intra action review (iar) of the zambia covid-19...

INTRA ACTION REVIEW (IAR) OF THE ZAMBIA COVID-19

OUTBREAK RESPONSECOVID-19 Outbreak Response IAR

report

MIKA CONVENTION CENTRE, CHONGWE, ZAMBIA23-25 SEPTEMBER, 2020

SEPT2020

Zambia COVID-19 Intra-Action Review (IAR) Report 2

ZAMBIA COVID-19 INTRA-ACTION REVIEW (IAR)

REPORT


ContentsABBREVIATIONS 51. RATIONALE AND METHODOLOGY OF THE REVIEW 61.1. Scope of the Zambia COVID 19 IAR 61.2. Methodology 72. FINDINGS 82.1. Country-levelcoordination,planningandmonitoring 82.2. Riskcommunicationandcommunityengagement 112.3. Surveillance,caseinvestigationandcontacttracing 132.4. Points of Entry 162.5. TheNationalLaboratorySystem 182.6. InfectionPreventionandControl 212.7. Casemanagementandknowledgesharingaboutinnovationsandthelatestresearch 232.8. Operationalsupportandlogisticsinthemanagementofsupplychainsandtheworkforce 252.9. MaintainingessentialhealthservicesduringtheCOVID-19outbreak 273. THE WAY FORWARD 284. ANNEXES 304.1. Annex1:ListofparticipantsandIntra-ActionReview(IAR)team 304.2. Annex2:AgendaoftheZambiaCountryCOVID-19Intra-ActionReview 344.3. Annex2:ActivityTable 38


ABBREVIATIONS AFENET – African Field Epidemiology NetworkBID – Brought in deadCDC –CenterforDiseaseControlandPrevention

COVID-19 – Coronavirus disease 2019DMMU –DisasterManagementandmitigationUnitEHS –EssentialHealthServicesFPP – Focal Point PersonIAR –Intra-actionReviewIDSR – Intergrated Disease Surveillance and ResponseIEC –Information,Education,CommunicationILI –Influenza-likeInfectionsIMS – Incident Management SystemIPC –InfectionPreventionandControlMOH – Ministry of HealthNIC –NationalInfluenzaCentersPIP –PandemicInfluenceSurveillanceProgramPOE – Points of EntryPPE –PersonalProtectiveEquipmentRCCE –RiskCommunicationandCommunityEngagementRRT – Rapid Response TeamsSA-RCC –SouthernAfricaRegionalCollaboratingCenterSARI –SevereAcuteRespiratoryInfectionSOP –StandardOperatingProcedureSVM –SchoolVetinaryMedicineTB – Tuberculosis UTH – University Teaching HospitalVHF – Viral Hemorrhagic FeverWASH –WaterSanitationandHygieneWHO –WorldhealthOrganizationZNPHI –ZambiaNationalPublicHealthInstitute


1. RATIONALE AND METHODOLOGY OF THE REVIEW

TheZambia IntraAction review (IAR)was conducted toprovideanopportunity to review the functionalcapacityofthepublichealthemergencyresponsesystemsatnationalandsubnationallevels.TheaimwastoidentifypracticalareasthatneededimmediateremediationortargetedforsustainedimprovementintheCOVID-19 response. TheobjectivesoftheIARareasfollows: • Toprovideanopportunitytoshareexperiencesandcollectivelyanalysethe ongoingin-countryresponsetoCOVID-19byidentifyingchallengesandbest practices;

• To facilitate consensus building among and compiling lessons learnt byvariousstakeholdersduringtheresponse,toimprovebysustainingbest practicesthathavedemonstratedsuccessandpreventingrecurrenterrors.

• Todocumentandapplythelessonslearntfromtheresponseeffortstodate to enable health system strengthening.

• Toprovideabasisforupdatingandvalidatingthecountry’sCOVID-19 strategic preparedness and response plan and other strategic plans accordingly.

1.1. Scope of the Zambia COVID 19 IARZambiahasbeenrespondingtotheCOVID-19outbreaksinceMarch,2020andhasaccumulatedexperiencewhichnecessitatedthereviewprocessinordertoconsiderstrategicmodificationstotheresponseplan.TheIARwasbasedontheWHOCOVID-19strategyupdateof23rdJuly,2020focusingonthefollowingpillarsofthe COVID-19 response:• Country-levelcoordination,planningandmonitoring• Riskcommunicationandcommunityengagement• Surveillance,caseinvestigationandcontacttracing• Points of entry• Nationallaboratorysystem• Infectionpreventionandcontrol• Casemanagementandknowledgesharingaboutinnovationsandthelatestresearch• Operationalsupportandlogisticsinthemanagementofsupplychainsandtheworkforce• MaintainingessentialhealthservicesduringtheCOVID-19outbreak

Although the pillar on maintaining essential health services during the COVID-19 outbreak was notincorporatedintheIMSstructure,itwasreviewedunderthecoordinationandplanningpillarduringtheIAR.


1.2. Methodology

TheMinistryofHealththroughtheZambiaNationalPublicHealthInstitute(ZNPHI)andotherstakeholdersinvolvedintheemergencyresponsewithinandoutsidethehealthsectorheldseveralpriorvirtualmeetingswherebackgroundinformationwascollectedandreviewed.Toensureawell-coordinatedprocessoftheIAR,pillar leadsandfacilitatorswere identifiedandtrainedduringwhichtoolswereshared.TriggerquestionswereselectedfromtheIARpackageandwererefinedtoensureimportantthemesofthepillarsunderreviewwerecovered.Theteamdesignedanintraactionreviewformatthatwasforonsiteandvirtual.

Taking intoconsideration the infectionpreventionandcontrolmeasures,onlyfifteenmembersperpillarwereallowedtoattendtheonsitemeetingwhiletherestofthemembersattendedvirtually.

