6.2.4 Conduct 104 three-day on-site trainings for 10 people/district on EP TB diagnostic
procedures.
1.6.2.5 Procure 30 Abrams needles for pleural biopsies for the 10 provinces (two for each general
and tertiary-level hospital).
1.6.2.6 Print and distribute SOPs for pleural biopsies.
1.6.2.7 Procure adenosine deaminase (ADA) reagents for 40,000 tests (for processing pleural and
ascitic fluid).
1.6.2.8 Procure 100 spinal needle sets.
In the last decade, the country has attained a treatment success rate of 85 percent or above. NTLP
aims to achieve a success rate of 90 percent and above during the life of this strategic plan. The
treatment success rate is affected negatively by death rate, lost to follow-up rate, treatment failure
rate and not evaluated which account for 15 percent of the total treatment outcome rates.
Procurement and supply chain management (PSM) of anti-TB medicines is a major component of
TB prevention, care, and control, reflecting one of the fundamental management capacities of a TB
programme. The NTLP recognizes the need to have well-functioning PSM to ensure that there are
no interruptions in the supply of quality-assured anti-TB medicines while minimizing wastage due
to expiry.
1.7.1 Ensure uninterrupted availability of adult and pediatric quality-assured formulations
(including good storage) for all patients
Sub-activities
1.7.1.1 Hold a five-day annual forecasting and quantification meeting for 20 people.
1.7.1.2 Hold quarterly forecasting and quantification review meetings (to be integrated into the
quarterly meeting organized by the NTLP).
1.7.1.3 Procure first-line adult anti-TB drugs.
1.7.1.4 Procure first-line new pediatric drugs one-year bank buffer stock.
1.7.1.5 Procure second-line anti-TB drugs for treatment of MDR-TB.
1.7.1.6 Procure isoniazid and pyridoxine for IPT for PLHIV who have no active TB and children
who are contacts of index cases and do not have active TB.
1.7.1.7 Procure new drugs (bedaquiline).
1.7.1.8 Intensify technical support supervision and mentorship.
1.7.2 Strengthen active TB drug safety monitoring and management (aDSM)
Sub-activities
1.7.2.1 Procure reagents for renal function and thyroid function tests: 57,000 each of alkaline
phosphatase, alanine aminotransferase, creatinine kinase, serum calcium, serum
potassium, and serum magnesium (over the five years of the plan).
1.7.2.2 Procure international consultant for 14 days to develop a framework document on
the implementation of aDSM in collaboration with the Zambia Medicines Regulatory
Authority (ZAMRA).
1.7.2.3 Orient staff to do active TB aDSM (pharmacovigilance) activities regarding first-line and
second-line TB medicines (during other training).
1.7.2.4 Adopt an electronic system to implement aDSM using Pharmacovigilance Monitoring
System (PViMS).
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1.7.2.5 Conduct training on PViMS for TB district officers and health workers dealing with TB
patients in health facilities equipped with computers.
1.7.3 Strengthen the logistics management information system for TB drugs
Sub-activities
1.7.3.1 Procure TA (international consultant for 14 days to evaluate the anti-TB drugs management
process (from estimate of needs for anti-TB drugs up to their distribution to patients).
1.7.3.2 Conduct a pre-test of the LMIS.
1.7.3.3 Hold a five-day meeting for 15 people to review the assessment report, revise the LMIS,
and develop a training package for the LMIS based on the findings.
1.7.3.4 Print 2,000 copies of the LMIS training package.
1.7.3.5 Hold a three-day workshop to train 10 provincial logisticians on the revised LMIS, including
the training package.
1.7.3.6 Hold 10 three-day workshops to train 300 district pharmacy and logisticians on the revised
LMIS.
1.7.3.7 Roll out implementation of the revised LMIS.
1.7.3.8 Hold a three-day meeting for 15 people to develop tools for routinely assessing the
logistics management of anti-TB drugs.
1.7.3.9 Print the tools for assessing the logistics management of anti-TB drugs.
1.7.3.10 Conduct quarterly supervisory visits for 14 days by four people to districts and facility
health staff on logistics management of anti-TB medicines.
1.8 Strenthen collaboration mechanisms between NTLP and CBOS, CSOs, and NGOs to improve
community TB services at central level
Patient care and support is an integral and essential component of TB control services. It removes
barriers to TB care services. External reviewers of the programme largely attributed the success of
the NTLP to care and support component of the programme. CSOs have a comparative advantage in
contributing to the TB patient care and support through community treatment supporters.
Strengthening the capacity of community systems to expand access to services is key and requires
a systematic and comprehensive strategy to address capacity, referral networks, and coordination
and feedback mechanisms. All provinces should implement strategies to support districts and local
communities to address challenges and strengthen community systems. These should be reflected
in the integrated development plans.
The NTLP will put in place a 25-member consultative body consisting of representatives from CSOs,
CBOs, NGOs, the NTLP, and HPO to strengthen collaboration between NTLP and these organizations.
Relevant existing documents on the national strategy to prevent and control TB in Zambia, the 5-year
NSP including the budget, and the annual operational plans will be shared with partners.
The Zambia TB Organizations Coalition (ZTOC), a CSO TB umbrella body, will work with the NTLP to
strengthen community TB services. To ensure that this umbrella body has the capacity to support
community-based initiatives in ensuring better accountability of TB and health programmes, core
funding for costs such as salaries, rent, and equipment will be sourced from other cooperating
partners and bilateral funders. An MOU will be developed between MOH and ZTOC indicating the
range of support to be provided to the coalition and its member organizations. CBOs and CSOs that
are not member of the ZTOC will establish separate agreements with the District Health Offices in
their operating areas.
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At the lowest level of health care are community health assistants (CHAs), a cadre of staff that should
work closely with CSOs and community TB/HIV supporters. There are about 1,640 CHAs deployed
throughout the 104 districts. The NTLP will ensure that former TB patients are included in all
community activities as peers.
NTLP will implement the following approaches to improve and strengthen community networks in
TB service provision.
1.8.1 Develop guidance documents, training materials, and M&E tools for community TB/HIV
activities
To ensure that community activities are standardized across the country, community TB/HIV
guidelines will be developed, the existing TB/HIV treatment supporter manual will be updated,
and M&E tools for monitoring the contribution and outcomes of community TB activities will be
developed.
Sub-activities
1.8.1.1 Establish an updated database of CBOs, CSOs, and NGOs that are involved in TB control.
1.8.1.2 Procure TA for 30 days to help develop community TB/HIV guidelines, update the TB/HIV
treatment supporter handbook, develop M&E tools, and create related training modules
(see also Sub-activity 1.9.1.1).
1.8.1.3 Conduct 2 five-day workshops for 25 participants to develop the community TB/HIV
guidelines, update the TB/HIV treatment supporter handbook, develop M&E tools, and
create related training modules.
1.8.1.4 Print 3,000 copies each of the community TB/HIV guidelines, updated TB/HIV treatment
supporter handbook, M&E tools, and training modules.
1.8.1.5 Distribute copies of the community TB/HIV guidelines, TB/HIV treatment supporter
handbook, and M&E tools to all the districts.
1.8.1.6 Conduct a three-day meeting to orient 20 CSO representatives on the TB/HIV guidelines,
treatment supporter handbook, M&E tools, and training modules.
1.8.1.7 Conduct annual two-day meetings for 50 participants to review the programme
performance.
1.8.2 Ensure capacity-building in TB prevention, care, and support for CBOs, CSOs, and NGOs to
improve community TB services, including DOT, contact tracing, and supervision of activities
Community engagement in TB services is a vital component to guarantee the success of the
programme. The community volunteers have the following roles in TB prevention, care, and
treatment: identification of presumptive TB patients in the community and referral to the health
facility; patient and community education to increase demand for TB health services and ensure
adherence to TB treatment (through directly observed treatment, or DOT); raising awareness of TB in
the neighborhoods of urban areas; conducting home visits and systematic screening for tuberculosis
among the TB patients’ contacts; and the identification and recovery of patients who have interrupted
treatment.
Special attention will be attached to providing the services of community volunteers in provinces
having the highest burden of TB.
To facilitate early diagnosis and treatment, all community health workers will be expected to
facilitate contact screening for TB in a confidential and sensitive manner. Contact tracing should be
accompanied by educational and awareness programmes. Contact tracing, especially of children of
TB patients, should be a prime function of the envisaged community-based outreach teams as well
as school health services and should strengthen referral and community follow-up to ensure rapid
treatment initiation, increase adherence, and eliminate loss to follow-up. However, implementation
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of contact investigation is not standardized because of the absence of clear guidelines. In addition,
the current information system does not capture the required data on the implementation and
outcomes of this intervention. To this end, the following activities will be undertaken.
Sub-activities
1.8.2.1 Conduct a five-day TOT training for 35 participants (two CSO reps and one TB focal person
from each province) and five facilitators.
1.8.2.2 Conduct 10 five-day TOT training for 238 participants (two per district) and three
facilitators.
1.8.2.3 Conduct 3 three-day initial district trainings for 10,000 community TB/HIV supporters (100
per district) in 104 districts in TB prevention, care, and support, including contact tracing.
1.8.2.4 Print and issue certificates to all trained volunteers.
1.8.2.5 Conduct a three-day refresher training after two years for 30 provincial facilitators.
1.8.2.6 Conduct 10 three-day refresher trainings after three years for 312 district trainers.
1.8.2.7 Conduct 3 two-day district refresher trainings for 10,000 community TB/HIV supporters
(10 per district per year) in 104 districts in TB prevention, care, and support.
1.8.2.8 Conduct 104 annual half-day meetings for 30 people to promote the involvement of 20
former TB patients in the network of CBOs, CSOs, and NGOs to combat TB in each of the
104 districts.
1.8.2.9 Conduct home visits for TB patients under treatment, with a priority for districts with a
high death rate (see Activity 1.8.3).
1.1.1.10 Hold monthly one-day on-site meetings for community volunteers and health facility staff
to review patient progress at facility level in each district and validate data of community
activities.
1.8.3 Procure logistics and provide incentives for community volunteers
Approximately 4,000 volunteers are involved in TB prevention, care, and support. It has been
observed that there is a high attrition rate of community-based volunteers which is affecting the
implementation of community-based programmes. According to the National Community Health
Worker Strategy, the most common reasons for attrition among the volunteers included lack of
motivation and incentives. In addition, the differences in the incentive packages offered by various
implementing partners are also a common reason for attrition. Community volunteers tend to
migrate to a programme that offers the best incentive package. Hence the need for standardization
of the support provided to the community volunteers.
Sub-activities
1.8.3.1 Procure gum boots, bags, T-shirts, umbrellas, and rain coats as appropriate for 10,000
volunteers.
1.8.3.2 Procure/issue ID cards and T-shirts/chitenges for 10,000 volunteers (general branding is
advised to reduce stigma in the community).
1.8.3.3 Procure 5,000 bicycles to be used by community volunteers, for patient support.
1.8.3.4 Grant annual performance bonuses of $100 to 210 volunteers.
1.8.3.5 Establish a reward system such a floating trophy for well-performing communities (one
per province).
1.8.4 Conduct on-site mentoring of volunteers in TB prevention, care, and support
The majority of community volunteers providing TB services have little access to mentorship to
enable them provide quality health care. This situation has brought about the need to strengthen
and scale up community volunteer mentorship activities that will yield sustainable high-quality
community care outcomes.
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Sub-activities
1.8.4.1 Conduct a one-day meeting for 10 participants to develop community TB mentorship
data recording and reporting tools.
1.8.4.2 Print 4,000 copies of the recording and reporting tools and distribute to all districts.
1.8.4.3 Conduct 20 three-day initial trainings for 200 community volunteer TB mentors from
among CHAs, lay counsellors, selected trained community volunteers, and selected
Neighborhood Health Committee members (five in each district).
1.8.4.4 Conduct refresher trainings for 200 community volunteer mentors (five in each district,
every three years).
1.9 Develop and disseminate a comprehensive ACSM strategy as part of the NTLP contribution
to the national effort in health promotion
A comprehensive national TB advocacy, communication, and social mobilization (ACSM) strategy
must serve to increase demand and uptake of services, promote positive norms and behaviors,
and challenge those that place people at risk. These norms can be addressed by health promotion
activities that seek to empower people with the knowledge to take control of their own health. The
strategy must aim to shift attitudes and behaviors related to the transmission of TB. The strategy
must also focus on all aspects of ACSM related to TB infection and disease. A comprehensive
communication strategy will cover TB symptom recognition, cough hygiene, and how to access
TB services. The planned ACSM strategy and guidelines to facilitate implementation of the above
remain in draft form; hence, there is no official guidance tool on TB ACSM currently. The NTLP will
build TB ACSM partnerships with international and national partners in the public and private sector.
The NTLP will coordinate with the Directorate of Health Promotion, Environmental Health and Social
Determinants in implementing this strategic activity.
1.9.1 Finalize the national ACSM strategy
Sub-activities
1.9.1.1 Procure local TA for 10 days to develop/finalize the ACSM strategy (linked to Sub-activity
1.8.1.2).
1.9.1.2 Conduct a five-day meeting for 30 participants to update and finalize the national TB
ACSM strategy and the ACSM guidelines.
1.9.1.3 Print 1,000 copies of the TB ACSM strategy and guidelines.
1.9.1.4 Distribute the TB ACSM strategy and guidelines to all districts.
1.9.1.5 Conduct a five-day national TOT training on TB ACSM for 25 participants.
1.9.1.6 Conduct 10 three-day trainings for 25 representatives of CSOs, CBOs, and NGOs engaged
in TB ACSM activities per province in collaboration with the Health Promotions Unit in
MOH.
1.9.1.7 Conduct a three-day meeting in each district for 25 representatives of CSOs, CBOs, and
NGOs engaged in TB ACSM activities to develop practical integrated ACSM work plans
with all programme partners to ensure consistent, evidence-based approaches and full
utilization of resources.
1.9.1.8 Conduct 10 provincial three-day workshops of 30 participants each to develop practical
integrated ACSM work plans with all programme partners to ensure consistent, evidence-
based approaches and full utilization of resources.
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1.9.2 Sensitize the community through television, radio programmes, print, and open media
messages
Sub-activities
1.9.2.1 Hold a five-day meeting for 20 people to develop information, education, and
communication (IEC) materials on TB.
1.9.2.2 Pre-test the IEC materials.
1.9.2.3 Print and distribute 5,000 copies each of posters, brochures, and flyers.
1.9.2.4 Sensitize the community through SMS messages twice a month.
1.9.2.5 Translate the TB/HIV community theatre approaches into radio shows.
1.9.2.6 Procure air time for radio programmes at provincial level to sensitize the community on
TB.
1.9.2.7 Translate the community theatre for television broadcast.
1.9.2.8 Procure air time for television programmes at provincial level to sensitize the community
on TB.
1.9.2.9 Procure 3,000 CDs for recording of radio plays for community distribution.
1.9.2.10 Procure the services of local artists to compose and record songs about TB.
1.9.2.11 Develop and MoUnt high-quality billboard messages in at least two strategic areas in each
of 40 high-burden districts. Identify potential walls on public- and private-sector buildings
and contract with signage suppliers and owners to paint TB educational messages on the
walls.
1.9.2.12 Conduct sensitization and screening of people during traditional ceremonies in all the
provinces.
1.9.2.13 Develop, print, and disseminate End TB annual newsletters to all provinces, including
best practices in TB prevention, care, and support in conjunction with the MOH Health
Promotions Unit.
1.9.2.14 Organize bi-annual TB/HIV press conferences in conjunction with the MOH Health
Promotion Unit.
1.9.3 Ensure support for quality assurance in TB services
Sub-activities
1.9.3.1 Incorporate QA in all TB training activities to increase efforts towards more patient-
centered approaches by service providers.
1.9.3.2 Incorporate patient satisfaction surveys and exit interviews and report findings to TB
programme and partners.
1.9.4 Conduct community-level training in TB ACSM strategy
Sub-activities
1.9.4.1 Conduct 10 one-day TB training workshops for media journalists (50 for Lusaka and 20 for
each province).
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1.9.5 Support TB peer education

