Joint external evaluation of IHR core capacities of Republic of Zambia: executive summary

Joint external evaluation of IHR Core Capacities of the Republic of Zambia Executive summary August 7 -11, 2017

WHO/WHE/CPI/SUM/2017.50 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NCSA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Joint external evaluation of IHR core capacities of Republic of Zambia: executive summary. Geneva: World Health Organization; 2017 (WHO/WHE/CPI/SUM/2017.50). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

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ACKNOWLEDGEMENTS The WHO JEE Secretariat would like to acknowledge the following, whose support and commitment to the principles of the International Health Regulations (2005) have ensured a successful outcome to this JEE mission:    The Government and national experts of the Republic of Zambia for their support of, and work in, preparing for the JEE mission; The governments of Japan, Kenya, Nigeria, Sierra Leone, Sweden and Tanzania for providing technical experts for the peer review process; The Nigerian Centre for Disease Control (NCDC), Public Health Agency of Sweden, The World Organisation for Animal Health (OIE) and Japan International Corporation Agency (JICA) for their contribution of experts and expertise; The governments of Germany and Finland for their financial support to this mission; The following WHO entities: Country Office of Ghana and Nigeria, WHO Regional Office – WHO (AFRO), WHO HQ Country Health Emergencies Preparedness and IHR Department, WHO HQ Emergency Operations Department; Global Health Security Agenda Initiative for their collaboration and support.

  

Full Report will be published on the WHO website http://www.who.int/ihr/procedures/mission-reports/en/

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Executive summary Findings from the joint external evaluation The Republic of Zambia is in the southern part of the African continent and is surrounded by 8 other countries; Tanzania, Democratic Republic of Congo (DRC) Malawi, Mozambique, Zimbabwe, Botswana, Namibia, and Angola, giving it a vast responsibility for border control. The country is divided into 9 provinces which are predominantly rural and 72 districts. Its population was estimated to be 13.2 million in the 2010 census. The overall responsibility for the coordination and management of the health sector lies with the Ministry of Health (MOH). The sector is coordinated through the National, Provincial, District and Community level which facilitates and maintains the link between the various communities and the health system. The Republic of Zambia is the 21st country in the Africa Region to take part in the joint External Evaluation (JEE) which took place in Livingstone in August 2017. The official request for the evaluation was made to the World Health Organization (WHO) in August 2016. The mission consisted of a multisectoral International team made up of individuals with recognized expertise in their field from different countries. Support was also provided by technical advisors from The World Organisation for Animal Health (OIE), The Nigerian Centre for Disease Control (NCDC), Public Health Agency Sweden and Japan International Corporation Agency (JICA). Technical presentations led by the Ministry of Health (MoH) were given by the multi-sectoral Zambian team focusing on the self-assessment they had conducted, followed by a joint multisectoral discussion. The joint recommendations that followed were the result of this process, supported with various field visits.

Overarching issues and priority recommendations: A few overarching themes emerged during the evaluation process. The joint discussions that followed between the host country and the team of experts generated the agreed priority actions during the various discussions and presentations.

Legislation, Guidelines, and Formalised Systems: The experts noted that although there are several laws in operation such as The Public Health Act 1995 and The Food and Drug Act 2007, they do not effectively accommodate the requirement of the International Health Regulations (2005) or the standards of the World Organisation for Animal Health (OIE). In Food Safety, there was a requirement for the new law to bring the food processing functions from farm to fork in line with IHR (2005) and to include the veterinary services and all other relevant ministries to ensure a multisectoral approach. Similar observations were made in other technical areas. They included the need for Zambia to finalize its multi-hazard health emergency preparedness and response plan and other plans that were still in draft. Also recommended was the legalisation of the neighbourhood health committees to boost health education at the community level and formalize relevant agreements regarding public health emergencies with neighbouring countries. The finalization of the national Nuclear and Radiological Emergency Preparedness Response Plan and the National Nuclear Policy was also recommended. In other areas, it was suggested by the experts that Zambia creates plans and strategies for limitation and restraint, for example, for the control and prevention of zoonotic diseases, and the uncontrolled use of antimicrobials in both human and animal health. Other recommendations from the team of experts was for the inclusion of some of the current structures such as the National Epidemic, Prevention, Preparedness, and Control Management Committee (NEPPCMC) to be formally adopted in the Public Health Act currently being reviewed and National Action Plans for designated Points of Entries.