The following steps were followed to conduct the IAR:• Identificationofactionstakenduringtheresponse• Analysisofthegapsandbestpractices• Identificationofactionstostrengthenorimproveperformanceandhowtofollowup


2. FINDINGS2.1. Country-level coordination, planning and monitoring

• Observations

Bestpractices

• Situationalreportsandupdatessharedconsistentlywithresponseteams

• Monitoringsupplychainstostrengthenlogisticalandresponsive-nessonthepartofcooperatingpartners

• DailyMinister’smeetinganddailyupdates• ActivationoftheIMSatNational,Provincialanddistrictlevelsand

seamlessintegrationwithsurveillance• Policy briefs and media statements developed to guide govern-

ment decisions based on disease epidemiology• Engagementofmultiplepartners/sectorsintheresponse• Utilizationofthetroikaplatformbycooperatingpartnersforadvo-

cacyandresourcemobilization• IMScoordinationactivatedandoperationalatnationaland

sub-nationallevel• Decisionmakingattechnicalandpolicylevelareinsynchroniza-

tion• SouthernAfricaRegionalCollaboratingCentre(SA-RCC)ofAfrica

CentresforDiseaseControlandprevention(Africa-CDC)weeklymeetingswhichsharebestpractices

• IMSmoremultisectoralandnotsoheavyleaningonhealthsector


Challenges

• InadequatefundsforCOVID-19preparednessmeasuresfollowingonset of the global pandemic in other countries

• Inadequatelinkageofpolicydirectivesandtechnicalrecommen-dationsinimplementingCOVID-19measures

• Testingofthepreparednessplanatoutbreakonsetnotdonethroughdrillsorsimulationexercises

• Forecastingdidnotaddresssomeimportantaspectsofthere-sponsee.g.surgecapacity,financialresources

• Unclearguidanceonrolesandresponsibilitiesduetoslowinitialresponse

• Inadequateidentificationofgapsandleveragingofresourcesduetoabsenceofintramultisectoralcollaborationmeeting

• PublicHealthGuidelinesweredisseminatedinsoftcopybutnoteasily accessible to all

• GlobalresponseandrecommendationsthathadbeenchangingquiteoftenduetotoomanyunknownsaroundtheCovid19virusthatdisabledtoprovideconsistentrecommendationsandguid-ance

• ResponsepersonnelwerenottrainedonIMSresultinginlackofpreparednessforitsestablishmentandcoordinationchallenges

• Concentrationofexpertiseandresponsepersonnelatthenationallevelresultinginunevendistributionatthesubnationallevel

• Communicationbetweenthepillarsandresponsecoordinationatthenationalandsubnationallevelrequirestrengthening

• Delayeddataandinformationflowneededforstrategicdecisionmaking

• Recommended actions


a. Forimmediateimplementation:a. a.Advocateforreviewofmultisectorplansresourceallocationwithregardto

emergency response b. b.Advocateforinstitutionalizationofemergencypreparednessandresponse

in all line ministries c. c.Finalize,validateanddisseminatethenationalactionplanforpublichealth

security(NAPHS)d. d.Developmonitoringandsupervisiontoolsforimplementationofidentified

actionse. e.Outbreakresponseplanstoincludeextraremunerationforresponders

(e.gfinancial,meals,psychologicalandmaterialsupport)f. f.Improved mapping of key players during preparednessg. g.Identifyanddistributeexpertiseandresponsepersonnelatthenational

andsubnationallevelh. h.ReorientandtrainresponsepersonnelonfoundationalIncidentMan-

agementprinciplesandoverviewofkeyfunctionalIMSrolestoimproveCOVID-19 preparedness and response

i. i.Establishtimelycommunicationchannelsforregularandfrequentcommu-nicationbetweenthepillarsandresponsecoordinationatthenationalandsubnationallevel

j. j.Developtimelydataandinformationsharingbetweenpillarsandresponsecoordinationatthenationalandsubnationallevel

b. Formidtolong-termimplementationtoimprovetheresponsetotheongoingCOVID-19 outbreak:

a. a.Scaleupcapacitiesinemergencypreparednessandresponseatnationalandsubnationallevels

b. b.Monitoring the linkage of health and non-health aspects of the outbreak.c. c.Strengtheninterandintracommunicationtoensurecoherencethrough-

out the responsed. d.Conductregularreviewsofcontingencyplanstoinformfutureresponsee. Includeapillaronessentialhealthservicestomonitorandensurecontinua-

tionofessentialhealthservicesprovisionduringfutureoutbreaks


2.2. Risk communication and community engagement • Observations

Best practices

Public Communicationo UseofamultimediacampaignthatincludesTV/Radio/Print/socialmedia/digitalandcom-

munity-based channels.o Strongmediapartnershipsinvolvingearlymediaengagementandnegotiationsforfreepro-

gramme/announcementsslotso (UniformityofmessagesusedbyRCCEpartners.AMessageguidancepackageforrespond-

ers was developed and is updated as new messages are produced. It is policy for all messag-estobestandardizedandapprovedbytheMinistryofHealthbeforedissemination.

o COVID 19 Messages embraced various topics and target audiences.o UseoftheWhatsAppBOTtoengagewithcommunitiesanddisseminateinformationo DevelopmentanddistributionofIECmaterialsinEnglishandlocallanguagesearlyoninthe

outbreako TheuseofCommunityradiotoreachallcommunitieswithmessagesinlanguagestheycan

understandparticularlyinruralareaso Media programmes and IEC material produced in local languages and brailleo Ongoing material development and review to keep up pace with the evolving pandemico Useofexistingplatformstoconductsurveys,collectdataanddisseminateinformationo UseoffreeWi-Fihotspotsforinformationdissemination

RCCE Systems, Partner Coordination and Communicationo oPartnermappingandEstablishmentofcoordinationandcommunicationstructuresatna-

tionalandsub-nationallevelso oStakeholderandpartnersupportforlogisticsandresourcemobilisationo oDevelopmentofNationalRCCEplanwithMandEframeworkandatdistrictlevelso oInnovationthroughtheuseofvirtualplatformstohostingregularmeetingsforRCCEpillar

anditssubgroupsincludingprovincesanddistrictsinordertoensurecoordinationoftheRCCE during the outbreak response

o Capacity building of RCCE teams in high risk districts and provincial and district health pro-motionofficersonRCCEplanning,coordination.