Sub-activities
1.9.5.1 Support CBOs, CSOs, and NGOs to establish TB patient support groups in all areas.
1.9.5.2 Conduct a one-day orientation meeting to the support groups on TB prevention, care,
and support in 104 districts to scale up peer-to-peer training (two support groups per
district, with 15 people per group).
1.9.5.3 Identify 10 potential advocates (celebrities, sports people, former patients, care providers,
community leaders, etc.) in each district.
1.9.5.4 Conduct 104 two-day ACSM training workshops for 10 advocates and provide IEC
materials and other incentives for advocacy work.
1.9.5.5 Support one former TB patient per year to present at an international/regional TB
conference.
1.9.5.6 Support one former TB patient in each district to present at national, provincial, and
district events once per year.
1.9.5.7 Integrate TB ACSM activities in community education opportunities and promotional
events with CBOs, CSOs, NGOs, schools, churches, sports days, etc.
1.9.5.8 Conduct a public forum on World TB Day about the history of TB and its impact on the
population through an interactive panel on television.
1.9.5.9 Award a well-performing journalist for electronic and print media in monetary form
($500) once a year during World TB Day.
1.9.6 Strengthen community-based infection control for TB prevention care and support
Instilling a culture of cough hygiene is essential to achieving better respiratory infection control
(IC) in the community. A greater emphasis on TB and respiratory IC is needed in households,
schools, and other congregate settings to ensure a safe environment. TB infection control requires
a combination of administrative, environmental, and personal respiratory infection interventions.
This should be delivered in the context of broader IC standards (e.g. hand washing). Respiratory IC
should also be prioritized in high-risk industries, single-sex hostels, long-distance public transport
(such as taxis, buses, and trains), schools (including preschool facilities), and homeless shelters.
NTLP will implement the following approaches to improve and strengthen community-based IC for
tuberculosis prevention, care and control
Sub-activities
1.9.6.1 Revise NTLP reporting and recording tools to include community activities above
1.9.6.2 Print and distribute IC materials (e.g. posters, leaflets).
1.9.6.3 Institute annual TB screening for active community volunteers using a standard TB
screening questionnaire and chest x-ray as part of health screening.
1.9.7 Implement the Patient Charter for TB
In addition to the existing stigma around TB, there is a lack of patients’ rights. The concept of the
Patient Charter will be introduced into the community. The Patient Charter document will be
developed and will be part of training materials of NTLP for health staff. Furthermore, community
access to TB information will be enhanced through conducting TB community events.
Sub-activities
1.9.7.1 Conduct a one-day meeting for 10 people to develop TB Patient Charter.
1.9.7.2 Procure translation services for the Patient Charter in seven local official languages.
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1.9.7.3 Print 500,000 copies each of the Patient Charter in English, Kaonde, Bemba, Nyanja, Lozi,
luvale and Tonga and distribute to the districts.
1.9.8 Build capacity for CBOs, CSOs, and NGOs in resource mobilization for TB
For the CBOs, CSOs, and NGOs to effectively contribute to the broader health agenda, they require
capacity-building in proposal writing, grant negotiation, management skills, and entrepreneurial
skills. There are several fora available in the country through which these organizations can obtain
assistance for their activities, such as village banking, the Citizens Economic Empowerment
Commission (CEEC), and other micro-finance ventures. The NTLP will collaborate with established
community systems-strengthening efforts to ensure that CBOs, CSOs, and NGOs that are engaged in
TB activities are strengthened to qualify for support under such schemes.
Sub-activities
1.9.8.1 Provide funds for CSOs, CBOs, and NGOS that are engaged in TB activities to enroll in
training programmes in proposal writing and grant management skills (to cover five
organizations each year).
1.9.8.2 Provide funds to support the training of up to five CBOs, CSOs, and NGOS engaged in TB
activities to enroll in entrepreneurial skills development workshop each year.
1.9.9 Strengthen social protection
Sub-activities
1.9.9.1 Lobby for nutrition supplements in collaboration with the World Food Programme, the
Food and Agriculture Organization of the United Nations, and World Vision.
1.9.9.2 Lobby with MCDSW and link patients to the social cash transfer programme, with
particular focus for patients with MDR/RR-TB.
1.9.10 Address social determinants of TB by engaging with other government ministries and
departments in TB prevention, care, and support
One of the key indicators for the End TB Strategy is the percentage of TB patients and their households
that face catastrophic costs as a result of TB disease—with the target for all the years being zero.
Whilst TB is a medical condition, there are many social determinants that increase susceptibility to
TB, such as poverty, crowded and poorly ventilated working conditions, and under-nutrition. Poverty
is also associated with poor general health knowledge and a lack of empowerment to act on health
knowledge, which leads to the risk of exposure to several TB risk factors, including HIV, smoking,
and alcohol abuse. Strategies that aim at alleviating poverty have significant impact on reducing
the risk of TB transmission and the risk of progression from infection to disease. They also help to
improve access to health services and adherence to recommended treatment. Though TB diagnosis
and treatment are provided free at the point of care, presumptive and TB patients incur costs such as
transport, long waiting time, and paying for laboratory and clinical investigations not directly linked
to tuberculosis. Reducing the impact of TB on individual and household-level economies therefore
requires a multisectoral approach to addressing the social determinants of health. In line with the
Global End TB Strategy to ensure that no TB patients or their families face catastrophic costs due to
TB, this NSP will cooperate with other government ministries and agencies to begin to understand
and address the social determinants of health and TB.
Sub-activities
1.9.10.1 Conduct an annual one-day consultative meeting for 30 officers from other government
ministries to discuss inter-ministerial contributions to TB control. The ministries include
Ministry of Local Government (housing/work environment), Ministry of Agriculture and
Ministry of Fisheries and Livestock (nutrition), Ministry of Home Affairs (vital registration
and TB services in correctional facilities), Ministry of Education (school health education),
Ministries of Mines and Labour (TB in the mines), Ministry of Information (use of public
media), and Ministry of Community Development and Social Welfare (social protection).
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1.9.10.2 Advocate for the inclusion of health and tuberculosis in the National Development
Policies as nearly all social determinants are outside the direct control of health sector.
1.9.10.3 Commission a study to understand the patient and household costs related to TB disease.
OBJECTIVE 2
Increase:
 The detection of MDR-TB patients from 196 in 2015 to 1,200 by 2021.
 The treatment success rate for MDR/RR-TB patients from 33 percent in 2013 to 80 percent by
2021.
The following strategic interventions will be implemented:
2.1 Scale up clinical and diagnostic capacity to detect DR-TB
2.2 Improve active contact tracing in households of MDR/RR-TB patients
2.3 Expand and strengthen capacity for treatment of DR-TB
2.4 Improve the social welfare of MDR/RR-TB patients
2.5 Improve and strengthen M&E for DR-TB, including operational research
2.6 Improve TB programme performance through operational research
The NTLP carried out a drug resistance survey (DRS) in 2008; the results indicated that the levels
of MDR-TB were low, at 1.2 percent among new pulmonary TB cases, and any resistance was 9.8
percent. According to the WHO Global Tuberculosis Report of 2016 and based on the 2008 DRS,
the estimated MDR-TB rate among new and previously treated TB patients in Zambia was 1.1 and
18 percent, respectively. Following approval by the Green Light Committee (GLC) in 2009, the NTLP
began implementation of the programmatic management of DR-TB, and currently there are two
designated DR-TB treatment facilities in the country. In 2015, only 99 cases of DR-TB were notified
to the NTLP, even though according to the National TB Strategic Plan (2011–2016) the NTLP had
planned to detect and enrol into treatment 275 DR-TB patients. Remaining gaps include:
 Coverage of drug-susceptibility testing among high-risk patient populations such as previously
treated TB cases has remained below 10 percent.
 There is no recent DRS information on the magnitude of the DR-TB and burden in the country to
inform planning and programming.
 Low coverage of first- and second-line anti-TB drugs susceptibility testing.
 Existing national DR-TB treatment guidelines are not consistent with current WHO diagnostic
and treatment recommendations, including classification of RR cases by Xpert MTB/RIF testing as
presumptive MDR-TB cases and adoption of decentralized, ambulatory, patient-friendly models
of care as standard models of care.
 There is continued reliance on conventional culture and DST technologies for diagnosis of DR-
TB cases, despite WHO recommendations for the use of rapid molecular tests as the first line of
diagnostic testing for DR-TB high-risk patient populations.
 The only two DR-TB treatment initiating sites, especially UTH, lack appropriate isolation facilities.
DR-TB patients are admitted and managed in the same ward as other TB and general medical
patients, albeit in “private rooms within the general ward”. These rooms are in no way structurally
made to provide for any acceptable levels of infection control.
 Low treatment success rate for patients commenced on second-line drugs particularly due to
high lost to follow-up rates.
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In this plan, the NTLP will decentralize DR-TB treatment initiation and management from only two
centres to all 10 provincial hospitals and to district-level accredited hospitals. The programme
will also update the DR-TB diagnostic and management algorithm to include making the Xpert
MTB/RIF assay an initial test for all people with TB symptoms and to start all rifampicin-resistant
confirmed cases on full MDR/RR-TB treatment. Provincial and district-level staff will be trained, and
technical supervision and mentorship will be intensified. MDR/RR-TB patients will be provided with
enablers, including linking them to social protection programmes run by the Ministry of Community
Development and Social Welfare.
Activities
To address this objective, the following strategic interventions will be implemented.
2.1 Scale up clinical and diagnostic capacity to detect DR-TB
The ultimate goal is to provide early detection and universal drug-susceptibility testing for all
patients.
2.1.1 Update laboratory diagnostic algorithm for universal access to DST (see Activity 1.5.9)
Sub-activities
2.1.1.1 Procure TA (one international and one local) for 25 days to update the PMDT guidelines
including SOPs, algorithms, and job aids on diagnosis, treatment and monitoring,
adherence counselling, and training materials. The guidelines will include the MDR-TB
regimen and new drugs.
2.1.1.2 Hold 3 five-day meetings with 15 participants to update PMDT guidelines including
SOPs on diagnosis, treatment, and monitoring of DR-TB patients and to develop training
materials.
2.1.1.3 Print and distribute 10,000 copies of the revised guidelines and 20,000 SOPs and job aids
(e.g. pocket guides, flip charts).
2.1.1.4 Print 2,000 copies of the revised and updated training materials.
2.1.1.5 Hold a three-day national orientation meeting for 45 participants (four per province with
five facilitators) on the revised guidelines.
1.1.1.6 Hold 2 five-day TOT meetings for 30 participants each meeting (with five facilitators).
2.1.1.7 Hold 10 five-day provincial orientation meetings on PMDT for 35 participants (with five
facilitators) including the provincial TB focal point and information officer.
2.1.1.8 Conduct 20 four-day training for 470 TB focal point persons from TB diagnostics centres
on PMDT.
2.1.1.9 Increase the number of Xpert platforms from 69 in 2016 to 400 by the year 2021 (see
laboratory activities in Objective 1).
2.1.1.10 Establish a specimen referral system (courier system) to link peripheral facilities without
Xpert testing to facilities with the Xpert platforms (see laboratory activities in Objective
1).
2.1.1.11 Establish a specimen referral system (courier system) to link health facilities to the three
culture/DST centres (see laboratory activities in Objective 1).
2.1.1.12 Orient health care workers of Xpert and PMDT sites on the referral system to the three
culture/DST centres.
2.1.1.13 Procure one-line probe assay (LPA) machine to be placed in UTH by 2018 (see Objective 1).
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2.1.1.14 Procure equipment service contracts for all WHO-recommended rapid diagnostic tools,
culture, and DST equipment (see Activity 1.5.8).
2.1.1.15 Establish a strong EQA programme (see Activity 1.5.5).