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However, Zambia is making steady progress in the legislative process to pass The Public Health Act and The Food and Drug Act. It is expected that these new pieces of legislation will bring about the coordination, strengthening, and the clarification of the roles and responsibilities of the various agencies under the banner of a One Health approach.

Collaboration and Information Sharing The need for collaboration and sharing of information with other stake holders and Ministries was emphasized by many experts. The absence of linkage created missed opportunities for joint working and systems that would assist in bringing about a One Health approach to encourage, extend, and facilitate interaction. Although guidelines and systems existed in some areas, these were not shared with the relevant stakeholders, and dialogue between the different sectors was sub-optimal. Some of the areas highlighted included: 1) Strengthening multisectoral coordination to enhance information sharing among stakeholders involved in Emergency Response. 2) A One Health approach in the testing of diseases and their surveillance that will incorporate the private laboratories. 3) Coordination for chemical safety between different relevant government agencies. 4) The establishment of protocols and Standard Operating Procedures (SOPs) between the various entities including health, defence, security, law enforcement and international organisations in Public Health and Security including the National IHR Focal Point. 5) Creation of an All Hazard Public Risk Communication Plan to be shared with all sectors for effective synchronization and collaboration. It is important not only to create these systems but to ensure that they are shared and effectively operated in order for them not to become fragmented and uncoordinated. Closely aligned to this will be the missed opportunities for joint training exercises which facilitate the sharing of knowledge and expertise between the various sectors. Here, the experts stressed the importance of an inclusive One Health approach that must fully embrace the animal and environmental health sectors and strengthen the National Focal Point (NFP) to enable proper coordination and reporting to all relevant stakeholders.

The Directors and Ministries Response: The way forward for Zambia In looking forward however, Zambia should be extremely proud of its workforce. The total commitment and dedication of the national experts to the evaluation process was evident in the clear and informative presentations and the discussions that ensured with the external team. The staff on the ground who were encountered during the field visits were also noted to be passionate in carrying out their various duties. The Ministry of Health (MOH) and the various Directors in their closing summaries were open and accommodating and fully embraced the results of the JEE; seeing it as a process that can only aid Zambia’s progress in fully meeting its IHR (2005) responsibility. It is an exciting time for Zambia as it embarks on major changes which includes the revision and finalization of The Public Health Act and the Animal Health Act and the amendment to the Disaster Management Act and The Food and Drug Act 2007. The experts, through the joint evaluation process and in collaboration with the presenters have provided some direction in terms of the gaps that should be filled. Another arm of change is the current overhaul of the health sector, focusing on health promotion, disease prevention and rehabilitative services. The Zambian National Public Health Initiative (ZNPHI) performs all functions pertaining to disease surveillance, intelligence, and epidemic preparedness. With a national budget, it is well placed to improve the surveillance capacity and is committed to a more timely and well documented data that will facilitate the sharing of information and good channels of communication. 4

The Director of Health acknowledged that this channel of communication needs to be widely extended to be allencompassing and it was stated that the imminent Public Health Act will bring together all the different ministries and coordinate roles and responsibilities. The limited resources of those on the ground will be appraised and issues around inadequate facilities will be addressed and working environments improved. The animal sector was equally aware of the gaps in collaboration with the human sector and the director very much hoped that the priority actions jointly agreed will assist Zambia to focus on working more collaboratively with other sectors. In summary, Zambia is rising to the challenges it faces with the current developments in the country. A multi-hazard National Action Plan for Health Security building on the JEE and other past assessments will help to channel resources from the government and partners to address gaps identified. This, in addition with adequate and relevant training of the workforce, essential guidelines and procedures and the realization of plans and legislation currently in the draft stage will set the scene for delivering the requirements of the IHR (2005) in a one health perspective.