Community Engagemento Development of SOPs for community engagemento UseofthePublicAddressSystemstodisseminateinformationo Employmentofdoortodoorsensitisationstrategythroughtheengagementofcommunity

volunteersandyouthvolunteerstoconductsensitizationinthecommunitieso Engagementoftraditionalleaders(chiefsandheadmenthroughtheMinistryofChiefsand

TraditionalAffairs)o Engagementofreligiousandotherinfluentialcommunityleaderssuchasmarketmasters

andtransportassociationso Useofcongregatesettingsaspartofcommunityengagementactivitieso Targetingandengagementofhigh-riskgroupssuchinmatesduringcommunityengagement

activities


Challeng-es

o Duplicationofeffortsarisingfrompoorcoordinationandsomepartnersoperatinginsiloso Availableresourceswerenotsufficienttocovertheplannedactivitieso PoorRCCEcoverageofdistricts,ruralareasandvillageso PoorpublicityaroundtheWhatsAppbotasadataplatformo Publicationofreportsislabourintensiveanddatatofeedintothereportsisnotalways

readilyavailable.Thishasresultedinareductioninthenumberofreportsproducedo SituationalreportsanddailyCOVID-19updateswereirregularwhichresultedinlowrisk

perceptiono The data from the call centre has not been readily available to feed into the dynamic listen-

inganddecisionmakingofthesub-committeeso Developmentofmaterialshasnotkeptpacewiththerapidlyevolvingsituationo Processes for the development and approval of IEC materials and messages was protracted. o StigmaaroundpersonswhotestpositiveforCOVID-19o Cultural norms were overlooked in some instances e.g. teams did not present tokens to

chiefs/traditionalleaderso Policypronouncementscaughttheimplementersoffguardandtherewasnotenoughtime

toadequatelyrespondandpreparethecommunities.o Communitiesexpectationofprovisionofmasksalongwithmessagingdisseminationashas

been the case with other outbreaks e.g. provision of soap and chlorine during cholera out-breaks

o Lowriskperceptionofthepublicandnon-compliancetopublichealthmeasures.o Variablecapacityamongjournalistsatcommunicatingemergencyhealthinformationmay

leadtomessagesconveyedthatdon’tstressthekeypoints


- a.Forimmediateimplementation:- Establishaclearanceprocessthataccountsforincoming,rapidlychanginginformationaswell

astimelyreleaseofcommunicationproducts.- Providetimelyresponsestoqueriesforinformation- Improvedmicroplanningtoincorporateactivitiestargetedatschools- Utiliselanguageofplayinthedevelopmentofmessagesforlearners- ImprovedcoordinationwiththeeducationsectorandtheMinistryofEducationstructuresat

districtandprovinciallevelsinordertoeffectivelyidentifytargetsforschooloutreachactivi-ties.

- Identifypopulationsindistricts,ruralareas,andvillages,aswellasattitudes,beliefs,andlan-guages.

- b.Formidtolong-termimplementationtoimprovetheresponsetotheongoingCOVID-19outbreak:

- Integrate the WhatsApp bot into the call centre so as to reduce the burden on the call centre staffaswellasintoSMSblastmessages

- IdentificationofuniqueRCCEneedsofruralcommunitiesandimprovedoutreach- IdentificationofuniqueRCCEneedsofvulnerable/differentlyabledcommunitiesandim-

proved outreach- Developmentofmaterialsinadditionallocallanguagesotherthanthe7mainonesused


2.3. Surveillance, case investigation and contact tracing• Observations

Bestpractices

o DevelopmentanddisseminationoftheintegratedCOVID-19guidelinesandSOPs for Zambia

o Availabilityofcasedefinitions,guidelinesandtoolsforCOVID-19o Strongleadershipandpoliticalwillo AlertcommunicationandmanagementbyDMMUwasusefulindirectingRRTs

responseo Rapidmobilizationanddeploymentofmulti-disciplinaryrespondersinthefacili-

tiesandcommunitieso Largescaletargetedcommunityscreeningsandtestingo Placement of data collectors at the major laboratories to help in data manage-

mentallowedfortimelycontacttracingo Provision of Technical Support from partners.o Epidemiological data was analysed and reported on a daily basis for all the key

variablesasstipulatedbyWHOo Aggressive contact tracing when cases were fewer in early part of outbreako UtilizationofsurveillancetoolsforcontacttracingsuchasformEandformDo Provision of COVID-19 updates to the RRTs o SupportfromWHO,AfricaCDC,AFENETforcontacttracingandmonitoringo Capacity building of swabbers and data collectorso Electronicplatform(Kobocollect)wasintroducedforcaptureoffielddata


Challenges

o Partnerfatigueduetoprotractedlengthoftheoutbreako FewRRTsmembersinvolvedintheresponseduetolackofmotivationresulting

inincreasedfatigueandstresslevelso RRT program was not established prior to the responseo

o RRTdeployershavenotreceivedCOVID-19specificjustin-timetrainingo Toomanyforms(paper/electronic)tofillinduringcontacttracing,massscreen-

ingandtestingandreviewingalerts,hencehigherchancesofomissionsandmaking mistakes.

o InadequateuseoftheIDSRinhealthcaresystemforCOVID-19o Inadequateuseofelectronicplatformfordatacollection,whichhasimpacted

dataqualityandabilitytofullyutilizeepidemiologicaldatatoinformdecisionmaking

o Unexpectedlogisticalrequirementsfromlineministrieswhichsupportedtheresponse e.g. servicing of vehicles

o DelayedturnaroundtimeforPCRtestsresults(morethan72hoursupto7-14daysatacertainmoment).