2.2 Improve active contact tracing of DR-TB patients (refer to Activity 1.8.3)
2.3 Expand and strengthen capacity for treatment of DR-TB
2.3.1 Enhance the physical infrastructure, staff, and community capacity for MDR-TB treatment
Sub-activities
2.3.1.1 Conduct an assessment of the existing DR-TB treatment facilities and other provincial and
select district hospitals by five teams of five people (MDR-TB subgroup with provincial
and district staff for 10 days/team.
2.3.1.2 Renovate the MDR-TB treatment sites to ensure appropriate infection control in the eight
new provincial sites.
2.3.1.3 Build and renovate state-of-the-art DR-TB treatment facilities in UTH, Kabwe General
Hospital, and Ndola Central Hospital as Centres of Excellence.
2.3.1.4 Procure 300 mycobactericidal ultra violet lights.
2.3.1.5 Procure 50 directional fans.
2.3.1.6 Procure one million N95 masks (see Sub-activity 1.5.11.17).
2.3.1.7 Procure two million surgical masks (see Sub-activity 1.5.11.20).
2.3.1.8 Procure nine sets of audiometry equipment (for the remaining nine provinces).
2.3.1.9 Train a multi-disciplinary team of 10 for two weeks at an international training centre as
national mentors.
2.3.1.10 Conduct 3 three-week training sessions for 10 staff from each Centre of Excellence.
2.3.1.11 Conduct quarterly four-day mentorship of provincial DR-TB sites by four national mentors.
2.3.1.12 Conduct quarterly four-day mentorship of district DR-TB sites by two provincial mentors.
2.3.1.13 Conduct in-house monthly clinical reviews for all DR-TB patients on treatment including
review of microscopy, culture, and other laboratory tests.
2.3.1.14 Procure TA (international consultant) for 14 days to develop community DR-TB training
materials.
2.3.1.15 Conduct a five-day workshop for 15 people to develop the community TB-DR training
materials.
2.3.1.16 Print and distribute 10,000 copies of DR-TB community training materials.
2.3.1.17 Procure TA (international consultant) for 14 days for the introduction and implementation
of MDR-TB short regimen and new drugs.
2.3.1.18 Carry out registration of short regimen and new drugs with ZAMRA.
2.3.2 Strengthen community DOT for MDR/RR-TB patients
Sub-activities
2.3.2.1 Conduct 10 three-day trainings for 1,040 DR treatment supporters (10 per district per
year)
2.3.2.2 Conduct 10 three-day training for 1,040 DR treatment supporters (10 per district per year)
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2.3.3 Implement infection control strategies

Sub-activities
2.3.3.1 Revise, print, and distribute sufficient numbers of infection control guidelines (see
Objective 3, TB/HIV infection control).
2.3.3.2 Procure negative pressure equipment for MDR-TB wards (see Activity 2.3.1).
2.3.3.3 Develop and print SOPs on infection control (see Objective 3, TB/HIV infection control).
2.3.4 Strengthen active TB drug safety monitoring and management (aDSM) (see Activity 1.7.2)
Sub-activities
2.3.4.1 Ensure availability of infection control guidelines (see Objective 3, TB/HIV infection
control).
2.3.4.2 Procure negative pressure equipment for MDR-TB wards (see Activity 2.3.1).
2.3.4.3 Develop and print SOPs on infection control (see Objective 3, TB/HIV infection control).
2.4 Improve the social welfare of MDR/RR-TB patients
2.4.1 Strengthen social welfare protection for MDR/RR TB patients
Sub-activities
2.4.1.1 Link MDR/RR-TB patients to the social cash transfer programme managed by the Ministry
of Community Development and Social Welfare.
2.4.1.2 Provide enablers (transport reimbursement and nutrition support) to MDR/RR-TB patients.
2.4.1.3 Provide K100/month as transport refund for 1,200 patients for 24 months/patient.
2.4.1.4 Provide a monthly food basket (2 kg of beans, 5litre of cooking oil, 2 kg of sugar, 1 kg of
soya flour).
2.5 Improve and strengthen M&E for DR-TB, including operational research
2.5.1 Implement a surveillance system for drug-resistant TB
Sub-activities
2.5.1.1 Establish a patient-based data management system in all DR-TB treatment sites by the
end of 2019 (see Objective 1).
2.5.1.2 Roll out a patient-based data management system in all DR-TB treatment sites by the end
of 2021 (see Objective 1).
2.5.1.3 Ensure that all DR-TB patients have a unique identifier.
2.5.1.4 Conduct quarterly cohort analysis (interim and final outcomes).
2.5.1.5 Extend the electronic data management system (DHIS2) to all districts by the end of 2018
2.6 Improve TB programme performance through operational research
2.6.1 Implement the drug resistance survey
The last drug resistance survey was conducted in 2008 and the results indicated that the prevalence
of MDR-TB was low at 1.2 percent. The WHO has recommended that a DRS be conducted every five
years.
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Sub-activities
2.6.1.1 Contract with a local research organization to conduct a DRS on behalf of NTLP (through
an MOU).
2.6.1.2 Conduct a five-day protocol development workshop with the contracted NGO with 10
people, including NTLP staff.
2.6.1.3 Print 500 copies of the final DRS report.
2.6.1.4 Hold a one-day meeting to disseminate the results of the DRS report for 50 people,
including two provincial staff (TB and laboratory).
OBJECTIVE 3
Scale up comprehensive TB/HIV collaborative activities to all facilities by 2021.
The following strategic interventions will be implemented:
3.1 Strengthen TB/HIV collaboration at all levels
3.2 Intensify HIV testing in presumptive and confirmed TB patients and offer high-quality patient-
centred HIV care for HIV-infected TB patients
3.3 Improve the quality of TB/HIV services provided in all districts
3.4 Reduce the burden of TB in PLHIV and people at high risk of HIV infection
3.5 Implement TB infection control in health services dealing with PLHIV
The implementation of interventions and activities aimed at reducing the burden of HIV among TB
patients has yielded excellent results. In 2015, as many as 95 percent of TB patients were tested for
HIV, of whom 61 percent were HIV positive. Of those who were infected, 92 percent and 76 percent
were provided cotrimoxazole preventive therapy (CPT) and antiretroviral therapy (ART), respectively.
However, the mechanisms to reduce the burden of TB among persons living with HIV have not
received the required attention. Although in ART clinics, all patients are routinely screened for TB,
there is no evidence that these patients are linked to TB diagnostic services. Treatment of latent TB
infection through the provision of isoniazid preventive therapy (IPT) has been suboptimal. Poor
coordination and collaboration between the TB and AIDS programmes has contributed to this poor
performance. The TB/HIV strategic interventions and activities will aim to sustain the achievements
already made through strengthened collaboration, joint planning with the HIV programme and
implementing partners, and strengthened joint supervision of the TB and HIV programmes. Early
detection and management of dual TB and HIV infections will reduce the burden of either disease and
will contribute to overall TB case detection in Zambia as well as reduction in morbidity and mortality
due to TB in PLHIV, with overall improvement in outcomes of PLHIV. Improved TB infection control
in health facilities, congregate settings, and communities will receive unprecedented attention. The
programme will routinely report TB treatment outcomes for TB patients with HIV infection. Depending
on the clinic setup, the TB and HIV programmes will be encouraged to develop an integrated model
of TB/HIV treatment. Where this may not be possible, partial integration will be implemented. Where
a standalone model is implemented, cross-referral will be strengthened
3.1 Strengthen TB/HIV collaboration at all levels
3.1.1 Strengthen national-level coordination of TB/HIV collaboration
Sub-activities
3.1.1.1 Hold quarterly one-day TB/HIV subcommittee meetings for 30 participants at national
level to review TB/HIV activities and develop a joint TB/HIV plan.
3.1.1.2 Distribute the joint TB/HIV plan to all provinces and districts.
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3.1.1.3 Conduct annual visits to monitor and evaluate the implementation of the joint TB/HIV
plan in each province for seven days by four members per team for each province from
the NTLP and HIV units.
3.1.2 Strengthen provincial coordination of TB/HIV collaboration
Sub-activities
3.1.2.1 Hold 10 quarterly one-day TB/HIV subcommittee meetings for 15 participants at provincial
level to review TB/HIV activities and develop a province-specific joint TB/HIV plan based
on input from the district committee.
3.1.2.2 Distribute the joint TB/HIV plan to all districts.
3.1.3 Strengthen district coordination of TB/HIV collaboration
Sub-activities
3.1.3.1 Hold 104 quarterly one-day TB/HIV subcommittee meetings for 30 participants at district
level with representatives from health facilities to review TB/HIV activities and develop
the joint TB/HIV plan.
3.1.3.2 Distribute the joint TB/HIV plan to all health centres.
3.1.4 Strengthen TB/HIV collaboration at health facility level
Sub-activities
3.1.4.1 Conduct quarterly on-site mentorship for health care workers in TB/HIV collaborative
activities by two district-level staff (one TB, one HIV, included in integrated supervision).
3.1.4.2 Ensure effective cross-referral between TB corners and HIV/ART clinics (this entails that TB
corner staff should guarantee that all TB/HIV co-infected patients are on the ART register
and vice versa).
3.1.4.3 Hold monthly half-day on-site facility-based TB/HIV subcommittee meetings and data
review meetings for 10 participants.
3.2 Intensify HIV testing in presumptive and confirmed TB patients and offer high-quality
patient-centred HIV care for HIV-infected TB patients
Currently close to 95 percent of all TB patients are offered HIV testing. The aim of this intervention
will be to ensure HIV testing of all TB patients (100 percent) and implementation of HIV testing for
presumptive TB patients.
3.2.1 Build capacity of health care providers in providing initiated HIV testing and counselling
Sub-activities
3.2.1.1 Conduct one-day facility-based orientation of 4,000 treatment supporters in provider-
initiated HIV testing and counselling (PITC), CPT, and ART for all presumptive and
confirmed TB patients.
3.2.2 Ensure HIV treatment and care for all TB/HIV co-infected patients
Sub-activities
32.2.1 Provide ART to all TB/HIV co-infected patients.
32.2.2 Provide CPT to all eligible TB/HIV co-infected patients.
32.2.3 Conduct quarterly ten-day on-site mentorship and supervision in TB/HIV collaborative
activities (two staff per team).
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3.3 Improve the quality of TB/HIV services provided in all districts

3.3.1 Enhance the quality of TB/HIV services
Sub-activities
3.3.1.1 Conduct a desk review meeting for two days for four members of the TB/HIV subcommittee
of the TWG to review health facilities implementing TB/HIV services and TB/HIV indicators
from the TB data.
3.3.1.2 Conduct geospatial mapping of health facilities that provide TB/HIV and ART services
(three staff ).
3.3.1.3 Hold a two-day meeting of 50 participants (TB programme, HIV programme, and partners)
to disseminate the findings and develop an implementation plan.
3.4 Reduce the burden of TB in PLHIV and people at high risk of HIV infection
3.4.1 Conduct intensified TB case finding of TB in PLHIV and people at high risk of HIV at each
clinical visit
Sub-activities
3.4.1.1 Hold a five-day meeting for 20 participants to revise the TB/HIV guidelines (that include
IPT/ICF), including recording and reporting tools.
3.4.1.2 Print 10,000 copies of the revised TB/HIV guidelines.
3.4.1.3 Present the key points of the revised TB/HIV guidelines during the National TB Data Review
meeting.
3.4.1.4 Ensure PLHIV identified as presumptive TB complete the diagnostic cascade for TB,
including testing with Xpert MTB/RIF.
3.4.1.5 Screen HIV-infected women during antenatal care or PMTCT for TB and complete the
diagnostic cascade
3.4.1.6 Implement a policy to use Xpert MTB RIF as an initial TB diagnostic test for all presumptive
TB cases in the country (see laboratory section in Objective 1).
3.4.1.7 Increase the availability and use of digital CXR as an additional screening tool (see section
on digital X-ray equipment acquisition in Objective 1).
3.4.1.8 Treat latent TB infections by providing IPT to all PLHIV without active TB disease (this
activity will be led by the HIV programme).
3.4.1.9 Procure isoniazid tablets (300 mg and 100 mg).
3.4.1.10 Conduct technical support supervision for health care providers through facility visits
(integrate with Activity 4.4).
3.5 Implement TB infection control in health services dealing with PLHIV
3.5.1 Improve health care workers’ infection control practices
Sub-activities
3.5.1.1 Procure an international consultant for 30 days to revise TB infection control guidelines,
develop training materials, and train 10 national trainers in infection control.
3.5.1.2 Hold 2 five-day meetings with practical sessions for 20 participants to revise TB infection
control guidelines and develop training materials.
3.5.1.3 Print 20,000 copies of infection control guidelines and 4,000 copies of the training
materials.
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3.5.1.4 Hold a five-day meeting to train a national team (15 staff ) in infection control.
3.5.1.5 Hold 10 three-day meetings for 30 participants per province to orient provincial and
district staff in TB infection control guidelines.
3.5.1.6 Conduct on-site mentorship for five days in each province on infection control practices
in four districts per province (two NTLP/HIV staff, one provincial staff ) once a year.
3.5.2 Improve facility-level infection control
Sub-activities
3.5.1.1 Procure air flow measurement equipment (120 vane anemometers, 120 thermal
anemometers, 120 two-metre measuring tapes, and 1,200 smoke tubes).
3.5.1.2 Print 2,500 copies of infection control assessment tools (already existing in the guidelines).
3.5.1.3 Conduct ten 15-day TB IC facility assessments in provincial and district facilities using
airflow equipment to support the development of TB IC plans (one provincial and four
district staff ). The visits will also help to identify facilities requiring renovations.
3.5.1.4 Conduct minor renovations to improve natural ventilation (such as procuring/installing
fans and creating windows, depending on assessment results). During the life span of the
NSP, 200 facilities will be renovated.
3.5.1.5 Procure 500,000 million N95 masks for health care workers at selected services points that
pose high risk (see Sub-activity 1.5.11.17).
3.5.1.6 Procure 50 N95 fit testing kits (one fit testing kit per district) (see Sub-activity 1.5.11.21).
Objective 4
Strengthen management, leadership, and governance of the NTLP by 2021.
Management, leadership, and governance are fundamental elements for the development and
implementation of the strategic interventions and activities of any health programme. Even though
Zambia has implemented a successful national TB control programme since 1964, the managerial
capacities that have been established are not entirely operational across the NTLP network. The
managerial and administrative functions of the NTLP Central Unit are still not well defined, such as
the coordination with the partners, the mobilization of additional resources, and the organization of
supervision across the country. At the NTLP Central Unit, officers have no clear job descriptions, and
if available, the descriptions are not linked to their competencies, making it difficult to assess their
performance. At the provincial level, there is no established post for TB. Medical schools and training
health colleges have no TB modules to prepare graduates to implement TB activities after leaving
school/college. This situation creates the burden of conducting numerous in-service trainings, which
drains the already-limited resources; in most instances, health care workers are out of their duty
stations while attending training workshops. Mentorship and on-site training have not fully been
adopted though they are the most productive and cost-efficient model of conducting training.
To successfully implement the interventions and activities specified in Objectives 1, 2 and 3, the
NTLP Central Unit, provincial health offices, and district health offices should fully play their role
in the management of NTLP activities. The actions that will be taken to reach this objective aim
at improving and strengthening the technical and managerial capacities of the NTLP at all levels
and will include a combination of in-service training as well as on-site training and mentorship as
appropriate.
4.1 Develop and reinforce the technical and managerial capacities at Central Unit and subnational
level
4.2 Strengthen coordination between the NTLP and implementing and cooperating partners
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4.3 Ensure resource mobilization