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Zambia Scores and Priority Actions Technical areas Indicators Consensual Priority Actions Score  Finalize the revision of the Public Health Act, Animal Health Act and Food and Drug Act to take into consideration the provision and 2 proper implementation and monitoring of the IHR 2005.  Finalize agreements/protocols on coordination among various government ministries and partners.  Document and finalize agreements, protocols, or Memorandum of Understanding (MOU) with neighbouring countries regarding public 2 health emergencies.  Develop Standard Operating Procedures (SOPs) to support implementation of IHR (2005) including provision for resources.   IHR coordination, communication and advocacy  P.2.1 1  Develop terms of reference that define the roles and responsibilities of IHR National Focal Point (NFP) and IHR technical working group. Develop relevant SOPs for communication and coordination between the NFP and identified sectors, WHO and OIE. Establish a one health platform where all stakeholders are represented for proper coordination of IHR activities. Conduct simulation exercises to test the coordination and communication mechanism between the NFP and stakeholders including WHO, and OIE. Build capacity of IHR NFP and focal persons of identified sectors to facilitate IHR implementation. Improve human resources and infrastructure to boost laboratory capacity for AMR testing for both human and animal health. Strengthen quality management systems in the laboratories performing antibacterial susceptibility testing in the human and animal health sectors. Set up more sentinel surveillance sites for AMR and strengthen the AMR surveillance system for human and animal health. Improve awareness of the importance of appropriate use of antimicrobials among health care workers, veterinary workforce, and the public. Promote the implementation of Infection Prevention and Control (IPC) guidelines in healthcare facilities.

P.1.1 National legislation, policy and financing P.1.2

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 P.3.1 4  P.3.2 Antimicrobial resistance P.3.3 3 4

 

P.3.4

3



6

 P.4.1 3 

Zoonotic diseases

P.4.2

4

  

P.4.3

1

Develop a strategic plan for zoonotic disease control and prevention which should include a priority zoonotic disease list, developed using a multisectoral decision- making process. Carry out laboratory capacity assessment to guide the strengthening of diagnostic capacity for prioritized zoonotic diseases at national and sub- national levels. Evaluate and strengthen existing surveillance system attributes to improve surveillance for priority zoonotic disease. Carry out a human resource needs assessment for veterinary workforce to identify human resource gaps. Establish a formal One Health platform to coordinate implementation of one health including the prevention and control of zoonotic diseases. Establish or strengthen a food safety platform comprising of the veterinary sector and other food safety stakeholders. Design, implement, monitor, and evaluate a National Food Control System as per International guidelines. Finalize the Food Safety Act and the Food Safety Strategy and develop implementing rules and SOPs according to the new strategy. Obtain validation for the Food Safety Strategy from the concerned ministries. Produce, implement, and evaluate action plans related to specific food safety aspects (e.g. residue, meat, hygiene). Include food borne events in the Health Management Information System (HMIS). Assess and revise the existing legislations so that biosecurity issues are fully addressed. Prepare a national plan for the high containment laboratories, (BSL3) which should include the maintenance of existing laboratories, establishment of new laboratories and the proper accreditation of such laboratories. Conduct a training needs assessment for biosafety and biosecurity and develop common curriculum and the train the trainer programme. Strengthen networking and collaboration among stakeholders in different sectors so that a whole of government biosafety and biosecurity system is fully implemented.

   Food safety P.5.1 2  

 