o Poorcommunicationofresultstoclientswhofollowingtesting.o Inadequatefundstosupportresponsedemandse.g.airtime,bundles,stationery,

refreshments,transportandsurgestaff,operationalizeandrolloutCommCaredata management system

o Mismatchbetweenincreasedtestingdemandsandlaboratorycapacityo Non-involvement of community-based volunteers in contact tracingo Delayedcommunicationofresultsfollowingswabbingoftruckdriverswhich

resultedinlackofcooperation.o Conflictinginstructionstotheresponseteamsbydifferentlevelsofhealthcare

systeme.g.oncontacttracing,testing,andalertresponseo Nopsychologicalhelprenderedtopatientsandresponderso Datasitsondifferentdatabaseshencenotabletoperformdetailedanalysiso Lack of proper system to share the results with end userso Centralizationofdataresultingindelayedtransmissionofdatatosub-national

levelso Non-availability of country-wide prevalence rates to inform decision making



a. Forimmediateimplementation:a. Responseactivitiestobeguidedbyscientificmethodsandepidemiologicaldatab. ProvideairtimeforbundlesforuploadingdataonKoboCollectandtalk-timeforcommuni-

cationwithclients.Provideclearsignagetoguideflowandimportantstepsforpassengersto follow.

c. Motivatestaffworkinginemergencyresponsethroughstaffrecognition,providingrestandrecuperationtimetoreducefatigueandstress

d. Increase the involvement of community-based volunteers in contact tracinge. TostrengthenutilizationofIDSRsystematalllevelsofthehealthcareandintegrateall

COVID-19reportingtoolsintotheIDSRsystem.f. Incorporateanautomatedsystemforcommunicationofresultstoclientsg. StrictlyadheretotheIMSstructureincommunicatingcommandsandinstructionstothe

response teamsh. Establish a Rapid Response Team management team dedicated to the training and wellbe-

ing of RRT deployers

i. ConductdeployerreadinessandCOVID-19justin-timetrainingj. Incorporate psychosocial counsellors in the RRTs to address psychologicalhallenges faced

bypatientsandrespondersMoH/ZNPHItoprovideregulartechnicalsupportsupervision,mobilizematerialandfinancialsupportforresponder

k. DisseminateCOVID-19resultsdatabasetoPHSandsurveillancestaffintheprovincesinrealtime

l. Toconductpromptandrepresentative(country-wide)prevalencestudiestogenerateevi-dence to guide decision making

b.Formidtolong-termimplementationtoimprovetheresponsetotheongoingCOVID-19outbreak:a.OperationalizenewCOVID-19testingsitesinalltheprovincialhubsinordertostrengthen COVID-19 surveillance. b. Surveillance and laboratory teams to liaise on average number of people to test per day in line with laboratory capacity. c.Mobilisefinancialandmaterialresourcestosupportvariousresponseneedscontinually.d.Train,engageandincentivisecommunity-basedvolunteersinCOVID-19responsee.g.Healthpromotion,contacttracing,communitycasemanagement.e.Surveillanceclustertoactivatetheweeklyepidemiologicaldataanalysisandutilizationmeetingsforpromptdetectionofeventsofpublichealthimportancef. Develop a COVID-19 surveillance strategy with short-term and long-term goals to en-hance surveillance in Zambiag.ConsideropportunitiesforresearchrelatedtoCOVID-19collateraldamageandbenefits


2.4. Points of Entry• Observations

Bestpractices

• Capacity building on surveillance, IPC and data management to POE staff

• POE surveillance was helpful in establishing areas of potential threats

• Multisectoral approach in surveillance at POE

• Existing cross border surveillance collaborations with neighbouring countries

• Screening and monitoring of travellers at POE

• Provision of the thermal scanners and hand-held infrared thermom-eters

• Timely provision of IEC materials at POE

• Availability of data collection tools at POE

• Availability of partner support (AFENET, WHO) towards monitoring of travellers on quarantine using mobile phones

• Provision of flight manifest by the national airports’ cooperation

• Consistent 14 day follow up of travellers passing through airports at the beginning of the outbreak

Challenges

• Inadequatesupplies,equipmentandotherlogisticsatPOEe.g.,PPES,gloves,swabs,airtime,databundles,tabletsandtransport

• Lack of uniformity in processes and data management at POEs suchasirregularsupport,multiplicityofvariedandconflictinginstructions

• DifficultiesinmanagingefficientlyallPoEandespeciallylandones• InadequateriskcommunicationatPoEs• Lack of signage to guide travellers on processes



a. Forimmediateimplementation:a. ProvideadequatesuppliesandotherlogisticssuchasPPEs,tabletsandair

timecommensuratewiththedemandsofthePOEb. ConsistentandharmonizedinstructionstocomefromtheIMSstructurein

ordertoavoidconflictingguidanceatsub-nationallevels

c. Provideclearsignagetoguideflowandimportantstepsforpassengerstofollow


a. Trainstaffinriskcommunicationandprovideinformationnotetotravellersb. Provide dedicated transport at POEc. MoH/ZNPHItoprovideregulartechnicalsupportsupervision,mobilizemate-

rialandfinancialsupportforresponders


2.5. The National Laboratory System• Observations

Bestpractices

o Existenceofpandemicinfluenzasurveillanceprogram(PIP),na-tionalinfluenzacentres(NIC)andviralhaemorrhagicfever(VHF)laboratories

o Presenceofcompetentpersonnel,skillsandsuppliesforthestartup process

o Thelaboratorypillarwasveryproactiveaboutintroductionofgenexpertonthemarket,teamconstitutedtoidentifylabsandconduct assessment to improve biosafety even before cartridges were available

o Useofexistinglaboratoryinfrastructureo Sentinelfacilitieswereavailableforinfluenzalikeinfections(ILI)

andsevereacuterespiratoryinfections(SARI)o Opening of private laboratories helped to increase public accessi-

bilitytotestingservices.o Centralreporting,datamanagementthroughtheconfidentiality

anddatadeclarationaswellasmandatorysharingofdataforsur-veillance and bio banking.