4.4 Ensure high-quality TB services through technical support and supervision
4.5 Improve the monitoring and evaluation of the programme
4.6 Strengthen programme management
4.1 Develop and reinforce the technical and managerial capacities at Central Unit and
subnational level
4.1.1 Build technical and managerial capacity of human resources
Sub-activities
4.1.1.1 Hold a two-day meeting with the MOH Human Resources Department to develop job
descriptions for TB programme officers at national, provincial, and district levels. Each
position will be appropriately matched with the qualifications, skills, and competencies.
4.1.1.2 Procure two international consultants (from the Union and WHO) for 10 days to facilitate
a tailored training on TB programme management.
4.1.1.3 Conduct a 10-day session to train 25 programme officers at the national (5) and provincial
(20) level on TB programme management.
4.1.1.4 Procure long-term (12 months) resident technical assistance for the National Reference
Laboratory (salary support for this TA will be through partner support) for accreditation.
4.1.1.5 Provide funds for national, provincial, and district staff to attend 10-day international
courses (three courses/year with three staff/course) needed according to their area of
work:
 Supply chain management
• TB laboratory techniques and management
• TB preventive therapy
• TB/HIV
• PMDT
• Clinical MDR training
• Infection control
• Childhood TB
• Short courses in epidemiology and surveillance
4.1.1.6 Conduct 10 two-day trainings for 20 provincial and 208 district staff on drug and supply
management, monitoring and evaluation, performing data analysis, data utilization for
planning, decision-making and policy formulation, and data quality audits.
4.1.1.7 Conduct initial and refresher TB trainings for health facility staff. New staff and health
workers who attended initial training 4 years ago or more should be trained. In case of
new updates, ad hoc trainings will be organized (see Objective 1).
4.1.1.8 Provide funds for five NTLP staff (from national, provincial, and district levels) to attend
the annual international conference of the International Union Against Tuberculosis and
Lung Disease for six days every year.
4.1.1.9 Provide funds for three NTLP staff to attend Africa Union Regional Conference (every two
years) for six days.
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4.1.1.10 Provide funds for three NTLP staff to attend International AIDS conference (every two
years) for six days.
4.1.1.11 Provide funds for three NTLP staff to attend unscheduled international conferences.
4.2 Strengthen coordination between the NTLP and implementing and cooperating partners
4.2.1 Enhance coordination between the NTLP and collaborating partners
Sub-activities
4.2.1.1 Hold quarterly National Technical Working Group (TWG) meetings for 40 people each year.
The TWG should include officers from the HIV programme, partners, academia, research
institutes, and representatives from PHOs, DHOs, and CSOs.
4.2.1.2 Hold quarterly sub-working group meeting for the following sub-groups: MDR-TB, TB/
HIV, Laboratory/Pharmacy, Childhood TB, Research and ACSM and Community TB, Public-
Private Mix (PPM) for 10 people per meeting.
4.3 Ensure resource mobilization
4.3.1 Ensure sustainability of TB programmes
Sub-activities
4.3.1.1 Hold a five-day meeting for 20 people to develop a resource mobilization plan in
conjunction with the Department of Policy and Planning.
4.3.1.2 Hold 10 five-day meetings for 15 people to develop funding proposals by the NTLP
Central Unit to mobilize financial resources in the framework of bilateral or multilateral
cooperation.
4.4 Monitoring and evaluation
Health sector reporting in Zambia occurs primarily through the Health Management Information
System (HMIS) that was established in 1996. This system collects information on disease morbidity
and mortality, maternal and child health, service delivery, and surveillance. Information is aggregated
at the health-facility level, compiled by the district, and sent to the provincial and national level using
a web-based system. TB indicators and corresponding definitions based on the 2013 WHO Reporting
Framework for National TB Programmes have already been adopted in this system.
TB data at health-facility level are collected through vertical, disease-specific recording and
reporting forms that allow for longitudinal follow-up of patients from initiation through completion
of treatment. The information is reported in a step-wise fashion, with the districts aggregating and
reporting facility-level data to the province, which in turn reports the aggregated data to the national
level. These reports are essential for monitoring the progress and achievements of the programme as
well as for management of the programme. Quantification and distribution of drugs and laboratory
supplies are based on the quarterly district reports.
The NTLP uses the WHO-recommended recording and reporting forms and is therefore able
to monitor and evaluate programme performance in a manner that is internationally accepted
and allows for both in-country comparisons of performance and inter-country comparisons as
standardized indicators are used. Currently, the recording and reporting forms are all paper-based;
however, in the period of this strategic plan the NTLP will develop and pilot an electronic system in
the two high-burden provinces (Lusaka and Copperbelt). This will complement the other efforts to
streamline data collection and analysis through the use of electronic platforms such as web-based
HMIS reporting and the SmartCare electronic medical records system.
To ensure that there is an effective and efficient system to monitor and evaluate the National TB
Strategic Plan, the NTLP has developed a comprehensive M&E Plan. The detailed M&E Plan provides
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guidance on the monitoring and evaluation activities that will be carried out by the programme at
all levels of the health care system. The plan further provides guidance on the information needed
for this to occur, details of when the data are collected, frequency of reporting for all levels, and
mechanisms to ensure quality of data through supervision and data quality assessments.
4.4.1 Ensure quality services through technical support and supervision
Supervision is a system process for increasing efficiency of the health personnel by developing their
knowledge, perfecting their skills, improving their attitudes towards their work, and increasing
their motivation. The NTLP will carry out supervision in consultation with all the health personnel,
as they need ongoing support to solve problems and overcome difficulties. The health personnel
need constructive feedback on their performance and continuous encouragement in their work. The
technical support visit will include data-quality audits as part of the supervisory checklist.
Sub-activities
4.4.1.1 Hold a workshop for 10 days for 20 people to develop a national guidelines document
and SOPs for supervising and conducting data-quality audits, including updating the
existing supervision checklist.
4.4.1.2 Print 700 copies each of the national guidelines and SOPs and 50,000 copies of the
supervision checklist.
4.4.1.3 Hold a three-day orientation for 30 provincial staff on how conduct a supervision visit,
including a data-quality audit.
4.4.1.4 Hold a four-day orientation for 320 district officers on how to conduct a supervision visit,
including a data-quality audit.
4.4.1.5 Conduct 10 technical support and supervision visits by three national-level staff for 10
days (one visit per province per year).
4.4.1.6 Conduct 104 semi-annual visits to districts by a team of two provincial staff for five days
per visit.
4.4.1.7 Conduct 104 quarterly four-day visits by the district TB focal person to the health facilities.
4.4.1.8 Conduct 420 quarterly TB death audits at on-site facility level to determine possible cause
of death.
4.4.1.9 Procure two vehicles for the NTLP Central Unit to strengthen supervision activities.
4.4.2 Strengthen the existing M&E system
The NTLP has maintained a nationwide recording and reporting (R&R) system in place for many years
now. Basic and integrated R&R tools are in place, as is an M&E system that links data capture at facility
level to district, provincial, and national levels. The paper-based system is aggregated at district,
provincial, and national levels. There are M&E focal persons in place at all levels, and supervisory and
data review meetings are conducted. The M&E system captures critical data needed for reporting
TB cases, and the paper-based system is gradually moving to electronic database and a TB-specific
module in the evolving DHIS2. Monitoring and evaluation are a major asset in the management of
any national TB programme. The data generated by an M&E system are paraMoUnt for managing the
programme resources, following the epidemiological situation of TB, and assessing the outcomes of
TB prevention, care, and control efforts. The NTLP will prepare an annual report based on the analysis
of the routinely collected data that will highlight the epidemiological situation of TB in Zambia and
the outcome of the prevention, care, and treatment of TB. These data will inform the operational
research agenda.
Sub-activities
4.4.2.1 Procure a local consultant for 20 days to undertake a nationwide assessment of data flows
to inform standardization across districts and, in the process, to streamline the recording
and reporting system.
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4.4.2.2 Print and distribute already-existing SOPs.

4.4.2.3 Train 208 district staff in DHIS2 in 104 districts (TB officer, data manager) for five days.
4.4.2.4 Hold semi-annual national TB review meetings with all provincial teams and implementing
partners for five days with 70 people.
4.4.2.5 Hold quarterly provincial review meetings with district TB teams and implementing
partners for four days with 30 participants.
4.4.2.6 Hold quarterly district TB review meetings with facility TB teams and implementing
partners that include CSOs for three days with 30 participants.
4.4.2.7 Procure internet modems for 104 districts for data management such as DHIS2.
4.4.3 Roll out TB electronic information system for both drug-susceptible and drug-resistant TB
Sub-activities
4.4.3.1 Procure TA (one international and one local) for 30 days to develop the TB electronic case-
based information system.
4.4.3.2 Hold a five-day meeting for 20 people to design the system with the TA consultant.
4.4.3.3 Define the goals related to digital health and the enhancement of TB surveillance
(including DR-TB) including coverage (that is, which levels are included at which stage).
4.4.3.4 Define the guiding principles in the design and development of the system.
4.4.3.5 Define project coordination (project coordinator and Technical Steering Committee and
the Terms of Reference for both).
4.4.3.6 Develop an information technology blueprint and system and data management plan as
well as the implementation plan.
4.4.3.7 Conduct prototyping, testing, and piloting of the system.
4.4.3.8 Hold a three-day meeting for 10 people to develop guidelines on how to use the electronic
case-based recording and reporting system.
4.4.3.9 Print 1,000 copies of the guidelines on how to use the electronic case-based recording
and reporting systems.
4.4.4 Conduct TB programme reviews
Sub-activities
4.4.4.1 Conduct national semi-annual programme reviews for four days for 50 people.
4.4.4.2 Conduct 10 quarterly provincial data review meetings for two days for 30 people (40
meetings/year).
4.4.4.3 Conduct 104 district quarterly meetings for two days for 30 people (416 meetings/year).
4.4.4.4 Procure 10 international and 5 local TA consultants for 15 days to conduct a mid-term
review of the NSP for 14 days at the end of 2019.
4.4.4.5 Procure 10 international and 5 local TA consultants to conduct an end-term review of the
NSP for 14 days in June–July 2021.
4.4.5 Develop and implement operational research
The operational research priorities will be based on the findings of the analysis of the data generated
through the information system of the NTLP, along with periodic surveys such as the national
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prevalence survey and the drug resistant survey and routine programme supervision. The findings will
help identify hypotheses and develop research questions. The operational research agenda will aim
at improving TB prevention, care, and control in the country; research findings will be disseminated
and will inform policy for programme implementation according to the stipulated guidelines. This
will be critical as the programme starts implementing interventions and activities towards ending
the TB epidemic in Zambia.
Sub-activities
4.4.5.1 Procure TA for 75 days to develop a training programme in operational research, train 20
national and provincial staff in operational research, facilitate the development of the
research agenda, and mentor staff in the development of operational research proposals.
4.4.5.2 Hold a 10-day workshop to train 20 national and provincial staff in operational research.
4.4.5.3 Organize a national workshop to define the operational research agenda in TB prevention,
care, and control in close collaboration with other research teams within the MOH for five
days with 30 people, facilitated by the TA (see Sub-activity 4.4.5.1).
4.4.5.4 Link with operational research teams through the MOH/NTLP working group and promote
use of research findings in policy formulation.
4.4.5.5 Prepare a report on the outcomes of the national workshop on operational research by
the NTLP Central Unit.
4.4.5.6 Develop and submit proposals for operational research studies to national and
international partners or organizations which can potentially provide financial support
to carry out operational research studies; these studies will be in line with the agenda
established in the national workshop on operational research, and mentorship will be
provided by the TA.
4.4.5.7 Undertake operational research studies in line with the National Health Research Authority
agenda but depending on the resources mobilized from the government and partners.
4.4.5.8 Hold an annual one-day research dissemination workshop for 50 people.
4.4.5.9 Collaborate with local and international research institutions to conduct innovative
research studies.
4.4.5.10 Document and share lessons learnt, best practices, costs, and impact to inform scale-ups.
4.4.5.11 Pay for an institutional subscription to the online International Journal of Tuberculosis and
Lung Disease (of the International Union Against Tuberculosis and Lung Disease).
4.4.5.12 Support publication fees for manuscripts submitted to international journals (five
manuscripts supported every year).
4.4.5.13 Support four programme officers (national, provincial, and district level) to participate in
local and international training on statistical packages (e.g. Stata, SPSS, EpiData).
4.5 Strengthen programme management
4.5.1 Secure and provide funds for programme management
Sub-activities
4.5.1.1 Procure office stationery and equipment.
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4.5.2 Ensure and advocate for adequate human resource for TB control
Sub-activities
4.5.2.1 Designate staff to serve as focal points for technical areas such as childhood TB, DR-TB,
training, and supervision.
4.5.2.2 Recruit one additional M&E officer with a background in data management and
epidemiology.
4.5.2.3 Recruit and sustain PPM focal person at central level.
4.5.2.4 Support the PPM focal person to attend PPM-related meetings and workshops both in the
public sector and private sector nationally.
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SECTION FIVE: OPERATION PLAN

An action plan for implementing the objectives and strategic interventions outlined in Section 4
has been developed. The plan indicates the objectives, interventions, activities, sub-activities, and
timeframe. Detailed action plans for Years I and 2 are shown in Annex III.
SECTION SIX: TECHNICAL ASSISTANCE PLAN

The objective of the technical assistance (TA) plan is to provide expert knowledge, skills, and
additional support for programme implementation. External TA will be required to support critical
programme implementation, such as the revision of the national guidelines for drug-susceptible
and drug-resistant TB and finalization of the advocacy, communication, and social mobilization
(ACSM) strategy/guidelines. Long-term TA will be procured and attached to the National Reference
Library (NRL) to build the capacity and technical competences of the NRL and the other two culture
and drug-susceptibility testing (DST) laboratories. TA will also be procured to support the NTLP in
monitoring and evaluation (M&E), operational research, public-private mix (PPM), procurement and
supply chain management (PSM), active drug safety monitoring and management (aDSM), and
childhood TB, particularly focusing on contact tracing and investigation and infection control. The
TA plan is in Annex I.
SECTION SEVEN: BUDGET PLAN

The costing for this National Strategic Plan (NSP) is based on activities defined and agreed on by
various stakeholders during the development process. The activities of the stakeholders complement
each other and will be coordinated, monitored, and supported by the Ministry of Health (MOH)
through the NTLP’s Central Unit.
The NSP will be funded through a number of sources which include the Government of the Republic
of Zambia through the MOH. Additional support will be mobilized from the Global Fund to Fight
AIDS, Tuberculosis and Malaria. Financial and technical support for the implementation of the NSP
will be mobilized from the traditional partners of the NTLP, namely; the United States Government
through USAID and CDC. The World Bank Southern Africa Health Health System Support Project will
provide resources targeting activities for TB in mines.
Multilateral partners such as the World Health Organization, United Nations Office on Drugs and
Crime (UNODC), and the International Organization for Migration (IOM) have supported the NTLP on
an ad-hoc basis and are expected to continue providing support during the life of this NSP. The NTLP
will work with all stakeholders to ensure that all funding and activities for TB control in the next five
years are aligned with the goals and objectives of this NSP.
74
The NSP was costed by developing a National Operational Plan (NOP) using an activity-based model. The total funding required for the five-year period from 2017
to 2021 is ZMW1,520,595,964 (US$154, 774,338). A summary of the cost by year, by objectives, and by interventions is provided below.
ZAMBIA TUBERCULOSIS NATIONAL OPERATIONAL PLAN 2017–2021 COSTING

SUMMARY BY 2017 2018 2019 2020 2021 TOTAL
OBJECTIVES
USD ZMW USD ZMW USD ZMW USD ZMW USD ZMW USD ZMW
Objective 1 - 31,302,674 307,536,251 29,209,391 286,970,586 22,825,633 224,252,710 25,939,404 254,844,269 23,904,066 234,847,889 133,181,168 1,308,451,704
Increase:
• The number of
notified cases of new
TB episodes from
36,700 in 2015 to at
least 59,000 in 2021
• The treatment
success rate for TB
from 85% in 2014
to at least 90% from
2018 onwards
Objective 2 - 1,074,852 10,559,989 1,083,216 10,642,167 - - - - - - 2,158,068 21,202,156