P.6.1

2

Biosafety and biosecurity



P.6.2

1



7

   Immunization  P.7.2 4

P.7.1

4



Expand cold chain facilities in newly created districts and veterinary sector to cater for expanding needs. Conduct capacity building among staff on immunization supply chain and stock management. Support outreach programmes in hard to reach areas to increase the uptake of measles rubella second dose vaccines. Conduct health education campaigns to improve uptake of immunization and reporting of Adverse Events Following Immunization (AEFI) in the community. Improve data quality in terms of timeliness, completeness of reporting and denominator challenges. Map the existing national laboratory capacity and use the findings to strengthen the national public and regional public health laboratories so that they are sustainably-funded and fully-functioning. Dedicate adequate budget for sample transportation at the district health level and tap into the existing sample transportation system of partner supported programmes in line with IDSR. Strengthen the referral and supervisory systems in the existing national laboratory network and roll out Laboratory Management Information System (LMIS) to all provincial laboratories. Support Quality Management System (QMS) activities in the laboratory network and pilot them towards the WHO Stepwise accreditation system. Conduct a mapping of national surveillance capacities in the animal and human health sectors and address the identified gaps. Finalize the development and roll out of the eIDSR (Integrated Disease Surveillance and Response) module by DHIS2 (District Health Information System) and conduct mass training in IDSR at all levels. Procure ICT (Information and Communication Technology) tools to facilitate timely capture and dissemination of surveillance data especially at health facility levels. Develop a syndromic surveillance system for animal health. Develop SOPs to strengthen formal collaboration and communication mechanism for IHR NFP with lower levels and stakeholders. Finalize development of protocols and legislation governing IHR and OIE reporting to ensure timely and accurate reporting of public health events. Build capacity for IHR NFP and other IHR stakeholders including other relevant sectors outside health on IHR reporting.

 D.1.1 4  D.1.2 National laboratory system D.1.3 3  D.1.4 3   D.2.2 Real-time surveillance D.2.3 3 2  2 

D.2.1

3

D.2.4

3

 

D.3.1 Reporting D.3.2

2

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2

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8

 D.4.1 3  Workforce development D.4.2 3  

D.4.3

2

Produce and fund annual action plans for upgrading human resources for public health purposes in both Ministry of Health (MOH) and Ministry of Fisheries & Livestock (MFL). Increase the number of staff trained in epidemiology and the diversity of profiles. Develop basic and intermediate Field Epidemiology Training Programme or similar courses in addition to the advanced course. Continue upgrade of the veterinary curriculum (OIE Vet Education standards). Conduct multi-hazard mapping and risk assessment of prioritized public health risks. Update, finalize and implement a multi hazard and multi-sectoral national public health preparedness and response plan. Establish a contingency fund for public health priority emergencies. Establish mechanism for coordinating the one health agenda at all levels. Strengthen multi-sectoral collaboration in public health emergency preparedness and build partnerships with other stakeholders. Finalize Standard Operating Procedures (SOPs) and test the SOPs through table top exercises. Define Incident Management System and Concept of Operations (CONOPs) for the activation of EOC. Build capacity for emergency response at all levels and increase the number of personnel with required skills for emergency response especially at the lower levels. Develop MOUs and SOPs between health, defence, security and law enforcement sectors at appropriate levels of government and with relevant regional and international organisations. Conduct joint training, simulations and epidemiological investigation and response at regional and national levels for public health and security authorities. Develop mechanisms for information sharing between public health and security authorities. Include medical countermeasures in the Public Health Act revision Develop National Countermeasures and Personnel Deployment Plan and SOPs. Formalize regional and international partnerships related to medical countermeasures and personnel deployment, procurement, and distribution. Conduct table –top exercises for sending and receiving medical countermeasures. 9

 R.1.1 Preparedness R.1.2 1 1    

R.2.1 Emergency response operations R.2.2 R.2.3 R.2.4

2 1 1 2

  



Linking public health and security authorities

 R.3.1 1 

R.4.1 Medical countermeasures and personnel deployment R.4.2

1

  

1



R.5.1 R.5.2 Risk communication R.5.3 R.5.4 R.5.5

2 3 4





 3 4  

Review and update Terms of Reference(TOR) for the National Epidemic Preparedness and Prevention Risk Communication SubCommittee. Develop an all-hazard public health risk communication plan to enhance collaboration and coordination among relevant stakeholders. Strengthen the communication and coordination between internal and external partners to create an effective risk communication mechanism. Legalize neighborhood health committees. Conduct assessment for Designation of Points of Entry and develop a National Action Plan for implementation of identified gaps for Core Capacities. Develop Public Health Contingency Plan for PoEs and incorporate them into Points of Entry (Civil aviation, Ports, and Ground crossing) Emergency Response Plans. Establish funding mechanisms and cost sharing schemes for port health services. Build the capacity of POE staff in port health operations and management. Develop guidelines and relevant SOPs to support POEs public health measures implementation. Establish and operationalize a national poison centre. Establish coordination mechanisms among stakeholders in chemical events surveillance and response. Build laboratory capacities so that all priority chemicals can be confirmed in a timely manner. Build capacity in chemical surveillance and management in relevant agencies. Develop indicators to monitor health ailments associated with chemical hazards. Finalize the national Nuclear and Radiological Emergency Preparedness Response Plan and the National Nuclear Policy. Establish a national committee on nuclear and radiological emergency response. Enhance the laboratory capacities and procurement of radiation detecting equipment for first responders. Develop technical guidelines for the management of radiation emergencies including risk assessment, reporting, event confirmation, notification, and investigation.