o Government and partner commitment to procurement of supplies o Epidemiologic numbers used within the laboratory network are

sharedwhichhelpsforquickreturnofresults

o AlllaboratoriesweresubjectedtoqualityassurancetestsbeforebeingaccreditedasSARS-COV2testinglaboratories


Challenges

• Inadequatecoordination,prioritization,consultationandcapacityforCOVID-19testingstrategies

• Non-availabilityoftestingstrategiesresultedinadhoctestingmethodologies

• Noincentivesprovidedforstaff• Communicationnotclearonwheretotakesamplesbetween

SchoolofVeterinaryMedicine(SVM)andUTH• Lack of cooler boxes for the RRTs due to stacks of unprocessed

samples• DelaysinprocessingsamplesfromBIDsandin-patients• Missing variables on laboratory forms and some samples not ac-

companiedbyformsledtotimelostsortingsamples• The laboratory was unable to stock pile supplies that could sustain

the demand due to limited market availability of supplies• Lackofincountrycapacity(engineers)toserviceandmaintain

equipment• Emergencyprocurementofsupplieswasnotinitiallyinplaceuntil

later in the outbreak• Lack of a dedicated sample transport system



a. Forimmediateimplementation:a. Capacitybuildingofnationalandsub-nationallevelstotheincidenceman-

agementsystem(IMS)toimprovecoordinationb. DevelopaCOVID-19testingstrategybasedonscientificevidencetoguide

methodology c. Review contingency plan and mobilize resources to help laboratories

with reagents to facilitate scale up and continued testing i. Generate an immediate needs request to partners for

3-6monthsii. Develop comprehensive laboratory reagents contingency plan

d. Improve results turnaround time by prompt analysis of samples in line with laboratory SoPs and testing strategy

e. QualityAssuranceandproficiencytesting,Intra-labtestingtobeprioritizedf. Developsystemsforsampletrackingfrompointofcollectiontolabe.gbar-

codingg. Encouragethelaboratoryteamtoanalyzelaboratorydatatogenerateevi-

dence to inform decision making h. Quickprocessingofsamplesforin-patientsandbroughtindead(BID)to

facilitatetimelydecisionmaking


a. Developadigitizedsystemforsampleandresultsmanagementb. Buildcapacityin-countryforservicinglaboratoyequipment c. Exploreuseofalternativesamplese.gsaliva


2.6. Infection Prevention and Control• Observations

Bestpractices

o Trainingofstaffheld(provincialanddistrictlevel,tertiaryhospi-tals)

o Partnersupporte.gsinkingofboreholesforisolationfacilitieso Multi-modalstrategyo Ongoing spot checks in the community to ensure complianceo Incorporationofallsectorsinthedevelopmentofguidelineso DisseminationofIPCSOPsandguidelineso DevelopmentoftoolsformonitoringIPCinPOEsandfacilitieso Workingwithlocalauthoritiesandlocalleadershipsinfostering

complianceo ConductingIPCorientationsinschoolso ExistenceofanIPCprogramatnationalleveltooverseeIPCcoun-

try-wideo Training of IPC trainer of trainers

Challenges

o PoorcoordinationoftrainingsbetweenMoHandPartnersresult-inginduplicityofefforts,insufficientdistrictcoverageandincom-pletepracticaldemonstrations

o Poor enforcement of public health measures by relevant authori-ties

o LowriskperceptionbythepubliconCOVID-19ledtopoorcompli-ance to IPC measures

o InadequateknowledgeandskillsinIPCamonghealthcareworkerscoupledwithpooratitude

o LimitedPPEandvariationsintypesusedo InadequatewatersupplyforIPCinsomefacilitieso Poor monitoring and supervision of burials in line with recom-

mended IPC guidelines due to delayed COVID-19 results o Indiscriminate disposal of surgical masks in the communityo Poorwastesegregationandcolorcodinginthehealthfacilities



a. For immediate implementation:a. MoH and partners to plan, and coordinate scale up IPC trainings for

health care workers at all levels of the healthcare system and conduct regular compliance monitoring

b. To strengthen health promotion activities at community level to raise index of suspicion and improve compliance to recommended mea-sures

c. Provide clean, adequate and safe water supply in all health facilities to promote hand hygiene

d. Prioritise processing samples from BIDs to enable timely supervision of burials

e. Provide guidelines, ongoing sensitization and monitoring on proper disposal of surgical masks in the community

f. Adhere to stipulated waste management guidelines on waste segre-gation and colour coding at all times

b. For mid to long-term implementation to improve the response to the ongoing COVID-19 outbreak:

a. Institutionalise IPC; all facilities to have IPC/WASH FPP b. Review IPC guidelines to suit the local context incorporating lessons

learnt from the responsec. Support non-incineration methods of waste management in keeping

with global green and health hospitals

d. Ensure focused procurement of IPC logistics to suit local requirement.