Increase:
• The detection of
MDR-TB patients
from 196 in 2015 to
1,200 by 2021
• The treatment
success rate for MDR-
TB patients from 33%
in 2013 to 80% by
2021
Objective 3 - Scale 745,066 7,319,973 291,819 2,867,009 176,277 1,731,846 194,274 1,908,668 214,110 2,103,543 1,621,546 15,931,038
up comprehensive
TB/HIV collaborative
activities to all
facilities by 2021
Objective 4 2,198,985 21,604,145 3,567,571 35,049,962 3,754,737 36,888,785 3,852,841 37,852,618 4,439,423 43,615,556 17,813,556 175,011,065
- Strengthen
management,
leadership and
governance of the
NTLP by 2021
TOTALS 35,321,576 347,020,358 34,151,998 335,529,723 26,756,646 262,873,341 29,986,519 294,605,555 28,557,599 280,566,987 154,774,338 1,520,595,964
75
SUMMARY BY 2017 2018 2019 2020 2021 TOTAL

INTERVENTIONS
USD ZMW USD ZMW USD ZMW USD ZMW USD ZMW USD ZMW
1.1 Improve case 653,737 6,422,705 114,892 1,128,771 20,547 201,871 22,645 222,482 24,957 245,197 836,780 8,221,025
detection by
expanding case
finding to all clinical
settings
1.2 Involve all care 1,015,302 9,974,941 909,341 8,933,914 1,175,236 11,546,220 1,014,885 9,970,842 1,427,470 14,024,320 5,542,234 54,450,236
providers operating
outside the NTLP
network in TB case
detection and
management
1.3 Strengthen TB 2,982,905 29,305,852 1,857,359 18,247,806 1,119,862 11,002,198 529,805 5,205,122 1,138,033 11,180,715 7,627,964 74,941,694
services for high-
risk groups and
vulnerable and key
populations
1.4 Improve and 54,094 531,450 31,185 306,384 34,369 337,666 37,879 372,141 41,746 410,137 199,273 1,957,777
reinforce TB services
in high TB-burden
areas
1.5 Strengthen TB 12,536,813 123,169,176 13,099,298 128,695,368 10,306,024 101,252,564 13,714,468 134,739,167 8,546,212 83,963,113 58,202,816 571,819,387
diagnostic capacity
through expansion
and enhancement
of the laboratory
network
1.6 Strengthen 725,537 7,128,114 163,010 1,601,508 143,692 1,411,713 145,847 1,432,889 148,035 1,454,382 1,326,121 13,028,606
the technical
platform to improve
TB diagnostic
procedures
1.7 Ensure 10,504,847 103,205,920 10,365,140 101,833,358 8,891,312 87,353,584 9,471,711 93,055,775 9,989,421 98,142,061 49,222,431 483,590,697
appropriate TB
treatment for all
detected patients
76

1.8 Ensure 1,377,676 13,535,116 2,114,308 20,772,226 524,214 5,150,197 330,191 3,243,995 1,848,347 18,159,266 6,194,736 60,860,800
collaboration
mechanisms
between NTLP and
CBOS, CSOs, and
NGOs to improve
community TB
services at central
level
1.9 Implement the 1,451,762 14,262,978 554,857 5,451,252 610,376 5,996,697 671,972 6,601,858 739,847 7,268,698 4,028,814 39,581,483
ACSM strategy to
raise the profile of TB
in the communities
2.1 Scale up clinical 574,852 5,647,689 240,269 2,360,544 - - - - - - 815,121 8,008,233
and diagnostic
capacity to detect
MDR TB
2.2 Improve active - - - - - - - - - - - -
contact tracing
and investigation
of bacteriologically
confirmed MDR/RR-
TB patients
2.3 Expand and - - - - - - - - - - - -
strengthen capacity
for treatment of
MDR-TB
2.4 Improve the - - 807,679 7,935,120 - - - - - - 807,679 7,935,120
social welfare of
MDR/RR-TB patients
2.5 Improve and - - - - - - - - - - - -
strengthen M&E for
MDR-TB, including
operational research
2.6 Improve 500,000 4,912,300 35,269 346,503 - - - - - - 535,269 5,258,803
TB programme
performance through
operational research
3.1 Strengthen TB/ 90,304 887,200 120,097 1,179,908 132,359 1,300,377 145,873 1,433,145 160,767 1,579,470 649,400 6,380,100
HIV collaboration at
all levels
77

3.2 Intensify HIV 36,486 358,457 13,231 129,985 14,581 143,256 16,070 157,883 17,711 174,003 98,079 963,584
screening in
presumptive and
confirmed TB
patients and offer
high-quality patient-
centred HIV care
for HIV-infected TB
patients
3.3 Improve the - - 15,190 149,240 - - - - - - 15,190 149,240
quality of TB/HIV
services provided in
all districts
3.4 Reduce the 20,153 198,000 - - - - - - - - 20,153 198,000
burden of TB in PLHIV
and people at high
risk of HIV infection
3.5 Implement TB 598,123 5,876,316 143,301 1,407,875 29,336 288,213 32,331 317,640 35,632 350,071 838,723 8,240,114
infection control
in health services
dealing with PLHIV
4.l Develop and 212,247 2,085,240 568,553 5,585,807 212,680 2,089,492 136,179 1,337,901 219,108 2,152,647 1,348,766 13,251,088
reinforce the
technical and
managerial capacities
at Central Unit and
subnational level
4.2 Strengthen 32,435 318,657 35,746 351,192 39,396 387,049 43,418 426,566 47,851 470,119 198,846 1,953,583
coordination
between the NTLP
and collaborating
partners
4.3 Ensure resource 142,127 1,396,343 - - - - 255,744 2,512,584 - - 397,871 3,908,927
mobilization
4.4 Monitoring and 1,799,315 17,677,555 2,949,098 28,973,713 3,487,040 34,258,777 3,400,284 33,406,430 4,153,491 40,806,385 15,789,229 155,122,859
evaluation
4.5 Strengthen 12,861 126,349 14,174 139,250 15,621 153,467 17,216 169,136 18,973 186,405 78,844 774,608
programme
management
TOTALS 35,321,576 347,020,358 34,151,998 335,529,723 26,756,646 262,873,341 29,986,519 294,605,555 28,557,599 280,566,987 154,774,338 1,520,595,964
78
SECTION EIGHT: MONITORING AND EVALUATION FRAMEWORK

Health sector reporting in Zambia occurs primarily through the Health Management Information
System (HMIS) that was established in 1996. This system collects information on disease morbidity
and mortality, maternal and child health, service delivery, and surveillance. Information is aggregated
at the health-facility level, compiled by the district, and sent to the provincial and national level using
a web-based system. TB indicators and corresponding definitions based on the 2013 WHO Reporting
Framework for National TB Programmes have already been adopted in this system.
TB data at health-facility level are collected through disease-specific recording and reporting forms
that allow for longitudinal follow-up of patients through to completion of treatment. The information
is reported in a step-wise fashion, with the districts aggregating and reporting facility-level data to
the province, which in turn reports the aggregated data to the national level. Once the country roll-
out of DHIS2 is achieved (expected by end of 2017), TB data will be viewable in real time both at
provincial and national level, allowing monitoring of progress and achievements of the programme
as well as management of the programme. Quantification and distribution of drugs and laboratory
supplies are based on the quarterly district reports.
The NTLP uses the WHO-recommended recording and reporting forms and is therefore able to monitor
and evaluate programme performance in a manner that is internationally accepted and allows
for both in-country comparisons of performance and inter-country comparisons as standardized
indicators are used. Currently, the recording and reporting forms are all paper-based, but by the end
of the first year of this strategic plan, the NTLP will have the DHIS2 electronic reporting system. The
programme is also in the process of establishing an electronic patient-based system that will entail
TB data entered at health-facility level.
To make sure that there is an effective and efficient system to monitor and evaluate the National TB
Strategic Plan, the NTLP has incorporated the M&E framework within this strategic plan. During the
life of this NSP, the NTLP will start tracking new indicators for which the programme has no baseline
or target. It is expected that in the first year of the plan the baseline and target will be agreed.
The detailed M&E framework provides guidance on the key indicators, data sources, frequency,
responsibility and targets for each year. The M&E framework is in Annex II.
79
ANNEX I: TECHNICAL ASSISTANCE PLAN

This technical assistance (TA) plan is closely linked to the Zambia NSP’s operational plan. In the operational plan, essential TA is identified in the “Other” column
for the relevant strategic interventions, activities, or sub-activities.
Goal
Reduce the number of TB deaths in the population by 40 percent in 2021 compared to 2015.
Objective 1
• Increase:
• The number of notified cases of new TB episodes from 36,700 in 2015 to at least 59,000 by 2021.
• The treatment success rate for TB from 85 percent in 2014 to at least 90 percent from 2018 onwards.
Implementer of the Timeframe of Estimated Source of Funding
Number Items Terms of reference of the TA Profile of the expert/consultant intervention/activity the TA cost (USD) funding gap
1.1.1.1 Procure TA (one The TB manual should describe: i) all Extensive in-country experience NTLP Central Unit Q2 2017 15,001 TBD
international and one the components of the NTLP strategy, in the implementation of TB
local) for 14 days for ii) NTLP organization and management, prevention, care, and control
revision of TB manual and iii) the process of identification and activities; NTLP assessments; and
development of standard management of presumed TB patients, development of NTLP guidelines,
operating procedures iv) the prescription and follow-up of TB algorithms, and SOPs. The national
(SOPs), algorithms, and treatment, v) monitoring and evaluation consultant should have full
job aids. (M&E), vi) contact investigation, vii) the knowledge and understanding of
indications to use WHO-recommended TB prevention, care, and control in
rapid diagnostics (e.g. Xpert testing), and Zambia.
viii) other issues. The SOPs, algorithms,
and job aids must be aligned with the
national TB manual.
1.1.3.1 Procure one local TA The guidelines on contact investigation The national consultant should NTLP Central Unit Q2 2017 4,872 TBD
consultant for one week must clearly i) define the index TB cases, have a full knowledge and
to develop guidelines for ii) identify contacts who need to be understanding of TB prevention,
contact tracing. screened, iii) specify the algorithm(s) care, and control in Zambia
and SOPs needed, iv) describe the role of and significant experience in
human resources that will be involved, developing guidelines, algorithms,
v) specify the indications of isoniazid and SOPs.
preventive therapy (IPT), vi) describe the
required information system, and vii)
identify the indicators. These guidelines
must fully align with World Health
Organization (WHO) guidelines.
80

1.2.1.1 Procure TA (one The PPM handbook must describe the Extensive experience in strategic NTLP Central Unit Q1 2018 24,451 TBD
international, one local) coordination mechanisms between implementation of PPM for TB
for 14 days to develop the the NTLP and the private health sector prevention, care, and control in
public-private mix (PPM) as well as the measures to ensure Zambia and NTLP assessment.
handbook that includes appropriate linkages between the NTLP Significant experience in the
the expected roles and network and private care providers. This development of strategic
responsibilities of various PPM handbook should highlight the TB documents and guidelines for
private care providers. services and activities required/desired NTLPs. The Zambian consultant
by each category of private care provider. should have full knowledge and
The handbook should also describe understanding of TB prevention,
the process to involve the relevant care, and control in Zambia,
private care providers. Additionally, including the current situation
M&E indicators must be specified in the of private case providers in the
handbook. provision of TB services.
1.7.2.2 Procure an international Develop a framework for active TB drug The international consultant NTLP Central Unit Q4 2017 12,695 TBD
consultant for 14 days safety monitoring and management in should have i) experience in
to develop a framework collaboration with ZAMRA. active drug safety monitoring
document on the and management and ii) good
implementation of active understanding of TB treatment and
drug safety monitoring management.
and management
(aDSM) in collaboration
with Zambia Medicines
Regulatory Authority
(ZAMRA).
1.7.3.1 Procure an international Develop a protocol for assessing drug The international consultant NTLP Central Unit Q3 2017 15,260 TBD
consultant for 14 days management, including assessment should have i) extensive
to evaluate the anti-TB tools. Undertake visits and interviews experience in supply chain
drugs management with the MOH procurement unit, NTLP, management and ii) full
process (from estimates and MSL. Conduct field visits to select understanding of TB dug
of needs for anti-TB drugs provinces, districts, and health facilities management including drug
up to their distribution to to review the process and obtain an quantification.
patients). assessment of drug stocks compared
to requirements based on estimated
patient loads.
81

1.8.1.2 Procure TA for 15 days to Develop simple TB/HIV guidelines, a TB/ The consultant should have NTLP Central Unit Q2 2017 19,500 TBD
develop community TB/ HIV treatment supporter handbook and extensive experience in
HIV guidelines, update M&E tools to be used by community community health and TB/
the TB/HIV treatment workers and volunteers. Develop training HIV services provision. She/he
supporter handbook, and modules to train community workers should have the technical and
develop training modules and volunteers. All documents must writing skills to develop working
including tools for M&E. align with Zambia NTLP policies. documents for community workers
and volunteers.
1.9.1.1 Procure local TA to Develop a framework document, which The consultant should have NTLP Central Unit Q3 2017 6,500 TBD
develop/finalize should include i) the various components extensive experience in public
the advocacy, of the ACSM strategy to support TB health, health promotion, and
communication, and activities in Zambia in line with the End communication. She/he should
social media (ACSM) TB strategy, ii) the process needed to have full knowledge of TB
strategy for 10 days. implement these strategy components, prevention, care, and control in
and iii) M&E procedures for ACSM Zambia. In addition, she/he should
implementation outcomes regarding TB have skills in writing documents on
notification and services. health promotion activities.
82
Objective 2
Increase:
• The detection of MDR-TB patients from 196 in 2015 to 1,200 by 2021.

• The treatment success rate for MDR-TB patients from 33 percent in 2013 to 80 percent by 2021.
Profile of the expert/ Implementer of the Timeframe of Estimated Source of

Number Items Terms of reference of the TA consultant intervention/activity the TA cost (USD) funding Funding gap
2.1.1.1 Procure TA (one The revised PMDT guidelines Extensive experience in NTLP central Unit Q2 2017 45,588 TBD
international and should include the new procedures PMDT management, TB
one local) for 25 to detect MDR and RR patients, programme management,
days to update indications for the short regimen, and PMDT guidelines
the programmatic WHO regimen, pre-XDR cases, and development. Good writing
management of drug- XDR patients. These guidelines skills.
resistant TB (PMDT) should clearly describe the process
guidelines including for administering and monitoring
SOPs, algorithms, treatment in PMDT patients. The
and job aids on TB monitoring and evaluation process
diagnosis, treatment must be described. In addition,
and monitoring. algorithms, SOPs, and job aids should
be developed in line with revised
guidelines.
2.3.1.14 Procure TA Develop materials on DR-TB for use Knowledge of MDR-TB NTLP Central Unit Q4 2017 15,260 TBD
(international in the community. management. Experience in
consultant) for 14 days the development of training
to develop community materials.
DR-TB materials.
2.3.1.17 Procure TA Develop a programme for the Extensive experience in the NTLP Central Unit Q4 2017 15,260 TBD
(international introduction of the MDR-TB short use of short-course MDR-TB
consultant) for 14 days course regimen, and train staff in treatment regimen.
for the introduction MDR-TB treatment centres on the
and implementation of indications and use of short course
MDR-TB short regimen regimens and management of side
and new drugs. effects and drug interactions.
83
Objective 3
Scale up comprehensive TB/HIV collaborative activities to all facilities by 2021.
Profile of the expert/ Implementer of the Timeframe of Estimated Source of

Number Items Terms of reference of the TA consultant intervention/activity the TA cost (USD) funding Funding gap
3.5.1.1 Procure an international Revise the existing infection Sound experience in TB infection NTLP Central Unit Q3 2017 28,155 TBD
consultant for 21 days to control guidelines in line with control implementation
revise TB infection control WHO requirements. and guidelines and material
guidelines, develop development. Good skills in
training materials, and Update the existing training writing and communication.
train national trainers in materials in line with the revised
infection control. guidelines. Facilitate workshops
to validate the revised guidelines
and the updated training
materials.
Objective 4
Strengthen the technical and managerial capacities of the NTLP.