PoE.1

1



Points of entry

  PoE.2 1 

  CE.1 Chemical events CE.2 3 2   

 RE.1 Radiation emergencies RE.2 2 2   

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List of indicators Technical areas National legislation, policy and financing IHR coordination, communication and advocacy Antimicrobial resistance P.1.1 Legislation, laws, regulations, administrative requirements, policies or other government instruments in place are sufficient for implementation of IHR (2005) P.1.2 The State can demonstrate that it has adjusted and aligned its domestic legislation, policies and administrative arrangements to enable compliance with IHR (2005) P.2.1 A functional mechanism is established for the coordination and integration of relevant sectors in the implementation of IHR P.3.1 Antimicrobial resistance detection P.3.2 Surveillance of infections caused by antimicrobial-resistant pathogens P.3.3 Health care-associated infection (HCAI) prevention and control programmes P.3.4 Antimicrobial stewardship activities P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens P.4.2 Veterinary or animal health workforce P.4.3 Mechanisms for responding to infectious and potential zoonotic diseases are established and functional P.5.1 Mechanisms for multisectoral collaboration are established to ensure rapid response to food safety emergencies and outbreaks of foodborne diseases P.6.1 Whole-of-government biosafety and biosecurity system is in place for human, animal and agriculture facilities P.6.2 Biosafety and biosecurity training and practices P.7.1 Vaccine coverage (measles) as part of national programme P.7.2 National vaccine access and delivery D.1.1 Laboratory testing for detection of priority diseases D.1.2 Specimen referral and transport system D.1.3 Effective modern point-of-care and laboratory-based diagnostics D.1.4 Laboratory quality system D.2.1 Indicator- and event-based surveillance systems D.2.2 Interoperable, interconnected, electronic real-time reporting system D.2.3 Integration and analysis of surveillance data D.2.4 Syndromic surveillance systems D.3.1 System for efficient reporting to FAO, OIE and WHO D.3.2 Reporting network and protocols in country D.4.1 Human resources available to implement IHR core capacity requirements D.4.2 FETP1 or other applied epidemiology training programme in place D.4.3 Workforce strategy R.1.1 National multi-hazard public health emergency preparedness and response plan is developed and implemented R.1.2 Priority public health risks and resources are mapped and utilized R.2.1 Capacity to activate emergency operations

Zoonotic diseases

Food safety Biosafety and biosecurity Immunization National laboratory system

Real-time surveillance

Reporting Workforce development

Preparedness Emergency

1

FETP:

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response operations Linking public health and security authorities Medical countermeasures and personnel deployment

R.2.2 EOC operating procedures and plans R.2.3 Emergency operations programme R.2.4 Case management procedures implemented for IHR relevant hazards. R.3.1 Public health and security authorities (e.g. law enforcement, border control, customs) are linked during a suspect or confirmed biological event R.4.1 System in place for sending and receiving medical countermeasures during a public health emergency R.4.2 System in place for sending and receiving health personnel during a public health emergency R.5.1 Risk communication systems (plans, mechanisms, etc.) R.5.2 Internal and partner communication and coordination R.5.3 Public communication R.5.4 Communication engagement with affected communities R.5.5 Dynamic listening and rumour management PoE.1 Routine capacities established at points of entry PoE.2 Effective public health response at points of entry CE.1 Mechanisms established and functioning for detecting and responding to chemical events or emergencies CE.2 Enabling environment in place for management of chemical events RE.1 Mechanisms established and functioning for detecting and responding to radiological and nuclear emergencies RE.2 Enabling environment in place for management of radiation emergencies

Risk communication

Points of entry Chemical events Radiation emergencies

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