2.7. Case management and knowledge sharing about innova-tions and the latest research

• Observations

Bestpractices

• Useofelectronicforms,guidelinesandapplicationswhichwereeasy to access

• Involvement of case management team in planning and distribu-tionoflogistics

• Onlineplatformswithdigitalizedcopiesoftrainingmaterials• Introductionofthecommunitycasemanagementmodelreduced

the pressure on the health system• Guidelines and SOPs developed on case management

Challenges

• Inadequatetechnicalexpertisetomanageseverecases• Limited supplies for case management • InfectionofseveralHCWsinvolvedincasemanagement• Limitedcapacityofisolationfacilities• The health care system was ill prepared for the surge in cases

especially from Nakonde• Private sector not included from the outset• LackofappreciationoftheroleofIMSbysomeofficesintryingto

getinformationespeciallywhenmappingouthumanresources• Most people wanted formal appointment through established

channelstobeaddedtothemultidiscplinaryresponseteams• Trainingsinitiallyfundedbygovernmentdidnotincorporatepri-

vate sector• Few people commited to case management due to fear of the

disease and all its unknowns• Lackofguidanceonsomecontroversialissuessuchasre-testing• Slow trickle down of guidelines to the lower levels• Treatment protocols were not put in print for fear of the rapidly

changingsituation• Datafromtheclinicalteamnotusedtoguidedistributionofoxy-

gen concentrators • Onlineplatformdevelopedforquickaccesstotrainingmaterials

wasnotauthorizedresultingindelayedaccesstotrainingmateri-alsandimplementation

• Resultswerenottimely• LackofSOPonpatienttransfertoisolationcentres• Lackoffinancialsupportgiventovulnerablegroupsaffectedwith

COVID-19,thisresultedintoresistancetofacilityisolateorfailureto observe public health guidelines.



a. Forimmediateimplementation:a. b. StrengthenSOPsonambulanceandpatientmovementc. Improvecoordinationbetweenpublichealthandcasemanagementforas-

sessments of home environment for community management d. Provide interim guidance always despite rapid changes in the outbreak situa-

tion•


a. Strengthencoordinationforpatientcarefromallentrypointswiththerefer-ral mechanism

b. Earlyincorporationoftheprivatesectorandadequatemobilizationoffundsc. Strengthensocialprotectionandlinkagetosocialsupportmechanismswith

relevant government departments


2.8. Operational support and logistics in the management of supply chains and the workforce

• Observations

Bestpractices

o Adequatelytrainedhumanresourcescapableofrespondingtoemergencieso IntegrationofprovincialupdatesinthenationalIMSmeetingso Technicalandoperationalleadershipworkingintandemo Leveragingexistingsystemse.g.IDSRo Expedited emergency procurement processes

o Interoperabilityoflogisticssystemsandregularreportingoflogisticsstatus

Challenges

• Planningwaslimited,forecastingdidnottakeintoaccountthattheoutbreakwould be protracted

• Evidenceinitiallydidnotindicatethateveryonewouldneedmasks• Inadequatefinancialresourcesforprocurementofrequiredresourcesresulting

inlotsofdeficiencies• Uncleardistributionplans/notproactive• Didnotadequatelyanticipateincreasedcasenumbers• Difficultiesinsourcinglogisticsfromsuppliers• Incorrectquantitiesinstockduetopoorcoordination and planning as well as

“partnercompetition”• Duplicityofefforts• Lackoftransparencywithregardtodonations,reducedbuy-inandnumberof

donations• Meetingsnotregularlyheldandadaptivemanagementnotinplace• Lackoftoolsforforecastinglogisticaldemands• TendencyofIMSmemberstofieldmorequestionsthansolutions• ConflictsarisingfromfailuretounderstandtheIMSrolesvsoperationalroles• Waitingtimetohavelogisticsarriveincountryandthechallengesposedto

HealthcareWorkersinthefield• Poorlogisticmanagementatalllevelsresultedindelayedidentificationofstock-

outs

• Differencesinqualityofcommoditiesprocuredlocallyversusinternationally.Internationalcommoditieswerebetter



a. Forimmediateimplementation:a. Ensureavailabilityofdistributionplansatalltimesb. Utilisationofexistingtechnologiesforsupplychainmanagementc. FacilitatefullparticipationintheIMSforallkeyplayersd. SupportleadsoftheIMSsectionstoactuatesectionobjectivese. IMS operations should be guided by plans developed through multisectoral collab-

oration f. Preventivemaintenanceplanforvariousequipmentmustbeprioritizedg. Consitentmonitoringandprovisionofsupportivesupervisiontotheresponseatnational

andsubnationallevelsh. Useavailableepidemiologicdatatoinformlogisticsplanningi. Develophumanresourcesurgeplanforlogisticsj. Streamlinerequestproceduresforemergencyprocurementstoavoidprotractedprocesses

k. FinalisepartnermappingandcoordinationtoolforlogisticmanagementatalllevelsStrictlyadheretonon-disclosureofinformationsharedduringclosedmeetingstothepublicthattends to be misconstrued and may results in panic

l. Strictlyadheretonon-disclosureofinformationsharedduringclosedmeetingstothepub-lic that tends to be misconstrued and may results in panic

b. Formidtolong-termimplementationtoimprovetheresponsetotheongoingCOVID-19outbreak:a. Ensureoperationalsupportandlogisticsarecapableofhandlingconcurrentoutbreaksb. Planandconducttrainingsforlogisticiansinemergencyoperationsc. Replicatelogisticcoordinationstructuresatsubnationallevelsd. Conductquantificationandprocurementplanninge. Promotetransparencyamongpartnersonavailablesupportandexpecteddurationf. Replicatepartnersupportandresourcemobilizationsystemsatsub-nationallevelsg. Prioritizefocusedprocurementanddeliveryofsuppliesh. Ensureprequalificationandconsiderationoflocalsuppliersabletodeliverqualitycom-

modities


2.9. Maintaining essential health services during the COVID-19 outbreak

• Observations

Bestpractices

• HIV/ARTcarecontinuedduringtheoutbreak• MaternalandChildhealthservicescontinuedincludingimplemen-

tationofchildhealthweekactivities• TBandmalariaactivesurveillancecontinued• Continuedactivesurveillanceforotherreportablediseasesusing