4.1.1.2 Procure two international Conduct two 10-day sessions Extensive experience with TB NTLP Central Unit Q2 2017 TBD TBD
TA consultants to train to train programme officers in management. Track record in
programme officers in PMDT. facilitation and training.
PMDT.
4.1.1.4 Procure a long-term Develop appropriate activities Sound experience in managing NTLP Central Unit Q1 2018 115,710 TBD
(12 months) local TA for to raise the NRL to the required TB laboratory networks. Extensive
the National Reference technical level and management experience in TB laboratory
Laboratory (NRL) for quality for accreditation. accreditation.
accreditation.
4.4.2.1 Procure a local Develop a plan to assess data Good understanding of the NTLP NTLP Central Unit Q4 2017 13,000 TBD
consultant for 10 days to flows, conduct an assessment structure and R&R systems.
undertake a nationwide through desk reviews and field
assessment of data flows visits, develop a plan to improve
to inform standardization the data flows, and develop SOPs
across districts and, in for the improved R&R system.
the process, streamline
recording and reporting
(R&R) systems.
84

4.4.3.1 Procure TA (one Develop a patient-based Excellent programming skills, NTLP Central Unit Q4 2017 51,623 TBD
international and one electronic information system knowledge of existing national
local) for 30 days to for TB. electronic data systems, and
develop the TB electronic good knowledge of a national TB
case-based information programme.
system.
4.4.4.4 Procure 10 international Conduct a mid-term International consultants who NTLP Central Unit June/July 2019 316,495 TBD
and 5 local TA assessment of the NSP and can provide a range of expertise
consultants for 15 days provide recommendations covering the main areas of the
to conduct a mid-term for adjustments in plans and NSP (programme management,
review of the NSP at the approaches. laboratory, TB drugs, MDR-TB, and
end of 2019. TB/HIV).
Local consultants who mirror

expertise of international
consultants.
4.4.4.6 Procure 10 international Conduct an end-term assessment International consultants who NTLP Central Unit June /July 2021 421,403 TBD
and 5 local TA of the NSP and provide can provide a range of expertise
consultants to conduct recommendations for the next covering the main areas of the
an end-term review of NSP (2022–2026). NSP (programme management,
the NSP for 14 days in laboratory, TB drugs, MDR-TB, and
June/July 2021. TB/HIV).
Local consultants who mirror

the expertise of international
consultants.
4.4.5.1 Procure TA for 75 Develop a training programme Proven experience in OR. Excellent NTLP Central Unit Q3 2017 48,750 TBD
days to develop a on OR, facilitate the training facilitating skills.
training programme in of staff in OR, facilitate the
operational research development of a national TB
(OR), train 20 national research agenda, and mentor
and provincial level staff in the development and
staff in OR, facilitate implementation of OR proposals.
the development of
a national research
agenda, and mentor staff
in the development of
OR protocols.
85
ANNEX II: MONITORING AND EVALUATION

Key national indicators and targets
By 2021, Zambia will achieve:
• 40 percent decrease in TB deaths (compared to 2015).

• 20 percent decrease in TB incidence rate (compared to 2015).
• No TB-affected households experience catastrophic costs.
Number Indicator Baseline 2015 2017 2018 2019 2020 2021
1. Number of TB deaths 17,000 15,640 14,280 12,920 11,560 10,200
and percent reduction
in deaths due to TB (8% decrease) (16% decrease) (24% decrease) (32% decrease) (40% decrease)
2. TB incidence rate and 391/100,000 375/100,000 359/100,000 344/100,000 318/100,000 313/100,000

percent reduction in TB
incidence rate (4% decrease) (8% decrease) (12% decrease) (16% decrease) (20% decrease)
3. Percentage of affected Projected 0% 0% 0% 0% 0%
families facing cata- baseline not
strophic costs due to TB available in
2015
86
Source of Level of data Baseline

Items Indicator Purpose Calculation information Periodicity Responsibility collection 2015 2021
Objective 1: Increase the number of notified cases of new TB episodes from 36,700 in 2015 to at least 59,000 in 2021 and increase treatment success rate from 85% in 2014 to at least 90% from
2018 onwards.
Number of new and relapse Outcome Value: Quarterly TB Quarterly NTLP TB treatment card 36,741 59,413
TB cases (all forms) notified case notification and yearly and register in
to the NTLP Number of notified new reports health facilities,
and relapse TB (all forms) with aggregation at
district, provincial,
and national level
TB case notification rate (new Outcome Number of notified new Annual TB cases Yearly NTLP TB treatment card 237 313
and relapse, all forms per and relapse TB cases notification and registers and
100,000 population) (all forms)/Estimated reports and WHO Annual Global TB
population) *100,000 estimates Report
Treatment success rate, new Outcome Numerator: TB treatment Quarterly NTLP TB treatment register 85% in > 90%
and relapse TB cases card and and yearly in health facilities, 2014
Number of patients with registers of NTLP with aggregation at
new and relapse TB who district, provincial,
were successfully treated quarterly cohort and national level
(cured plus completed report
treatment) in a treatment
cohort
Denominator:
Total
number of new and
relapse TB patients
in the same treatment
cohort
1.1 Improve case detection through expanding case finding to all clinical settings
Updated NTLP guidelines for Process N/A NTLP Central Yearly NTLP NTLP Central Unit No Updated NTLP
drug-susceptible TB available Unit updated guidelines
NTLP available from
guidelines 2017 onwards
available
87
Percentage of presumptive Output Numerator: TB microscopy/ Quarterly NTLP Health facilities Not known 100%
TB patients who undergo Xpert laboratory and yearly (including primary
diagnostic testing for TB Number of patients with register health care [PHC]
presumptive TB who are facilities), with
tested for TB according to aggregation at
NTLP standards district, provincial,
and national level
Denominator: The total
number presumptive
TB patients in the
presumptive register in
the same period
Percentage of new and Output Numerator: TB microscopy Quarterly District TB Health facilities 45% 70%
relapse TB cases with and Xpert and yearly coordinator, with TB diagnostic
bacteriological confirmation Number of new and laboratory province TB facilities (including
relapse TB cases register and and HIV liaison PHC facilities), with
with bacteriological TB treatment officer, and NTLP aggregation at
confirmation register of NTLP Central Unit district, provincial,
and national level
Denominator:
Total number of new and
relapse TB cases notified
during the specified
period
1.2 Involve all care providers practicing outside the NTLP network in TB case detection and management
Percentage of notified TB cases Output Numerator: Number of NTLP and Yearly NTLP TB notification Unknown TBD
who were detected through notified TB cases who Churches Health health facilities,
faith-based health facilities were identified through Association of with aggregation at
faith-based health facilities Zambia (CHAZ) district, provincial,
Denominator: records and national level
Total number of TB cases
notified with pulmonary
TB during the specified
period
Percentage of notified TB cases Output Numerator: Routine TB Yearly NTLP TB notification Unknown TBD
who were detected through notification health facilities,
community-based, civil Number of notified TB reports to the with aggregation at
society, and nongovernmental cases who were identified NTLP district, provincial
organizations (CBOs, CSOs, and through CBOs, CSOs, and and national level
NGOs) NGOs
Denominator:
Total number of TB
patients notified to the
NTLP
Percentage of notified TB cases Output Numerator: Routine TB Yearly NTLP TB notification health Unknown TBD
who were detected through notification facilities
private hospitals and clinics Number of notified TB reports to the
cases who were identified NTLP
through private hospitals
and clinics
Denominator:

notified to the NTLP
Percentage of private Process Numerator: NRL records and Yearly NRL Private laboratories Unknown TBD
laboratories which participated reports
in the external quality Number of private
assurance (EQA) system of the laboratories which
National Reference Laboratory participated in the EQA
(NRL) system of the NRL
Denominator:
Total number of private

laboratories that provide
any TB diagnostics service

Percentage of patients with Output Numerator: Number of NTLP records Yearly NTLP Health facilities, Unknown TBD
presumptive TB referred to patients with presumptive pharmacies and
health facilities for TB diagnosis TB referred to health chemists with
by private pharmacies and facilities for TB diagnosis Presumed TB
chemists by private pharmacies and patients registers
chemists
Denominator: Total
number of presumptive TB
cases registered
Percentage of notified TB cases Output Numerator: Number NTLP Presumed Yearly NTLP Health facilities, Unknown TBD
diagnosed through referrals of notified TB cases TB patients pharmacies and
by private pharmacies and diagnosed through registers and chemists with
chemists referrals by private TB treatment presumed TB
pharmacies and chemists registers patients registers
Denominator: Total and TB notification
number of TB cases health facilities
notified to the NTLP in the
same period
Percentage of notified TB cases Output Numerator: Number of NTLP records Yearly NTLP Health services Unknown TBD
that were detected through notified TB cases that of the Ministry of
health services of the Ministry were identified through Defense and Ministry
of Defense and Ministry of health services of the of Home Affairs
Home Affairs Ministry of Defense and
Ministry of Home Affairs
Denominator: Total
number of notified TB
patients
Overall percentage of notified Output Numerator: NTLP Yearly NTLP TB notification health Unknown TBD
TB cases identified through facilities
care providers practicing Total number of TB cases
outside the NTLP network identified through care
providers practicing
outside the NTLP network
(sum the total number
of TB cases identified
through all public-private
mix (PPM) interventions)
Denominator:
notified to the NTLP
90

1.3 Improve and strengthen TB services for high-risk groups and vulnerable populations
Percentage of Output Numerator: Number NTLP Quarterly NTLP Health facilities Unknown TBD
bacteriologically confirmed of bacteriologically and yearly
index TB cases whose confirmed index TB cases
household contacts were whose household contacts
screened for TB were screened for TB
Denominator:
Total number of
bacteriologically
confirmed TB cases who
were registered during a
specified period
Percentage of identified Output Numerator: Number Contact Quarterly NTLP Health facilities Unknown At least 80%
contacts who are screened of identified contacts investigation and yearly
for TB who are screened for TB register and
according to the NTLP forms
algorithm
Denominator: Total
number of contacts
identified in the same
period
Percentage of TB cases Output Numerator: Number NTLP records Quarterly NTLP TB notification health Unknown At least 5%
who are identified through of TB cases who are and yearly facility
contact investigation among identified through contact
all notified TB cases investigation
Denominator: Total
number of TB cases
notified
91

Percentage of children < 5 Output Numerator: Number NTLP Quarterly NTLP TB notification health Unknown 100%
years who are contacts of of children < 5 years and yearly facility
bacteriologically confirmed who are contacts
TB cases, screened and found of bacteriologically
to have no active TB and who confirmed TB cases,
received isoniazid preventive screened and found to
therapy (IPT) have no active TB and who
received IPT
Denominator: Total
number of children < 5
years who are contacts
and are screened and
found to have no active to
TB in specified period
Percentage of diabetic Output Numerator: Non- Quarterly NTLP Diabetes clinics Unknown TBD
patients who are screened Communicable and yearly
for TB Number of diabetic Disease (NCD)
patients who are screened and NTLP Unit
for TB records
Denominator:
Total number of diabetic

patients
Percentage of diabetic Output Numerator: NCD and NTLP Quarterly NTLP and NCD Diabetes clinic and Unknown TBD
patients who are screened Units and yearly Units TB notifications units
for TB and diagnosed with Proportion of diabetic
active TB disease patients who are screened
for TB and diagnosed with
active TB disease
Denominator:
Total number of diabetic

patients who are screened
for TB
92

1.3.3 Improve and reinforce TB services in correctional facilities
Percentage of new prisoners Output Numerator: Correctional Quarterly Correctional Correctional health Unknown TBD
screened for TB on entry to health services and yearly health services services TB recording
prison Number of new prisoners and NTLP and NTLP registers and forms
screened for TB on entry
to prison
Denominator:
Total number of new

prisoners admitted into
prison during a specified
period
Percentage of prisoners Output Numerator: Correctional Quarterly Correctional Correctional health Unknown TBD
who receive routine TB health services and yearly health services services TB recording
screening during the Number of prisoners and NTLP and NTLP registers and forms
reporting period who receive routine TB
screening
Denominator:
Total number of prisoners

during a reporting period
Percentage of prisoners who Output Numerator: Correctional H Quarterly Correctional Correctional health Unknown TBD
are diagnosed with TB and yearly Services services TB recording
Number of prisoners who health services registers and forms
are diagnosed with TB and NTLP
Denominator: Number NTLP

of prisoners who are
screened for TB in a
specified period
Overall percentage of Output Numerator: Number of Correctional Quarterly Correctional Correctional health Unknown TBD
prisoners diagnosed with TB prisoners diagnosed with health services and yearly health services services TB recording
TB and NTLP and NTLP registers and forms
Denominator: Total
number of TB cases
notified to the NTLP in a
specified period
93

1.3.4 Strengthen TB control within the mining sector
Percentage of miners who Output Numerator: NTLP and mining Quarterly NTLP and mining Mining clinic/ Unknown TBD
are screened for TB health services and yearly health services hospital TB registers
Number of miners
screened for TB
Denominator:
Total number of miners

(permanent and contract
workers) in specified
period
Percentage of miners Output Numerator: NTLP and mining Quarterly NTLP and mining Mining clinic/ Unknown TBD
screened for TB who are health services and yearly health services hospital TB registers
diagnosed with TB Number of miners who are
diagnosed with TB
Denominator:
Total number of all miners

in specified period
Overall percentage of miners Output Numerator: NTLP and mining Quarterly Mining health Mining clinic/ Unknown TBD
diagnosed with TB among all health services and yearly services and hospital TB registers
notified TB cases Number of miners NTLP
diagnosed with TB
Denominator:
Total number of notified

TB cases to the NTLP
1.3.5 Improve and strengthen TB services for children and adolescents
Number of notified TB cases Output Number of notified TB TB treatment Quarterly NTLP TB notification health 2,585 8,912
aged < 15 years (any form patients aged < 15 years register and yearly facility, aggregated
of TB) at district, provincial,
and national levels
94