IDSR • ConsistentreleaseoffundsforessentialservicesfromGRZand

partners• Continuedtargetedmentorship/tacticalsupporttoensure

strengthened EHS• Availabilityofguidelinesfortheprovisionofessentialhealthser-

vices• Monitoringandevaluationcontinuedsharingtrendsonvarious

indicators

Challenges

• Absence of EHS pillar on the IMS structure• Intheearlystagesoftheoutbreak,therewasareductioninthe

numberofpeopleaccessingEHSduetofearsofgettingtheinfec-tion

• Absenceofaplanforcontinuityofessentialhealthservicesduringoutbreaks/publichealthevents

• Inadequatefocusandevaluationofessentialhealthservicesprovi-sion during the COVID-19 response

• LackofprovisionofadequateservicesforNCDsduringCOvid-19proved to be a serious challenge and risk in Zambia

• Recommended actions- Forimmediateimplementation:

- Toconductanin-depthanalysisontheimpactofCOVID-19onessentialhealth services

- Set up the EHS pillar on the IMS structure- To ensure RCCE is enhanced at the onset of the outbreak- Prioritizeessentialhealthservicesprovisioninthecommunicationstrategy- Monitorprovisionofessentialhealthservicesduringoutbreaksthroughthe

useofinteractiveplatformssuchasthesituationroom

- Plan and conduct studies on the impact of COVID-19 pandemic on health-care seeking behavior

- Formidtolong-termimplementationtoimprovetheresponsetotheongoingCOVID-19 outbreak:

- Planforcontinuityofessentialhealthservicesduringpublichealthemergen-cies


3. THE WAY FORWARD

DescribethestrategyforimplementingtheactivitiesidentifiedduringtheIAR:- -Establish an IAR Follow-up Team.- -OutlinetheprocesstodocumentandmonitorprogressinimplementingtheIARrecommendations.- -Engagetheseniorleadershipteamthroughouttheentireprocess.- -Thefollow-upandmonitoringoftherecommendationsandactionsidentifiedduringtheIARwillbe

conducted on a bi-weekly basis. - -Theresultofthefollow-upwillbecommunicatedtoseniormanagementfordirectionandfeedback.

Below is the suggested follow-up team.


Follow-up teamPillars Team members Institution/level of

operationCoordination,planningandmoni-toring

- DrKapata- Dr. A. Silumesi- Dr.Kapaya- Dr Hamoonga- Dr. T. Chisenga- Dr. O. Shikanga- Dr. Nyambe Sinyange

- ZNPHI- MoH- ZNPHI- ZNPHI- MoH- WHO- ZNPHI

Riskcommunicationandcommunityengagement

- -Ms.MazyangaLiwewe- -Ms W. Mulenga- Ms.AlbertinaMoraes

- -ZNPHI- -MoH- ZNPHI

Surveillance,caseinvestigationandcontact tracing

- DrM.Kapina- DrN.Kayeyi- Dr. D. Simwaba- Mr. W. Malambo- Ms.P.Kalubula

- ZNPHI- ZNPHI- ZNPHI- CDC- WHO

Nationallaboratorysystem - Dr.K.Musonda- Dr. A. Shibemba- Dr. N. Saasa- DrM.Monze

- ZNPHI- MOH- UNZA VET- UTH

Points of Entry - Mr. M. Cheelo- Mr. I.Hamuganyu- Ms. C. Mwela

- MOH- MOH- WHO

Casemanagement,knowledgeshar-ingaboutinnovations

- Dr P. Zulu- Dr. Duncan Chanda

- ZNPHI- MOH

InfectionpreventionControl - MsC.Kaziya- Ms C. Mibenge

- MOH- MOH

OperationalsupportandLogisticsin management of supply chain and workforce

- Mr.MpangaKasonde- DrK.Musonda- Mr A M Mwanamwenge

- ZNPHI- ZNPHI- WHO


4. ANNEXES

4.1. Annex 1: List of participants and Intra-Action Review (IAR) team


4.2. Annex 2: Agenda of the Zambia Country COVID-19 Intra-Action Review

• Day 1: 23rd September 2020Time Activity Moderator

Team 1: Risk Communication and Community Engagement (Zoom link: https://echo.zoom.us/j/98193125758?pwd=K1hQWVFJT25oWWJjTnVwZkQrb3hTUT09

Password: IAR2020)

08:30 - 09:00 Registration,introduction,administrativeformalities,objectives Facilitator: ZNPHI

ZNPHI

09:00 - 09.20 Inter-ActionReviewmethodologyandinstructions Facilitator: WHO

09:20 - 09:45Introduction: Response plan and actual timeline of the response Facilitator: Mrs. Mulenga and Mr. Ngoni Nyambawaro

09:45 - 10:45Session 1 - What worked well? What worked less well? And why? Partici-pants work to identify the challenges and best practices of the response. Facilitator: Mrs. Mulenga and Mr. Ngoni Nyambawaro

10:45-11:00 Coffeebreak

11:00 - 12:00Session 1 (continued) - What worked well? What worked less well? And why? Participants work to identify the challenges and best practices of the response. Facilitator: Mrs. Mulenga and Mr. Ngoni Nyambawaro

MoGE12:00-13:00Session 2 - What can we do to improve for next time?Participants work to identify what can be done to strengthen the ongoing COVID-19 response. Facilitator: Mrs. Mulenga and Mr. Ngoni Nyambawaro

13:00-13:30Session 3 – The Way Forward: discussion on the best way to implement these activities moving forward. Facilitator: Mrs. Mulenga and Mr. Ngoni Nyambawaro

12:30-13:30 LunchTeam 2: Coordination and Essential Services

(Zoom link: https://who.zoom.us/j/99587126621 Meeting ID: 995 8712 6621 Passcode: 4F$*g3S#)

14:00 - 14:30 Registration,introduction,administrativeformalities,objectives Facilitator: MOH

ZNPHI

14:30 - 14.50 Inter-ActionReviewmethodologyandinstructions Facilitator: WHO

14:50 - 15:15 Introduction: Response plan and actual timeline of the response Facilitator:Dr.NathanKapata&CP

15:15 - 16:15Session 1 - What worked well? What worked less well? And why? Partici-pants work to identify the challenges and best practices of the response. Facilitator:Dr.NathanKapata&CP


16:30 - 17:30Session 1 (continued) - What worked well? What worked less well? And why? Participants work to identify the challenges and best practices of the response. Facilitator:Dr.NathanKapata&CP

DMMU17:30-18:30Session 2 - What can we do to improve for next time?Participants work to identify what can be done to strengthen the ongoing COVID-19 response. Facilitator:Dr.NathanKapa-ta&CP

18:30-19:00Session 3 – The Way Forward: discussion on the best way to implement these activities moving forward. Facilitator:Dr.NathanKapa-ta&CP


• Day 2: 24th September 2020Time Activity Moderator

Team 3: Surveillance and PoEs(Zoom link: https://echo.zoom.us/j/98193125758?pwd=K1hQWVFJT25oWWJjTnVwZkQrb3hTUT09

Password: IAR2020)


ZNPHI

09:00 - 09.20Inter-ActionReviewmethodologyandinstructions Facilitator: WHO

09:20 - 09:45Introduction: Response plan and actual timeline of the response Facilitator:MuzalaKapina&PreciousKa-lubula

09:45 - 10:45

Session 1 - What worked well? What worked less well? And why? Partici-pants work to identify the challenges and best practices of the response. Facilitator:MuzalaKapina&PreciousKa-lubula


11:00 - 12:00

Session 1 (continued) - What worked well? What worked less well? And why? Participants work to identify the challenges and best practices of the response. Facilitator:MuzalaKapina&PreciousKa-lubula

Innocent Ha-mugannyu12:00-13:00

Session 2 - What can we do to improve for next time?Participants work to identify what can be done to strengthen the ongoing COVID-19 response. Facilitator:MuzalaKapina&Pre-ciousKalubula

13:00-13:30Session 3 – The Way Forward: discussion on the best way to implement these activities moving forward. Facilitator:MuzalaKapina&PreciousKalubula

12:30-13:30 LunchTeam 4: Laboratory

Zoom link: https://cdc.zoomgov.com/j/1604029144?pwd=TVBkVWNPaWlkclVIZE9lQjFOYXl6QT09 Meeting ID: 160 402 9144

Passcode: $t4ZY9V!

14:00 - 14:30 Registration,introduction,administrativeformalities,objectives Facilitator:

UTH Virology

14:30 - 14.50Inter-ActionReviewmethodologyandinstructions Facilitator:

14:50 - 15:15Introduction: Response plan and actual timeline of the response Facilitator:KundaMusonda&ThomasSte-vens

15:15 - 16:15

Session 1 - What worked well? What worked less well? And why? Partici-pants work to identify the challenges and best practices of the response. Facilitator:KundaMusonda&ThomasSte-vens



16:30 - 17:30

Session 1 (continued) - What worked well? What worked less well? And why? Participants work to identify the challenges and best practices of the response. Facilitator:KundaMusonda&ThomasSte-vens

UNZA VET lab17:30-18:30

Session 2 - What can we do to improve for next time?Participants work to identify what can be done to strengthen the ongoing COVID-19 response. Facilitator:KundaMusonda&Thomas Stevens

18:30-19:00Session 3 – The Way Forward: discussion on the best way to implement these activities moving forward. Facilitator:KundaMusonda&ThomasStevens

• • • • Day 3: 25th September 2020

Time Activity Moderator

Team 5: Case Management and IPC(Zoom link: https://echo.zoom.us/j/98193125758?pwd=K1hQWVFJT25oWWJjTnVwZkQrb3hTUT09

Password: IAR2020)


UTH

09:00 - 09.20Inter-ActionReviewmethodologyandinstructions Facilitator: WHO

09:20 - 09:45Introduction: Response plan and actual timeline of the response Facilitator:PaulZulu&MutintaNalubamba

09:45 - 10:45Session 1 - What worked well? What worked less well? And why? Partici-pants work to identify the challenges and best practices of the response. Facilitator:PaulZulu&MutintaNalubamba


11:00 - 12:00Session 1 (continued) - What worked well? What worked less well? And why? Participants work to identify the challenges and best practices of the response. Facilitator:PaulZulu&MutintaNalubamba

MOH12:00-13:00

Session 2 - What can we do to improve for next time?Participants work to identify what can be done to strengthen the ongoing COVID-19 response. Facilitator:PaulZulu&MutintaNa-lubamba

13:00-13:30 Session 3 – The Way Forward: discussion on the best way to implement these activities moving forward. Facilitator:PaulZulu&MutintaNalubamba12:30-13:30 Lunch

Team 6: Logistics management and others Zoom link: https://who.zoom.us/j/91637812664 Meeting ID: 916 3781 2664 Passcode: 9u^cPpT@


MOH

14:30 - 14.50Inter-ActionReviewmethodologyandinstructions Facilitator:

14:50 - 15:15Introduction: Response plan and actual timeline of the response Facilitator:FredKapaya&GeorgeSinyangwe

15:15 - 16:15Session 1 - What worked well? What worked less well? And why? Partici-pants work to identify the challenges and best practices of the response. Facilitator:FredKapaya&GeorgeSinyangwe



16:30 - 17:30Session 1 (continued) - What worked well? What worked less well? And why? Participants work to identify the challenges and best practices of the response. Facilitator:FredKapaya&GeorgeSinyangwe

MSL17:30-18:30

Session 2 - What can we do to improve for next time?Participants work to identify what can be done to strengthen the ongoing COVID-19 response. Facilitator:FredKapaya&GeorgeSinyangwe

18:30-19:00 Session 3 – The Way Forward: discussion on the best way to implement these activities moving forward. Facilitator:FredKapaya&GeorgeSinyangwe

intra action review (iar) of the zambia covid-19...

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