Percentage of notified TB Output Numerator: TB treatment Quarterly NTLP TB notification health 7% 15%
cases aged < 15 years (any register and yearly facility, aggregated
form of TB) out of the total Number of TB patients at district, provincial,
notified TB cases < 15 years (all forms) and national levels
Denominator:

TB cases (all forms of TB)
reported to the NTLP in a
specified period
Percentage of notified TB Output Numerator: TB treatment Quarterly NTLP TB notification health 36% TBD
cases aged cards and and yearly facility
0–4 years (any form of Number of TB patients register
TB) among all TB cases in aged
children 0–4 years (all forms)
Denominator:

TB cases (all forms of TB)
who are aged < 15 years
1.3.6 Promote TB services for women
Number of women Process Number of women MCH and NTLP Yearly MCH and NTLP NTLP and MCH Unknown TBD
diagnosed with TB (any diagnosed with TB (any registers and forms
form) identified through form) identified through
the services of the national the services of the national
Maternal and Child Health MCH, Reproductive
(MCH), Reproductive Health, Health, and eMTCT
and eMTCT programmes programmes
95

Percentage of women Outcome Numerator: MCH and NTLP Yearly NTLP and MCH MCH and NTLP Unknown TBD
diagnosed with TB through registers and forms
the services of the national Number of women
MCH, Reproductive Health, diagnosed with TB
and eMTCT programmes through the services
of the national MCH,
Reproductive Health, and
eMTCT programmes
Denominator:

notified to NTLP during a
specified period
1.4 Improve and reinforce TB services in high TB-burden hot spot areas
Percentage of new and Outcome Numerator: TB treatment Quarterly NTLP TB notification health 18% TBD
relapse TB cases detected in register of NTLP and yearly facilities located and
Copperbelt Province Number of new and (Copperbelt Copperbelt Province
relapse TB cases notified Province) and and NTLP Central
from Copperbelt Province compiled Unit
notification of TB
Denominator: cases in the NTLP
Central Unit
notified at national level
Percentage of new and Outcome Numerator: TB treatment Quarterly NTLP TB notification health 34% TBD
relapse TB cases detected in register of NTLP and yearly facilities located in
Lusaka Province Number of new and (Lusaka Province) Lusaka Province and
relapse TB cases notified and compiled NTLP Central Unit
from Lusaka Province notification of TB
cases in the NTLP
Denominator: Central Unit

notified at national level
1.5 Strengthen TB diagnostic capacity through expansion and enhancement of the laboratory network
Number of functional/ Process Number of functional TB District, Yearly NTLP and NRL TB notification health 370 > 451
operational TB microscopy microscopy laboratories provincial, and facilities and NRL
laboratories national reports
96

Number of sites with Output Number of functional/ District, Quarterly NTLP and NRL HMIS at district, 69 490
functional/ operational operational GeneXpert provincial, and and yearly provincial, and
GeneXpert machines machines national reports national levels
Percentage of notified new Output Numerator: Laboratory Quarterly NTLP and NRL Laboratory registers unknown TBD
and relapse TB cases tested reports and yearly
with GeneXpert as the Number of notified new
initial diagnostic test for all and relapse TB cases
presumptive TB cases tested with GeneXpert
as the initial diagnostic
test for all presumptive TB
cases
Denominator:
Total number of TB tests

performed in the same
period
Percentage of testing sites Output Numerator: GXAlert system Yearly NTLP and NRL NRL Not TBD
using a GeneXpert machine established
at which a data connectivity Number of testing sites
system has been established using a GeneXpert
that transmits results machine at which a data
electronically to clinicians connectivity system
and to an information has been established
management system that transmits results
electronically to clinicians
and to an information
management system
Denominator:
Number of GeneXpert
sites
97

Percentage of presumed TB Output Numerator: TB microscopy Quarterly NTLP and NRL TB notification health 12% TBD
patients examined through laboratory and yearly facilities and NRL
microscopy with sputum Number of presumed registers and NRL
smear-positive microscopy TB patients examined reports
result through microscopy with
sputum smear-positive
results
Denominator: Number
of presumed TB patients
examined by microscopy
Percentage of diagnostic Process Numerator: Routine NRL Yearly NTLP and NRL TB diagnostic centres 30% (for 100%
testing sites that monitor reports on and NRL microscopy
performance indicators Number of diagnostic management of only)
and are enrolled in an EQA testing sites (stratified by the TB laboratory
system for all diagnostic type of diagnostic testing) network
methods performed that monitor performance
indicators and are enrolled
in an EQA system for
all diagnostic methods
performed
Denominator:
Number of testing sites

(stratified by type of
diagnostic testing)
Percentage of drug- Output Numerator: NRL EQA reports Quarterly NTLP and NRL TB notification health Not known At least 90%
susceptibility testing (DST) and yearly facilities and NRL
sites that have demonstrated Number of TB microscopy
proficiency by EQA panel laboratories with
testing for all DST methods acceptable proficiencies as
performance evaluated through EQA
Denominator:
Total number of TB
microscopy laboratories
linked to the EQA system
98

Percentage of laboratories Numerator: No data 3
conducting culture, line
probe assay (LPA), or Number of laboratories
phenotypic DST, or a conducting culture, LPA
combination of these, in or phenotypic DST, or a
which a formal quality combination of these, in
management system is which a formal quality
being implemented that management system
aims to achieve accreditation is being implemented
according to international that aims to achieve
standards accreditation according to
international standards
Denominator:
Number of laboratories
conducting culture, LPA
or phenotypic DST, or a
combination of these
Number of functional/ Process Number of functional NTLP and NRL Yearly NTLP and NRL TB notification health 56 490
operational GeneXpert GeneXpert machines reports facilities and NRL
machines installed throughout the
country
Percentage of notified new Output Numerator: TB laboratory Quarterly NTLP and NRL TB notification health 24,140 TBD
and relapse TB cases tested registers and yearly facilities and NRL
with GeneXpert as the initial Number of notified new
diagnostic test and relapse TB cases
tested with GeneXpert as
the initial diagnostic test
Denominator:
Number of notified new

and relapse TB cases
Percentage of Xpert tests Process Numerator: TB laboratory Quarterly NTLP and NRL TB notification health 14% TBD
positive for MTB registers and yearly facilities and NRL
Number of Xpert tests
positive for MTB
Denominator: Total
number of Xpert tests
performed
99

Percentage of positive MTB Output Numerator: TB laboratory Quarterly NTLP and NRL TB notification health 3% TBD
Xpert tests with positive registers and yearly facilities and NRL
rifampicin-resistant (RR) TB Number of positive Xpert
result tests with positive RR-TB
result
Denominator: Total
number of Xpert tests that
are positive for MTB
Percentage of notified, Numerator: TB laboratory Quarterly NTLP and NRL TB notification health No data 100%
bacteriologically confirmed registers and yearly facilities and NRL
TB cases with DST results for Number of notified,
rifampicin bacteriologically
confirmed TB cases with
DST results for rifampicin
Denominator:
Number of notified,
bacteriologically
confirmed TB cases
Percentage of notified, Numerator: DST registers Quarterly NTLP and NRL DST centres No data 100%
RRTB cases with DST results and yearly
for fluoroquinolones and Number of notified RR-TB
second-line injectable agents cases with DST results
for fluoroquinolones and
second-line injectable
agents
Denominator:
Number of notified RR-TB

cases
100

Percentage of new and Process Numerator: Xpert, LPA, Quarterly NTLP and NRL TB notification sites, unknown 100%
retreatment TB cases that culture and DST, and yearly GeneXpert sites,
received DST Percentage of new and registers and culture and DST
retreatment TB cases that centres
received DST
Denominator:
Number of all TB cases for

the same period
1.6 Improve the technical platform for TB diagnostic procedures
1.6.1 Expand the use of chest x-ray as a TB screening tool
Number of functional Process Number of digital x-ray NTLP Yearly NTLP and Health facilities Not known At least 20
digital x-ray machines in the machines installed Central Unit, Radiology Unit
country maintenance
records
Number of x-ray tests carried Output Number of x-ray tests x-ray register Yearly NTLP and Health facilities Unknown TBD
out among presumptive TB carried out among Radiology Unit
cases presumptive TB patients
Percentage of x-ray tests Output Numerator: x-ray register Yearly NTLP and Health facilities Unknown TBD
among presumptive TB Radiology Unit
cases with a radiological Number of x-ray tests
abnormality suggestive of TB among presumptive TB
cases with a radiological
abnormality suggestive
of TB
Denominator: Total
number of x-ray tests
carried out among
presumptive TB cases
1.1.1 Enhance the diagnosis of extra-pulmonary TB
A document including Process NA NTLP NA NTLP NTLP Updated Incorporated
guidelines and algorithms document within the
to set the diagnosis and not updated
management of extra- available guidelines
pulmonary (EP) TB prepared for drug-
and produced susceptible TB
101

Percentage of districts which Process Numerator: Quarterly Quarterly NTLP and MSL TB notification health 0% 0%
experienced at least one reports of NTLP, and yearly facilities and districts
stockout episode lasting 14 Number of districts which MSL records,
days as defined by NTLP experienced at least one and district
stockout lasting 14 days as information
defined by NTLP system
Denominator:
Total number of districts in

the country
Treatment success rate for Outcome Numerator: TB treatment Quarterly NTLP TB notification health 85% in > 90%
new TB cases cards and and yearly facility 2014
Number of new TB cases registers of the
who were cured or NTLP
completed TB treatment in
a specific cohort
Denominator:
Total number of new TB

cases who were
registered for treatment in
the same cohort
Lost to follow-up rate Outcome Numerator: TB treatment Quarterly NTLP TB notification health 4% < 2%
registers and and yearly facility
Number of new TB cases cards of the NTLP
who were lost to follow-up
in a treatment cohort
Denominator:
Number of new TB cases
registered in the same
treatment cohort
102

TB treatment success rate for Outcome Numerator: TB treatment NTLP NTLP TB notification health 84% (2016 > 90%
HIV-positive TB patients cards and facilities report
Number of HIV-positive registers and 2015
TB patients who were cohort)
cured or completed TB
treatment in a specific
cohort
Denominator:
Number of all TB/HIV

co-infected TB patients
registered for treatment in
the same cohort
TB treatment success rate for Outcome Numerator: TB treatment NTLP TB notification health Unknown > 90%
new TB patients diagnosed registers and facilities
by Xpert MTB/RIF Number of new TB cards
patients diagnosed
through Xpert MTB/RIF in
a treatment cohort who
are cured or complete TB
treatment
Denominator:
Number of new TB cases

diagnosed through Xpert
MTB/RIF registered in the
same treatment cohort
1.8 Strengthen community systems to improve the provision of TB services
Number of presumptive TB Output Number of presumptive Community TB Quarterly NTLP and TB Health facilities Not known TBD
cases referred for diagnostic TB cases referred for registers and and yearly Coalition with presumed TB
testing through the diagnostic testing through presumptive TB patients registers
community network the community network registers
103

Percentage of identified TB Output Numerator: Presumptive Quarterly NTLP and TB Health facilities Not known TBD
patients among those who TB registers and yearly Coalition with presumed TB
were referred through the Number of presumptive and treatment patients registers
community network (yield of TB cases referred through registers and TB notification
community-based efforts to community network who health facilities
improve TB case detection) were diagnosed with TB
Denominator:
Total number of patients

with presumptive TB
referred through the
community network
Percentage of notified TB Output Numerator: NTLP records and Quarterly NTLP TB notification health Unknown TBD
cases identified through reports and yearly facilities
the community network Number of new TB cases
among all notified TB cases identified through the
(community contribution to community network
the TB notification)
Denominator: Total
number of notified TB
cases
Percentage of successfully Output Numerator: Community Quarterly NTLP TB notification health Unknown TBD
treated TB patients who were registers and and yearly facilities
being followed through the Number of new TB NTLP records
community network patients who were cured
or completed treatment
and who were supervised
by the community
network in a treatment
cohort
Denominator:
Total number of TB
patients on treatment who
were supervised by the
community in the same
treatment cohort
104

Percentage of TB cases Output Numerator: Number of TB NTLP records and Quarterly NTLP TB notification health Unknown TBD
detected through contact cases detected through reports and yearly facilities
investigation conducted by contact tracing conducted
the community by the community
Denominator:

TB cases reported to the
NTLP
1.9 Implement the ACSM strategy to raise the profile of TB in the communities
Number of presumed TB Output Number of presumed Presumed TB Quarterly NTLP Health facilities Unknown TBD
patients who are self-referred TB patients who are self- patients registers and yearly with presumed TB
referred patients registers
Percentage of presumed TB Output Numerator: Presumed TB Quarterly NTLP Health facilities Unknown TBD
patients who are self-referred patients registers and yearly with presumed TB
Number of presumed patients registers
TB patients who are self-
referred
Denominator:
Total number of presumed

TB patients in a specified
period
Percentage of identified Output Numerator: Presumed TB Quarterly NTLP Health facilities Unknown TBD
TB patients among the patients registers and yearly with presumed TB
presumed TB patients who Number of self-referred and TB treatment patients registers
were self-referred presumed TB patients who registers and TB notification
were diagnosed with TB health facilities
Denominator:
Total number of presumed

TB patients who were self-
referred
105

Percentage of notified TB Output Numerator: NTLP records and Quarterly NTLP TB notification health Unknown TBD
cases who were self-referred reports and yearly facilities
presumed TB patients Number of notified TB
among all notified TB cases cases who were self-
referred presumed TB
patients
Denominator:

TB cases in a specified
period
106
Baseline
Source of
Number Items Indicator Purpose Calculation information Periodicity Responsibility Level of data collection 2015 2021 target
Objective 2: Increase the detection of MDR-TB patients from 196 in 2015 to 1,200 by 2021.by 2021 and increase the treatment success rate for MDR-TB patients from 33% in 2013 to 80% by
2021.
Number of retreatment Output Number of TB treatment and Quarterly NTLP and NRL Health facilities with Unknown All
TB cases who are tested retreatment TB Xpert registers and yearly GeneXpert machines and TB
with Xpert MTB/RIF cases who are notification health facilities
tested with Xpert
MTB/RIF
Percentage of Output Numerator: TB treatment register Quarterly NTLP TB notification health 10% 100%
retreatment TB cases and Xpert registers and yearly facilities
who are tested with Number of
Xpert MTB/RIF retreatment TB
patients who are
tested with Xpert
MTB/RIF
Denominator:
Total number of
retreatment TB
cases registered in
the same period
Output Number of MDR/ MDR/RR-TB trestment Quarterly NTLP MDR/RR-TB notification 196 > 1,200
Number of MDR/RR-TB
RR-TB patients register and yearly centres
patients detected
detected
Output Number of MDR/ MDR/RR-TB treatment Quarterly NTLP Central Unit MDR/RR-TB treatment 99 > 1,200
Number of MDR/RR-
RR-TB cases who register and yearly health facilities
TB cases who initiate
initiate second-
second-line anti-TB
line anti-TB
treatment
treatment
Percentage of detected Outcome Numerator: MDR-TB registration Yearly NTLP and NRL MDR/RR-TB treatment 46% 100%
MDR/RR-TB cases system of NTLP; Xpert health facilities
initiated on second-line Number of registers; and Xpert,
anti-TB treatment detected MDR/ culture, and DST
RR-TB patients registers (NRL)
initiating second-
line anti-TB
treatment
Denominator:
Total number of
detected MDR/RR-
TB patients
107
Baseline
Source of
Number Items Indicator Purpose Calculation information Periodicity Responsibility Level of data collection 2015 2021 target
Percentage of estimated Outcome Numerator: MDR/RR-TB Yearly NTLP and NTLP central unit and NRL 7% 100%
MDR/RR-TB cases registration system of World Health
enrolled on second line Number of MDR/ NTLP; Xpert registers; Organization
anti-TB treatment RR-TB patients and Xpert, culture, and (WHO) estimates
enrolled on DST registers (NRL)
second-line anti-
TB treatment
Denominator:
Number of
estimated MDR/
RR-TB patients in
the same year
Treatment success rate Outcome Numerator: MDR/RR-TB treatment Yearly NTLP MDR/RR-TB treatment 33% in 2013 > 80%
of MDR/RR-TB patients cards and registers centres
who are enrolled on Number of
second-line drugs patients with
MDR/RR-TB
who are cured
or complete
treatment
among a specific
treatment cohort
Denominator:
The total
number of
patients with
MDR/RR-TB who
were
enrolled in the
same second-line
treatment cohort
108
Baseline
Source of Level of data
Number Items Indicator Purpose Calculation information Periodicity Responsibility collection 2015 2021 target
Objective 3: Scale up comprehensive TB/HIV collaborative activities to all facilities by 2021.
Percentage of Output Numerator: TB treatment Quarterly NTLP TB notification 95% 100%
notified TB patients register and yearly health facilities
with documented Number of TB patients with
HIV status documented HIV status
Denominator:
Total number of notified TB

patients in the same year
Percentage of TB Output Numerator: TB treatment Quarterly NTLP TB notification 61% No target but
patients who test register of NTLP and yearly health facilities is expected to
HIV positive Number of notified TB patients go down each
with documented HIV status who year during
are HIV positive the life of the
NSP
Denominator:
Total number of TB patients with

documented HIV status in the same
period
Percentage of HIV- Output Numerator: TB treatment Quarterly NTLP TB notification 92% 100%
positive TB patients register of NTLP and yearly health facilities
who are initiated Number of HIV-positive TB patients
on cotrimoxazole who are initiated on CPT
preventive therapy
(CPT) Denominator:
Total number of HIV-positive TB

patients in the same period
Percentage of Output Numerator: TB treatment Quarterly NTLP TB notification 76% 100%
HIV-positive TB register and yearly health facilities
patients initiating Number of HIV-positive TB
or continuing patients who initiate or continue
antiretroviral antiretroviral therapy
therapy (ART)
Denominator: Number of HIV-
positive notified TB patients
registered for TB treatment
109
Baseline
Number Items Indicator Purpose Calculation information Periodicity Responsibility collection 2015 2021 target
Number of people Output Number of PLHIV newly enrolled Smart Care/HMIS Quarterly HMIS of the M&E Health facilities Unknown > 800,000
living with HIV who are screened for TB and yearly Unit and HIV with HIV services
(PLHIV) newly programme
enrolled into HIV
care who have
documented TB
screening in their
last visit
Percentage of Output Numerator: Smart Care Quarterly HMIS of the M&E Health facilities Unknown TBD
PLHIV enrolled and yearly Unit and HIV with HIV services
on care who are Number of PLHIV enrolled on care programme
diagnosed with TB who are diagnosed with TB
Denominator:
Number of PLHIV newly enrolled

into care and/or on ART who are
screened for TB
Percentage of Output Numerator: DHIS2 Quarterly HMIS officer and Health facilities 15% 100%
eligible PLHIV and yearly province TB and with HIV services
initiated on latent Number of PLHIV newly enrolled HIV officer (2016 Report)
TB infection into care who were screened for TB
treatment using IPT with negative results for active TB
who received IPT
Denominator:
Total number of PLHIV screened for

TB with negative results for active
TB
110
Baseline
Numbering Items Indicator Purpose Calculation information Periodicity Responsibility collection 2015 2021 target
Objective 4: Strengthen the technical and managerial capacities of the NTLP.
4.1 Develop and reinforce the technical and managerial capacities at Central Unit and subnational levels
The performance Process Qualitative data from External Mid-term and NTLP NTLP NA The performance
of the NTLP external evaluation, which evaluation final reviews of NTLP
improved at includes assessment of improved
Central Unit and whether recommendations
subnational levels were taken up/acted on
between mid-term and
final review
Number of health Process Number of health care NTLP reports Quarterly NTLP NTLP reports Not known TBD
care workers workers trained on TB at all and yearly at national and
trained on TB (new levels (new and refresher) subnational level
and refresher),
disaggregated by
gender
4.2 Ensure high-quality services through technical support and supervision
Percentage Process Numerator: Report on each Quarterly NTLP Central NTLP Central Unit NA At least 90%
of planned supervision visit and yearly Unit
supervision visits Number of supervision made
carried out visits carried out
Denominator: Number of
supervision visits planned
in the same year
4.3 Uninterrupted supply of quality-assured medications
Percentage of Process Numerator: Quarterly reports Quarterly NTLP and MSL TB notification health Not known 0
districts which and supervision and yearly facilities and districts
experienced at Number of districts which reports
least one stockout experienced at least one
episode lasting 14 stockout lasting 14 days as
days as defined by defined by NTLP
NTLP Denominator:
Total number of districts in
the country
4.4 Monitoring and evaluation system
Number of Process Number of technical Quarterly reports Quarterly, NTLP District, provincial, 20 20
technical support support supervision visits yearly and national reports
supervision visits conducted
conducted
111
Baseline
Numbering Items Indicator Purpose Calculation information Periodicity Responsibility collection 2015 2021 target
Percentage of Process Numerator: Quarterly Quarterly, NTLP District, provincial, 100% 100%
routine technical supervision yearly and national reports
supervision Number of routine reports at district,
reports received technical supervision provincial, and
on time reports received national level
Denominator:
Total number of
supervision visits planned
for the same period
Percentage Process Numerator: Quarterly Quarterly, NTLP District, provincial, No data 100%
of complete supervision yearly and national reports
data quality Number of complete data reports at district,
assessments quality assessments provincial, and
performed Denominator: national level
Number of data quality
assessments planned for
the same period
4.5 Developing operational research
Number of Process Number of research studies Annual report Yearly NTLP NTLP One known 10 (at 2 least per
operational conducted research year)
research studies study
(OR) conducted conducted by
in 2016
Number of TB Process Number of TB manuscripts Annual report Yearly NTLP NTLP and partner Not known 10 (at least 2 per
manuscripts by the NTLP and partners reports year)
submitted for published in peer-reviewed
publication journal
Number of OR Process Number of Annual report Yearly NTLP Ministry of Health Some TBD
recommendations recommendations taken by reports actions taken
taken up by NTLP the NTLP that resulted in following
via policy change policy and practice change the TB
or programmatic prevalence
practices survey report
112
ANNEX III: ACKNOWLEDGEMENT

The Ministry of Health would like to express special gratitude to the following individuals and
organizations for their role in developing this NTLP Strategic Plan:
Core Writing Team
Dr. Sylvia Chila Simwanza NTLP Manager, Ministry of Health (MOH)
Dr. Mwendaweli Maboshe Challenge TB Director, FHI360
Dr. Lastone Chitembo HIV/TB National Professional Officer, World Health Organization
Dr. Monde Muyoyeta Researcher, Centre for Infectious Disease Research in Zambia
Dr. Patrick Lungu Medical Officer, University Teaching Hospital
Dr. Chishala Chabala Pediatrician, University Teaching Hospital
Dr. Rhehab Chimzizi TB Technical Advisor, National Tuberculosis and leprosy Programme,
MOH
Clara Kasapo TB Liaison Officer–Focal Monitoring and Evaluation Officer, MOH
Lutinala Mulenga Biomedical Scientist, Chest Disease Laboratory, MOH
Tendai Munthali Senior TB Officer–TB/HIV Focal Person, MOH
Morton Khunga Chief TB Officer–Pharmacist, MOH
Judith Mzyece TB Laboratory Focal Person, MOH
Grace Hameja Principal TB and Leprosy Officer, MOH
Charity Habeenzu Chief Executive Officer, Zambia TB and Leprosy Trust (ZATULET)
Vainess Mfugwe TB/HIV Officer, Research Institute of Tuberculosis/Japan Tuberculosis
Association (RIT/JATA)
Working Group Members and NSP Writing Team
Name Organization Designation

Dr. Kaseya Chiyenu Livingstone Central Hospital Internal Medicine Consultant
Constance Ngenda CITAM Plus Programme Officer
Joseph Mwewa Chest Disease Laboratory, MOH Biomedical Scientist
Matindo Kelvin Liboma Ministry of Health TB/HIV Logistics Officer
Clifford Munyandi Ministry of Health Monitoring and Evaluation Of-
ficer
Chrispine Silavwe Ministry of Health TB in the Mines roject Coordi-
nator
Carol Nawina CITAM Plus Executive Director
William Ngosa Ministry of Health Biostatistician
Dr. Alwyn Mwinga Zambia AIDS Related TB (ZAMBART) Executive Director
Dr. Albert Kaonga Global Fund to Fight AIDS, Tuberculosis and TB/HIV Officer
Malaria Programme Management Unit, MOH
Kaluswikwa Kakoma National AIDS Council TB/HIV Officer
Grace Mbulo University Teaching Hospital Chief Biomedical Scientist
Namundi Siwale Ministry of Health TB Information Officer
Mevin Sikazwe Ministry of Health Planner
Vainess Mfungwe Research Institute of Tuberculosis/ Japan TB/HIV Officer
Tuberculosis Association
Mannix Ngabwe Ministry of Health Senior Planner
Powell Choonga Churches Health Association of Zambia Senior Lab Specialist
Lynn Tamba Churches Health Association of Zambia Senior TB/HIV Officer
113
Dr. Henry Phiri Global Fund PMU, MOH TB/HIV Officer

Dr Ona Nyirenda University Teaching Hospital Medical Officer
Graham K. Samungole Lusaka District Health Office District TB Coordinator
Namushi Mwananyambe US Centers for Disease Control and Preven- TB Specialist
tion
The following organizations and individuals made special technical or financial contributions:
United States Agency for International Development (USAID) through the Challenge TB mechanism
and the Resident TB Technical Advisor
Global Fund to Fight AIDS, Tuberculosis and Malaria
World Health Organization
US Centers for Disease Prevention and Control (CDC)
Global Fund Country Coordinating Mechanism (CCM)
Centre for Infectious Disease Research in Zambia (CIDRZ)
Churches Association of Zambia (CHAZ)
Zambia AIDS Related Tuberculosis (ZAMBART) Project
Japanese Tuberculosis Association (JATA)
Provincial Health Directors and District Health Directors who participated in the consultation
meetings in Kabwe
Civil society organizations and community members who participated in the consultation meetings
in Kabwe
CITAM Plus
Zambia Tuberculosis and Leprosy Trust (ZATULET)
Zambia TB Organizations Coalition
Former NTLP Managers Dr. Nathan Kapata and Dr. Callistus Kaayunga
114
115
Disclaimer
This document is made possible by the support of the American People through the United States Agency for Inter-
national Development (USAID) and the US President’s Emergency Plan for AIDS Relief (PEPFAR). The contents
are the sole responsibility of Ministry of Health and do not necessarily reflect the views of USAID or the United
States Government
116
REPUBLIC OF ZAMBIA
MINISTRY OF HEALTH
NATIONAL STRATEGIC PLAN (Back cover)

(Back cover)
FOR TUBERCULOSIS
PREVENTION, CARE AND CONTROL
(2017 - 2021)
Produced for the Ministry of Health, Zambia

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NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS PREVENTION, CARE AND CONTROL (2017–2021)

NATIONAL STRATEGIC PLAN

National Strategic Plan

DR. CHITALU CHILUFYA, MP

DR. JABBIN MULWANDA

PERMANENT SECRETARY-TECHNICAL SERVICES

Executive Summary viii

SECTION ONE: BACKGROUND 1

1.1 Political and Administrative Structures and Economy 1

1.2 Demographic Characteristics of Zambia 1

1.3 Population Health Status in Zambia 2

1.4 Health Care System in Zambia 3

1.5 Health Sector Financing 5

1.6 Health Sector Reform and Policy Changes 5

1.7 HIV Treatment Programme 6

SECTION TWO: TUBERCULOSIS IN ZAMBIA 7

2.2 Partner Coordination 7

2.3 The Burden of TB Disease in Zambia 8

2.4 Programme Performance 11

2.6 Infection Control 14

2.7 Laboratory Services for TB Control 14

2.8 Management of TB Medicines 17

2.9 Involving All Care Providers (Public-Private Mix) 18

2.10 TB and the Mining Sector 18

2.12 TB and Cross-Border Populations 19

2.14 Routine TB Data Systems and Surveillance 20

2.15 Funding for TB Control 20

2.16 National TB Strategic Plans 24

SECTION THREE: PROGRAMMATIC ANALYSIS 22

3.1 Evaluation of Surveillance and TB Epidemiological Analysis 2014 22

3.2 National TB Review 2016 22

3.3 SWOT Analysis 23

3.4 Gap Analysis 26

3.5 Rationale for National Strategic Plan 31

SECTION FOUR: VISION, MISSION, GOALS AND OBJECTIVES, AND STRATEGIC

4.4 Guiding Principles 32

4.5 Major Focus Areas 32

4.6 Strategic Interventions and Activities 33

SECTION FIVE: OPERATION PLAN 74

SECTION SIX: TECHNICAL ASSISTANCE PLAN 74

SECTION SEVEN: BUDGET PLAN 74

SECTION EIGHT: MONITORING AND EVALUATION FRAMEWORK 79

ANNEX I: TECHNICAL ASSISTANCE PLAN 80

ANNEX II: MONITORING AND EVALUATION 86

ANNEX III: ACKNOWLEDGEMENT 113

MOH Ministry of Health

Identify the missing TB cases

Enhance TB diagnostic services

Expand programmatic management of multidrug-resistant TB

Enhance TB/HIV collaboration

Strengthen multisectoral and community partnerships for TB

SECTION ONE: BACKGROUND

1.2 Demographic Characteristics of Zambia

Figure 1: Zambia’s population by provinces (2015 estimates)

1.4 Health Care System in Zambia

1.4.5 Traditional health care providers

Province Number of health facilities (HF) by ownership

1.5 Health Sector Financing

1.6 Health Sector Reform and Policy Changes

1.7 HIV Treatment Programme

SECTION TWO: TUBERCULOSIS IN ZAMBIA

2.2 Partner Coordination

2.3 The Burden of TB Disease in Zambia